Retinal changes in COVID-19 hospitalized cases

The prone position in COVID-19 impacts the thickness of peripapillary retinal nerve fiber layers and macular ganglion cell layers

The prone position reduces mortality in severe cases of COVID-19 with acute respiratory distress syndrome. However, visual loss and changes to the peripapillary retinal nerve fiber layer (p-RNFL) and the macular ganglion cell layer and inner plexiform layer (m-GCIPL) have occurred in patients undergoing surgery in the prone position. Moreover, COVID-19-related eye problems have been reported. This study compared the p-RNFL and m-GCIPL thicknesses of COVID-19 patients who were placed in the prone position with patients who were not. This prospective longitudinal and case-control study investigated 15 COVID-19 patients placed in the prone position (the "Prone Group"), 23 COVID-19 patients not in the prone position (the "Non-Prone Group"), and 23 healthy, non-COVID individuals without ocular disease or systemic conditions (the "Control Group"). The p-RNFL and m-GCIPL thicknesses of the COVID-19 patients were measured at 1, 3, and 6 months and compared within and between groups. The result showed that the Prone and Non-Prone Groups had no significant differences in their p-RNFL thicknesses at the 3 follow-ups. However, the m-GCIPL analysis revealed significant differences in the inferior sector of the Non-Prone Group between months 1 and 3 (mean difference, 0.74 μm; P = 0.009). The p-RNFL analysis showed a significantly greater thickness at 6 months for the superior sector of the Non-Prone Group (131.61 ± 12.08 μm) than for the Prone Group (118.87 ± 18.21 μm; P = 0.039). The m-GCIPL analysis revealed that the inferior sector was significantly thinner in the Non-Prone Group than in the Control Group (at 1 month 80.57 ± 4.60 versus 83.87 ± 5.43 μm; P = 0.031 and at 6 months 80.48 ± 3.96 versus 83.87 ± 5.43 μm; P = 0.044). In conclusion, the prone position in COVID-19 patients can lead to early loss of p-RNFL thickness due to rising intraocular pressure, which is independent of the timing of prone positioning. Consequently, there is no increase in COVID-19 patients' morbidity burden.

Outer Retinopathies Associated with COVID-19 Infection: Case Reports and Review of Literature

Background

The coronavirus disease (COVID-19) is a highly contagious disease with profound health implications. It can affect any part of the body with variable severity. Various ophthalmic manifestations of coronavirus disease have been documented. Case Presentations. We reported three cases of outer retinopathies associated with COVID-19 infection. All three patients were young females. The first two patients presented within days of COVID-19 infection with complaints of black spots in the eyes. Multimodal retinal imaging showed lesions consistent with acute macular neuroretinopathy. Lesions were bilateral in the first patient and unilateral in the second one. Our third patient presented with blurred vision in one eye, 3 months after a suspected COVID-19 infection. Retinal imaging showed outer retinopathy. Our patients' vision was good and maintained during the follow-up. All three were monitored on observation only, and symptoms and lesions improved with time.

Conclusion

In conclusion, COVID-19-related thromboinflammatory response can result in localized vascular inflammation and hypoperfusion in any of the retinal capillary plexuses or choriocapillaris resulting in ischemia of the corresponding retinal or choroidal layers.

Retinal Changes in Patients With Covid-19 and Different Expressiveness of Metabolic Changes

AIMS

 To study the relationship between the severity of COVID-induced metabolic changes and the structure and frequency of retinal changes, according to funduscopy data in patients with different clinical courses of COVID-19.

MATERIALS AND METHODS

 117 patients with COVID-19 were examined. While examining patients, severity of the course of COVID-19, the expressiveness of changes in the metabolic status were determined; fundus image registration was performed with portable fundus cameras Pictor Plus Fundus Camera and VistaView (Volk Optical).

RESULTS

 As a result of the research, retinal changes were found in 49 (41.9 %) patients with COVID-19. In 8 (16.3 %) cases, clinically significant (vitreous hemorrhage, prethrombosis of the central retinal vein or branches of the central retinal vein, thrombosis of the central retinal vein or branches of the central retinal vein) COVID-induced retinal and ophthalmological changes were observed, which caused a decrease in visual acuity. In 41 (83.7 %) cases, clinically insignificant changes (cotton wool spots, narrowed retinal vessels, intraretinal and petechial hemorrhages, tortuosity and dilatation of retinal venules) COVID-induced retinal changes were observed. Clinically significant retinal changes occur in patients with a statistically significantly higher level of D-dimer and a greater percentage of lung parenchyma lesion than in the group of patients with clinically insignificant retinal changes (p < 0.05).

CONCLUSIONS

 The structure of retinal changes in patients with COVID-19 correlates with the severity of the clinical course of the disease and changes in the metabolic status of patients. Metabolic changes are correlated with retinal changes and can be predictive for preventing general vascular complications in COVID-19.

The spectrum of COVID-19-associated chorioretinal vasculopathy

Purpose

Although conjunctivitis represents the most common ocular manifestation of COVID-19 infection, sight-threatening retinal involvement has been reported. Herein, we report and characterize with multimodal retinal imaging 5 cases of acute vision loss secondary to presumed chorioretinal vasculopathy temporally associated with COVID-19 infection with varying severity, visual morbidity, and treatment response, and review the available literature on the association between COVID-19 infection and retinal microvascular changes.

Design

Observational case series and literature review.

Methods

Multicenter case series of 5 patients who presented to academic centers and private offices with acute vision loss temporally associated with COVID-19 infection. A review of the literature was conducted using online databases.

Results

10 eyes of 5 patients, 3 men and 2 women, with a mean age of 30.8 years (median 33, range 16-44) were described. All patients had a recently preceding episode of COVID-19, with symptomatology ranging from mild infection to life-threatening encephalopathy. Treatment for their retinal disease included topical, oral, intravitreal, and intravenous steroids, steroid-sparing immunosuppression, retinal photocoagulation, antivirals, and antiplatelet and anticoagulant agents. Treatment response and visual recovery ranged from complete recovery of baseline acuity to permanent vision loss and need for chronic immunosuppression.

Conclusions and Importance

Clinicians should be mindful of the potential for vision-threatening retinal involvement after COVID-19 infection. If found, treatment with both anti-inflammatory therapy and anticoagulation should be considered, in addition to close monitoring, as some patients with this spectrum of disease may require chronic immune suppression and/or anti-VEGF therapy.

Endogenous endophthalmitis in post-COVID-19 patients: a case report

Ocular involvement in coronavirus disease 2019 (COVID-19) can be due to direct viral invasion or indirectly due to an immunosuppressed state. Prolonged hospitalization also makes them susceptible to various secondary infections. The purpose of this case report is to report two rare cases of endogenous endophthalmitis (EE) in COVID-19 recovered patients.

CASE PRESENTATION

Two patients who were hospitalized and received treatment for COVID-19 pneumonia with remdesivir and systemic steroids presented with decreased vision. The first case had a severe anterior chamber reaction with a hypopyon and dense exudates in the vitreous. The second case had cells and flare in the anterior chamber and exudates in the vitreous. They were diagnosed with EE and underwent a diagnostic vitreous tap followed by pars plana vitrectomy and intravitreal antibiotic and steroid. The culture of vitreous fluid was negative for any bacteria and fungus in both cases. However, the first case demonstrated Escherichia coli in urine culture. The follow-up visual acuity was no perception of light and only perception of light in the first and second case, respectively.

CLINICAL DISCUSSION

Severe COVID-19 patients who are hospitalized, receive systemic steroid and have associated comorbidities like diabetes mellitus are at high risk of EE.

CONCLUSION

Delay in diagnosis and appropriate treatment in these patients leads to poor visual outcome.

Choroidal Microvascular Alterations in COVID-19 Patients

OBJECTIVE

To evaluate alterations in the choroidal angioarchitecture of COVID-19 patients using optical Coherence Tomography (OCT) based surrogate markers.

METHODS

This prospective case-control study recruited 56 COVID-19 patients (111 eyes) and 61 healthy individuals (120 eyes). Choroidal thickness (CT) and Choroidal vascularity index (CVI) were derived from OCT images using a purpose-built automated software for choroidal image segmentation. A linear mixed model with age and gender as covariates was employed to compare CVI and CT between groups.

RESULTS

COVID-19 patients had significantly higher subfoveal (81.3um vs 86.8um, p = .02), temporal (78.8um vs 84.3um, p = .005), nasal (87.5um vs 95.1um, p = .001) and average CT (82.5um vs 88.7um, p = .001). COVID-19 patients had significantly lower subfoveal (64.0 vs 63.5, p = .02) and average CVI (63.5 vs 63.1, p = .02).

CONCLUSION

COVID-19 results in significantly thicker choroid with reduced relative vascularity. This may be attributable to increased vascular permeability secondary to inflammation, resulting in choroidal stromal edema.

Retinal vascular occlusions in COVID-19 infection and vaccination: a literature review

PURPOSE

Abnormal hypercoagulability and increased thromboembolic risk are common in patients with coronavirus disease (COVID-19). COVID-19 has been suggested to cause retinal vascular damage, with several studies on COVID-19 patients with retinal vascular occlusions. We reviewed and investigated studies on retinal vascular occlusions in patients diagnosed with COVID-19 and in those vaccinated for COVID-19.

METHODS

Studies that reported retinal vascular occlusion in COVID-19 patients or in vaccinated people were identified using the terms "retinal occlusion," together with "severe acute respiratory syndrome coronavirus 2", "SARS-CoV-2," "COVID-19," "coronavirus," and "vaccine," through systematic searches of PubMed and Google Scholar databases until January 7, 2022.

RESULTS

Thirteen cases of retinal artery occlusion (RAO) and 14 cases of retinal vein occlusion (RVO) were identified among patients diagnosed with COVID-19. Half of the patients with RAO or RVO revealed no systemic disorders except current or past COVID-19, and ocular symptoms were the initial presentation in five cases. Among patients with RAO, most presented with central RAO at 1-14 days of COVID-19 diagnosis, with abnormal coagulation and inflammatory markers. Among those with RVO, two-thirds presented with central RVO and one-third with RVO. Eleven cases with acute macular neuroretinopathy (AMN) and/or paracentral acute middle maculopathy (PAMM) were reported among patients with COVID-19, presenting scotoma resolved spontaneously in most cases. Among the 26 cases vaccinated with either mRNA or adenoviral vector vaccines for COVID-19 and presenting retinal vascular occlusions, there were more RVO cases than RAO cases, and ocular symptoms mostly occurred within 3 weeks after vaccination. One case presented bilateral AMN and PAMM after COVID-19 vaccination.

CONCLUSION

Retinal vascular occlusions might be a manifestation of COVID-19, although rare, especially in patients at risk of systemic hypercoagulability and thromboembolism. For COVID-19 vaccines, the causal relationship is controversial because there are few case reports of retinal vascular occlusions after COVID-19 vaccination.

Alterations in the optic nerve and retina in patients with COVID-19. A theoretical review

The objective of this research is to identify and systematize the medical conditions generated by SARS-CoV-2 on the optic nerve and retina of young, adult, and elderly adults who suffered from COVID-19 in the period 2019-2022. A theoretical documentary review (TDR) was conducted within the framework of an investigation to determine the current state of knowledge of the subject under study. The TDR includes the analysis of publications in the scientific databases PubMed/Medline, Ebsco, Scielo and Google. A total of 167 articles were found, of which 56 were studied in depth, and these evidence the impact of COVID-19 infection on the retina and optic nerve of infected patients, both during the acute phase and in subsequent recovery. Among the reported findings, the following stand out: anterior and posterior non-arteritic ischemic optic neuropathy, optic neuritis, central or branch vascular occlusion, paracentral acute medial maculopathy, neuroretinitis, as well as concomitant diagnoses such as possible Vogt-Koyanagi-Harada disease, multiple evanescent white dot syndrome (MEWDS), Purtscher-like retinopathy, among others.

Evaluation of Retinal Vascularity Index in Patients with COVID-19: A Case-Control Study

INTRODUCTION

The purpose of this study was to evaluate the impact of COVID-19 infection on retinal microvasculature by topographically mapping the retinal arteriole-to-venule ratio (AVR).

METHODS

In a comparative cross-sectional case-control study, fundus photos were obtained in COVID-19-infected patients and healthy controls. AVT was measured over 16 points across the retina using retinal vascularity index (RVI)-a novel semi-automated computerized parameter based on retinal vasculature.

RESULTS

A total of 51 COVID-19-positive patients and 65 healthy controls were enrolled in the study. Overall, the mean RVI of all 16 points across the retina was 0.34 ± 0.02 in patients with COVID-19 and 0.33 ± 0.02 in control subjects (p = 0.64). Out of the 16 points being measured, three points had a statistically significant greater value in patients with COVID compared to normal controls.

CONCLUSION

Localised greater RVI values were found in some of the points in COVID-19-positive patients, which likely indicates a more focal change of the vasculature.

Long-term follow-up of choroidal changes following COVID-19 infection: analysis of choroidal thickness and choroidal vascularity index

OBJECTIVE

To investigate subclinical choroidal involvement in patients with systemic coronavirus disease 2019 (COVID-19) infection and evaluate its long-term course.

MATERIALS AND METHODS

This prospective, longitudinal study included 32 eyes of 16 COVID-19 patients and 34 eyes of 17 age-matched healthy control subjects. All the participants had a detailed ophthalmologic assessment, including visual acuity assessment, slit-lamp examination, and indirect ophthalmoscopy. Enhanced depth optical coherence tomography imaging of the posterior pole and peripapillary region was performed in the early (days 15-40) and late (ninth month) postinfectious periods. Choroidal vascularity index (CVI) was calculated using ImageJ software (National Institutes of Health, Bethesda, Md.).

RESULTS

None of the patients had any examination finding associated with the ocular involvement of COVID-19. Subfoveal choroidal thickness (SFCT) decreased significantly in the early postinfectious period compared with the healthy control individuals (p = 0.045). SFCT increased significantly in the late postinfectious period compared with the early period (p = 0.002), and the difference between patients and control individuals became statistically insignificant (p = 0.362). There was a similar trend for the peripapillary choroidal thickness measurements. CVI remained unchanged (p = 0.721) despite the significant decrease in SFCT and total choroidal area (p = 0.042), indicating that this decrease occurred both in choroidal stroma and in blood vessels. CVI remained unchanged in the late postinfectious period (p = 0.575) compared with the early period, indicating that recovery occurred in the entire choroidal tissue.

CONCLUSION

This study demonstrates that choroidal thickness was reduced in all measured areas and that this decrease affected all choroidal layers. This choroidopathy was reversible and recovered in the ninth postinfectious month.

Relationship of the main indicators of systemic COVID-associated endotheliopathy with the morphofunctional state and hemodynamics of the retina and chorioid in the acute period of the disease

BACKGROUND: Nonspecific angio- and retinopathy is one of the clinical manifestations of a new coronavirus infection. The frequency of occurrence of these changes in people with severe COVID-19 does not exceed 55%. The causes, course and consequences of these microcirculatory disorders of the retina are currently not well understood. AIM: To study and compare of retinal morphometric parameters and systemic endothelial dysfunction markers, as well as the main clinical and laboratory parameters in patients with moderate and severe coronavirus infection during convalescence. MATERIALS AND METHODS: The study involved 44 patients (86 eyes) who had COVID-19 during the previous 3 months, who were divided into 2 groups: with moderate and severe disease. The control group consisted of 18 healthy volunteers (36 eyes). All patients underwent a standard ophthalmological examination and optical coherence tomography, which included an assessment of the choroidal thickness (CT) and measurement of the mean diameter of the peripapillary arteries (MAD) and veins (MVD). During hospitalization, all patients underwent a laboratory study of venous blood parameters, as well as an assessment of the microcirculation of the sublingual plexus by examining the density of the endothelial glycocalyx (PBR) using the GlycoCheck. RESULTS: In patients who underwent COVID-19, there was a significant increase in CT relative to the control group, amounting to 308, 344 and 392 m, respectively. The most pronounced difference was observed between MVD in patients with severe infection and the control group (119.1 m vs. 99.2 m). In patients with moderate and severe COVID-19, MAD and MVD were positively correlated with TC, with r = 0.389 and r = 0.584, respectively. MVD also correlated with the level of leukocytes (r = 0.504), the ESR value (r = 0.656). Correlations between MVD and data characterizing the state of the glycocalyx in the sublingual vascular plexus were revealed: the filling of small capillaries with erythrocytes (r = 0.587), as well as the marginal perfusion value in large capillaries 2025 m (r = 0.479) and PBR (r = 0.479). Only significant differences and correlations are shown (p 0.005). CONCLUSIONS: In patients who underwent moderate and severe COVID-19 during the convalescence period (up to 30 days), an increase in the diameter of peripapillary vessels and TC is observed, proportional to the severity of COVID-19, laboratory markers of systemic inflammation and hypercoagulation (the number of leukocytes, the ESR value, D-dimer and prothrombin), which indicates the inflammatory nature of the changes. The severity of postcovid retinal microangiopathy correlates with indicators detecting a decreasing of the endothelial glycocalyx thickness in the sublingual capillary plexus, which indirectly indicates a connection with systemic endotheliopathy.

COVID-19-associated retinovasculitis in the late stage of HIV infection: a clinical case

A clinical case of retinovasculitis with coronavirus infection COVID-19 involving a female patient in the late stage of HIV infection is reported. The patient had no antiretroviral therapy. Clinical features of eye changes, their severity and dynamics influenced by the ophthalmic therapy were revealed. A relationship between the course of COVID-19 and the state of immunodeficiency causes by HIV was found. As a result of the long disease duration and the complications, the patient died.

Direct, indirect, post-infection damages induced by coronavirus in the human body: an overview

Background

Severe acute respiratory syndrome Coronavirus-2 invades the cells via ACE2 receptor and damages multiple organs of the human body. Understanding the pathological manifestation is mandatory to endure the rising post-infection sequel reported in patients with or without comorbidities.

Materials and methods

Our descriptive review emphasises the direct, indirect and post-infection damages due to COVID-19. We have performed an electronic database search according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines with selective inclusion and exclusion criteria.

Results

The included studies substantiated the extensive damages in the multiple organs due to direct and indirect consequences of COVID-19. After an apparent recovery, the prolonged presentation of the symptoms manifests as post-COVID that can be related with persisting viral antigens and dysregulated immune response.

Conclusion

A few of the symptoms of respiratory, cardiovascular, and neuropsychiatric systems that persist or reappear as post-COVID manifestations. Vaccination and preventive programs will effectively reduce the prevalence but, the post-COVID, a multisystem manifestation, will be a significant tribulation to the medical profession. However, the issue can be managed by implementing public health programs, rehabilitation services, and telemedicine virtual supports to raise awareness and reduce panic.

Bilateral Conjunctivitis, Keratitis, and Anterior Uveitis in a Patient Co-infected with Parvovirus B19 and SARS-CoV-2

Parvovirus B-19 (B19V) is a common infection in children, occasionally complicated by ocular manifestations. In patients infected with severe acute respiratory syndrome virus (SARS-CoV-2), many cases of bacterial, fungal, and viral co-infections have been described. We report on a case of bilateral conjunctivitis, keratitis, and anterior uveitis that occurred in a patient co-infected by B19V and SARS-CoV-2. A young nurse developed, 20 days after the onset of asthenia and fever, a maculopapular rash and, in the following month, B19V-related arthritis. Shortly after a course of antibiotics and corticosteroids and the resolution of the arthritis, she began to complain of hearing loss and tinnitus. A polymerase chain reaction for SARS-CoV-2, previously negative, turned out positive; IgM for B19V decreased while IgG increased and antinuclear autoantibody and rheumatoid factor test results were positive. Ear symptoms disappeared after a course of prednisone, but eye burning and itching appeared 2 weeks after the coronavirus disease 2019 (COVID-19) positive swab. Bilateral conjunctivitis, keratitis, and anterior uveitis were diagnosed, which responded completely to a topical corticosteroid and mydriatic therapy. No relapses were observed in the following 12 months. The onset and progression of the symptoms, along with the laboratory findings, suggest a double pathogenesis of the ocular manifestations: keratitis and uveitis, along with the ear symptoms, seem to be the expression of an autoimmune reaction to B19V infection, while the conjunctivitis was likely related to direct infection of the conjunctiva by SARS-CoV-2.

Retinal Microvascular Changes in COVID-19 Bilateral Pneumonia Based on Optical Coherence Tomography Angiography

The purpose of this study was to evaluate retinal and choroidal microvascular alterations with optical coherence tomography angiography (OCTA) in COVID-19 patients hospitalized because of bilateral pneumonia caused by SARS-CoV-2. The vessel density (VD) and foveal avascular zone (FAZ) of 63 patients with SARS-CoV-2 pneumonia who had positive polymerase chain reaction (PCR) tests and who recovered after receiving treatment and 45 healthy age- and gender-matched controls were evaluated and compared using OCTA in the superficial capillary plexus (SCP) and deep capillary plexus (DCP). The VD was also estimated in both groups in the choriocapillaris (CC). In COVID-19 patients, there was a statistically significant difference between the patients and a control group in both superficial (FAZs) and deep (FAZd) avascular zone (p = 0.000). The VD was significantly lower in the foveal area in choriocapillaris (p = 0.046). There were no statistically significant changes in the VD in the superior, inferior, nasal, and temporal quadrants in superficial and deep plexus, or in the choriocapillaris. The VD was not significantly lower in the foveal area in superficial or deep plexus. COVID-19 may affect the retinal vasculature, causing ischemia, enlargement of the FAZ, and lowering of the VD in the choriocapillaris area. Routine ophthalmic examination after SARS-CoV-2 infection should be considered in the course of post-infectious rehabilitation.

Use of Imaging Technology to Assess the Effect of COVID-19 on Retinal Tissues: A Systematic Review

PURPOSE

To evaluate the effect of COVID-19 on retinal tissues by conducting a systematic review and meta-analysis of the current literature.

BACKGROUND

The novel coronavirus disease is not yet well understood. The orbit provides a window into the body's microvasculature, and as such, it is a non-invasive opportunity to analyse the systemic circulation in vivo. By analysing the current literature, we test the hypothesis that non-invasive imaging of the retina could provide insight into the effect of COVID-19 on the retinal microvasculature.

METHODS

For this systematic review and meta-analysis, we screened PubMed databases and LitCOVID19 using the search criteria: (OCTA or Optical Coherence Tomography Angiography) AND (COVID-19 or corona or SARS-CoV-2) AND (retina or fundus). Databases were searched on 11 January 2022. The primary study outcomes were studies that utilised OCTA to analyse the retina; secondary outcomes involved studies that involved other imaging modalities such as OCT, fundus photography, and fundus autofluorescence.

FINDINGS

The total number of studies included in this review was 32. Optical coherence tomography angiography scans show reduced central retinal vascular density, a thinner ganglion cell layer, a thicker retinal nerve fibre layer, and an enlarged foveal avascular zone. Optical coherence tomography scans demonstrate a thicker central macular thickness and other changes to the macula, ganglion cell, and inner nuclear layers. Many fundus photographs depicted cotton wool spots, microhaemorrhages, and vascular occlusions. Non-invasive imaging technology has demonstrated that COVID-19 can profoundly affect the retina. Therefore, there is a requirement for long-term follow-up of COVID-19 patients to assess whether the retinal damage caused by COVID-19 is reversible.

Retinal Findings of Hospitalized Neonates Recovered from COVID-19 Infection: A Prospective, Observational, Descriptive Study

PURPOSE

Coronavirus disease 2019 (COVID-19) that is caused by severe acute respiratory syndrome coronavirus 2 can cause microvascular alterations that can lead to irreversible complications in multiple tissues and organs. Detrimental effects of COVID-19 on retinal structure have recently been reported in adult population. However, literature data about neonatal population is very scarce. Thus, we aimed to assess possible retinal changes of neonates recovered from COVID-19 infection in this prospective, observational, descriptive study.

METHODS

The neonates recovered from COVID-19 infection were included to the study between 01 September 2020 and 30 April 2021. Their initial ophthalmological examination was made after a negative real-time reverse transcription-polymerase chain reaction obtained and all patients were re-examined 1 month later. All examinations were performed by same retina specialist using a binocular indirect ophthalmoscopy.

RESULTS

A total of 15 neonates [9 (60%) male, 6 (40%) female, mean gestational age of 38.9 ± 0.9 weeks (ranging from 37 to 40 week)] were evaluated in the study. The mean age at the time of hospitalization was 17.5 ± 8.7 days (ranging from 2 to 29 days), and the mean duration of hospitalization was 12.5 ± 6.2 days (ranging from 4 to 27 days). Except for one patient with bilateral avascular area in Zone-III, no further retinal manifestation related to COVID-19 was found in the study.

CONCLUSION

COVID-19 infection can cause retinal damage in neonates. Therefore, these patients should be closely monitored for signs of ocular involvement.

Non-arteritic Anterior Ischemic Optic Neuropathy with Macular Star following COVID-19 Vaccination

PURPOSE

To report a case of non-arteritic anterior ischemic optic neuropathy (NAAION) with macular star after receiving the second dose of SARS-CoV-2 vaccination.

METHOD

Case report.

OBSERVATION

A 51-year-old male presented with acute visual disturbances one day after the second dose of BNT162b2 mRNA SARS-CoV-2 vaccination. At presentation, best corrected visual acuity (BCVA) was 20/25 right eye (OD) and counting fingers at 3 feet left eye (OS). Anterior segment examination was normal in both eyes. Dilated fundoscopy was unremarkable OD, however, it disclosed optic nerve swelling and subretinal fluid OS. Patient was treated with a gradual tapering dose of oral prednisone over 1 month. At the five-week follow-up visit, optic disc swelling and subretinal fluid resolved with minimal improvement in BCVA to 20/400 OS.

CONCLUSION

It is unclear whether COVID-19 vaccination was the triggering agent to the NAAION or just a coincidence, yet ophthalmologists should be aware of such a possible association.

Longitudinal Alterations of Retinal and Choroidal Structure in Patients Recovered from COVID-19

Objective

To evaluate the midterm longitudinal changes in chorioretinal structures in patients with coronavirus disease 2019 (COVID-19).

Methods

Thirty-four eyes of 17 COVID-19 patients were enrolled. The patients underwent retinal and choroidal imaging upon the recovery (baseline) after 1 and 3 months. Retinal measurements in fovea, parafovea, and perifovea were recorded. To calculate choroidal vascularity index (CVI), luminal and total choroidal areas were measured using Sonada's method. Choroidal thickness was measured at the subfovea 500 microns temporal and nasal to the fovea.

Results

Mean CVI was 0.64 ± 0.04 at baseline that significantly increased to 0.67 ± 0.05 (P = 0.012) after 1 month and again significantly decreased to 0.63 ± 0.05 after 3 months (P < 0.001). While the stromal component showed a significant decrease between the baseline and first-month values (1.16 ± 0.29 to 1.01 ± 0.27, P = 0.03), the luminal area mostly changed between months 1 and 3 (2.03 ± 0.28 to 1.91 ± 0.23, P = 0.045). The average of subfoveal choroidal thickness and retinal thickness remained unchanged.

Conclusion

CVI is increased in patients with COVID-19 1 month after recovery from COVID-19 and returns to baseline values after 3 months. Regarding the reversible nature of changes, there might be a prominent role in inflammation.

CHARACTERIZING COVID-19-RELATED RETINAL VASCULAR OCCLUSIONS: A Case Series and Review of the Literature

PURPOSE

To describe clinical and ophthalmologic features and outcomes of patients with coronavirus disease-19 with retinal vascular occlusions.

METHODS

Retrospective multicenter case series and PubMed review of cases reported from March 2020 to September 2021. Outcome measures are as follows: type of occlusion, treatments, best-corrected visual acuity, and central macular thickness on optical coherence tomography.

RESULTS

Thirty-nine patients were identified. Fifteen patients with a median age of 39 (30-67) years were included in the multicenter study. Vascular occlusions included central retinal vein occlusion (12 eyes), branch retinal vein occlusion (4 eyes), and central retinal artery occlusion (2 eyes). Three cases were bilateral. Baseline best-corrected visual acuity was 20/45 (no light perception-20/20). Baseline central macular thickness was 348.64 (±83) μm. Nine eyes received anti-vascular endothelial growth factor agents, dexamethasone intravitreal implant, or both. Final best-corrected visual acuity was 20/25 (no light perception-20/20), and central macular thickness was 273.7 ± 68 μm (follow-up of 19.6 ± 6 weeks). Among the 24 cases from the literature review, retinal vein occlusion was the predominant lesion. Clinical characteristics and outcomes were similar to those found in our series.

CONCLUSION

Coronavirus disease-19-associated retinal vascular occlusions tend to occur in individuals younger than 60 years. Retinal vein occlusion is the most frequent occlusive event, and outcomes are favorable in most cases.

COVID-19-Related Retinal Micro-vasculopathy - A Review of Current Evidence

PURPOSE

To evaluate the occurrence of retinal microvasculopathy in patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and who developed coronavirus disease (COVID-19).

DESIGN

Systematic review and meta-analysis.

METHODS

The Pubmed and Embase databases were comprehensively searched to identify studies that reported retina vascular changes in eyes with COVID-19. Two independent reviewers selected papers and extracted data for analysis. Data of interest were extracted and analyzed in RevMan Web versions 3.3. Quality of evidence was assessed using the National Institute of Health quality assessment tool for a case-control study.

RESULTS

Thirty-one studies reporting on 1373 subjects (972 COVID-19 and 401 controls) were included. Only case-control studies were included in the pooled analysis. There was a significantly higher likelihood of retinal microvasculopathy in subjects with COVID-19 compared to controls (odds ratio [95% confidence interval], 8.86 [2.54-27.53], P < .01). Optical coherence tomography angiography (OCTA) revealed reduced vessel density and enlarged foveal avascular zone in subjects with COVID-19 compared to controls.

CONCLUSIONS

The results suggested that COVID-19-related retinal microvasculopathy is a significant ocular manifestation of COVID-19 and may herald future retinal complications. These microvascular impairments might have occurred antecedent to clinically visible changes and could be detected earlier by OCTA. These findings are significant, due to the large numbers with COVID-19, and need to be recognized by ophthalmologists as a potential long-term sequalae of the disease.

Retinal nerve fibre layer and ganglion cell layer changes in children who recovered from COVID-19: a cohort study

OBJECTIVE

To investigate the optic nerve and macular parameters of children who recovered from COVID-19 compared with healthy children using optical coherence tomography (OCT).

DESIGN

Cohort study.

SETTING

Hospital Clinico San Carlos, Madrid.

PATIENTS

Children between 6 and 18 years old who recovered from COVID-19 with laboratory-confirmed SARS-CoV-2 infection and historical controls were included.

INTERVENTIONS

All patients underwent an ophthalmological examination, including macular and optic nerve OCT. Demographic data, medical history and COVID-19 symptoms were noted.

MAIN OUTCOME MEASURES

Peripapillary retinal nerve fibre layer thickness, macular retinal nerve fibre layer thickness, macular ganglion cell layer thickness and retinal thickness.

RESULTS

90 patients were included: 29 children who recovered from COVID-19 and 61 controls. Patients with COVID-19 presented an increase in global peripapillary retinal nerve fibre layer thickness (mean difference 7.7; 95% CI 3.4 to 12.1), temporal superior (mean difference 11.0; 95% CI 3.3 to 18.6), temporal inferior (mean difference 15.6; 95% CI 6.5 to 24.7) and nasal (mean difference 9.8; 95% CI 2.9 to 16.7) sectors. Macular retinal nerve fibre layer analysis showed decreased thickness in the nasal outer (p=0.011) and temporal inner (p=0.036) sectors in patients with COVID-19, while macular ganglion cell layer thickness increased in these sectors (p=0.001 and p=0.015, respectively). No differences in retinal thickness were noted.

CONCLUSIONS

Children with recent history of COVID-19 present significant changes in peripapillary and macular OCT analyses.

Two Cases of Acute Macular Neuroretinopathy Associated with the Adenovirus-based COVID-19 Vaccine Vaxzevria (Astrazeneca)

PURPOSE

To report two cases of acute macular neuroretinopathy (AMN) in young female patients following the administration of the adenovirus-based coronavirus disease 2019 (COVID-19) vaccine Vaxzevria (AstraZeneca).

METHODS

Spectral-domain optical coherence tomography and infrared imaging were used to confirm the diagnosis of AMN.

RESULTS

Both patients showed a parafoveal hyperreflective band in the outer nuclear layer, disruption of the ellipsoid and interdigitation zones of the photoreceptor layers, and correlating hyporeflective areas on the near-infrared images. Both patients presented with flu-like fever and sudden onset of fortifications within 48 hours of vaccination. One patient showed altered flow in the deep capillary plexus and highly elevated thrombotic parameters.

CONCLUSION

We report a possible association between immune-mediated AMN and the administration of adenovirus-based COVID-19 vaccine Vaxzevria.

Non-invasive brain microcurrent stimulation therapy of long-COVID-19 reduces vascular dysregulation and improves visual and cognitive impairment

BACKGROUND

An effective treatment is needed for long-COVID patients which suffer from symptoms of vision and/or cognition impairment such as impaired attention, memory, language comprehension, or fatigue.

OBJECTIVE

Because COVID-19infection causes reduced blood flow which may cause neuronal inactivation, we explored if neuromodulation with non-invasive brain stimulation using microcurrent (NIBS), known to enhance blood flow and neuronal synchronization, can reduce these symptoms.

METHODS

Two female long-COVID patients were treated for 10-13 days with alternating current stimulation of the eyes and brain. While one patient (age 40) was infected with the SARS CoV-2 virus, the other (age 72) developed symptoms following AstraZeneca vaccination. Before and after therapy, cognition was assessed subjectively by interview and visual fields quantified using perimetry. One patient was also tested with a cognitive test battery and with a retinal dynamic vascular analyser (DVA), a surrogate marker of vascular dysregulation in the brain.

RESULTS

In both patients NIBS markedly improved cognition and partially reversed visual field loss within 3-4 days. Cognitive tests in one patient confirmed recovery of up to 40-60% in cognitive subfunctions with perimetry results showing stable and visual field recovery even during follow-up. DVA showed that NIBS reduced vascular dysregulation by normalizing vessel dynamics (dilation/constriction), with particularly noticeable changes in the peripheral veins and arteries.

CONCLUSIONS

NIBS was effective in improving visual and cognitive deficits in two confirmed SARS-COV-2 patients. Because recovery of function was associated with restoration of vascular autoregulation, we propose that (i) hypometabolic, "silent" neurons are the likely biological cause of long-COVID associated visual and cognitive deficits, and (ii) reoxygenation of these "silent" neurons provides the basis for neural reactivation and neurological recovery. Controlled trials are now needed to confirm these observations.

Posterior segment manifestations and imaging features post-COVID-19

Background

To report the posterior segment (uvea and retinal) manifestations and imaging characteristics of eyes of patients with and after coronavirus disease 2019 (COVID-19).

Methods

We searched the PubMed/MEDLINE database to identify relevant articles using the following search terms: COVID-19, SARS-CoV-2, retina, uvea, optic nerve, retinal findings, posterior segment manifestations, and endophthalmitis. Articles published from December 1, 2019, to May 30, 2021, and indexed in PubMed/ MEDLINE were screened.

Results

For the purpose of this review, we included clinical features of 26 case reports and 8 case series. The posterior segment manifestations reported included cotton wool spots, retinal hemorrhages, central serous retinopathy, papillophlebitis, optic neuritis, panuveitis, multifocal retinitis, necrotizing retinitis, central retinal artery/vein occlusion, and Purtschner like retinopathy. In this review, we have also included optical coherence tomography angiography (OCTA) features that have been described in COVID-19 patients with pneumonia.

Conclusions

COVID-19 patients can experience uveo-retinal manifestations even after recovery. These patients, even if asymptomatic for eye symptoms, should undergo an eye evaluation to rule out posterior segment involvement. OCTA performed in these patients revealed microvascular changes in the superficial and deep retinal plexuses. Some of these patients may require anticoagulant or antiplatelet therapy.

Ocular manifestations in COVID-19 patients: A systematic review and meta-analysis

Introduction

With the accumulating evidence of ocular manifestations of the 2019 novel coronavirus disease (COVID-19), the study aimed to systematically summarize the ocular manifestations in COVID-19 patients.

Methods

The PubMed, EMBASE, Web of Science databases were searched through June 2021. Studies that provided clinical characteristics and outcomes and reported on the ocular manifestations or conjunctival swab RT-PCR tests among COVID-19 patients were included.

Results

A total of 30 studies involving 5,717 patients were identified. Ocular manifestations including conjunctival hyperemia (7.6%, 95% confidence interval [CI] 1.8–8.9%), conjunctival discharge (4.8%, 95% CI 1.8–8.9%), epiphora (6.9%, 95% CI 2.8–12.8%), and foreign body sensation (6.9%, 95% CI 2.4–13.0%) were observed. The positive rate of conjunctival swab tests was 3.9% (95% CI 0.2–6.4%). Severe cases of COVID-19 were associated with an increased risk of developing ocular complications (odds ratio [OR] = 2.77, 95% CI 1.75–4.40).

Conclusions

Despite their relatively low incidence rate in COVID-19 patients, ocular manifestations may be non-specific and present as the initial symptoms of infection. The presence of SARS-CoV-2 in the conjunctival swabs implicates the eye as a potential source of infection. Early diagnosis and proper eye protection would help prevent viral transmission.

[Bilateral central serous chorioretinopathy post-COVID-19]

La maladie à virus corona (COVID-19) peut provoquer de nombreuses manifestations oculaires. Nous rapportons un cas rare de choriorétinopathie séreuse centrale bilatérale, post-infection au COVID-19, chez une femme âgée de 38 ans qui s’est présentée pour un flou visuel bilatéral, 1 mois après l’infection au COVID-19. Elle avait de la fièvre, des frissons, une toux et un essoufflement avec fatigue et elle était positive au COVID-PCR. Pendant son séjour de 10 jours à l’hôpital, elle a reçu une oxygénothérapie, des antibiotiques, de l’héparine et des corticoïdes par voie intraveineuse puis relais par voie orale en ambulatoire. Après sa guérison du COVID-19, la patiente a développé une baisse progressive de l’acuité visuelle des 2 yeux : son acuité visuelle de loin corrigée était de 3/10 dans les 2 yeux, le segment antérieur était normal et le vitré était clair. L’examen du fond d’œil, complété par la tomographie en cohérence optique et l’angiographie à la fluorescéine a montré des décollements séreux rétiniens bilatéraux. L’évolution a été marquée par une amélioration de l’acuité visuelle et une régression des décollements séreux rétiniens. La choriorétinopathie séreuse centrale peut survenir après une infection au COVID-19 en raison de l’administration des corticoïdes et un contrôle ophtalmologique précoce est indispensable pour dépister au plus tôt une atteinte oculaire.

Retinal and choroidal manifestations of COVID-19

PURPOSE OF REVIEW

The novel coronavirus disease in 2019 (COVID-19) has a wide range of systemic manifestations. Ocular manifestations are now well recognized, with conjunctivitis being the most common. Posterior segment involvement is uncommon and has mainly been described in case reports. This review provides an overview of the posterior segment involvement of COVID-19.

RECENT FINDINGS

Severe acute respiratory syndrome coronavirus 2 affects the retina and the choroid through either direct entry or triggering an indirect inflammatory response. Majority of the retinal findings is a result of microvascular derangement leading to cotton wool spots, intraretinal hemorrhages, paracentral acute middle maculopathy, acute macular neuroretinopathy, or retinal vein occlusions. Rarely, inflammation involving the retina or the choroid, or reactivation of previously quiescent uveitis, can be seen.

SUMMARY

It is important to recognize the possible correlation between ophthalmic conditions and COVID-19 as it can aid in diagnosis, management, and mitigation of the disease.

COVID-19 as a new risk factor for the development of acute vascular diseases of the optic nerve and retina

The new coronavirus disease (COVID-19) is a viral respiratory infection accompanied by systemic endotheliitis. COVID-19 patients usually encounter changes related to hypercoagulability, hypofibrinolysis, and increased intravascular platelet aggregation. There is also a vascular wall thromboresistance decrease and impaired vasomotor function, which significantly increase the risk of thromboembolic complications. Currently, pathogenic aspects of the relationship between COVID-19 and vascular and inflammatory conditions of the optic nerve and retina are actively investigated. One of the triggers of impaired blood flow in ocular vessels may be a perfusion pressure decrease, observed in the acute period of the infectious process. This is related to both COVID-19 clinical course features and to resuscitation specificity as well. Secondary autoimmune inflammation is being considered as a mechanism of damage to the vascular wall in the post-infectious period. In this publication, possible pathogenic links of these diseases are considered for the first time in a specific context of the example of ischemic optic neuropathy associated with coronavirus infection.

Acute-onset central serous retinopathy after immunization with COVID-19 mRNA vaccine

Purpose

We report the case of a 33-year-old male who presented with unilateral central serous retinopathy three days after the injection of a COVID-19 vaccine.

Observations

A 33-year-old healthy Hispanic male referred to the ophthalmology service due to blurry vision and metamorphopsia in the right eye without any flashes, floaters, eye redness or pain. The patient reported that 69 hours prior to presentation he received the first dose of the Pfizer-BioNTech BNT162b2 mRNA COVID-19 vaccine. He denied any past ocular history or pertinent medical history. He does not take any medicines and denies stressful factors in his life. The clinical examination and imaging tests were consistent with central serous retinopathy that resolved in three months.

Conclusions and importance

This is the first report of an ocular complication potentially associated with a COVID-19 vaccination. Our case contributes information of a side effect potentially related to this new vaccine.

Expression of the SARS-CoV-2 Receptor ACE2 in Human Retina and Diabetes-Implications for Retinopathy

Purpose

To investigate the expression of angiotensin-converting enzyme 2 (ACE2), the receptor for SARS-CoV-2 in human retina.

Methods

Human post-mortem eyes from 13 non-diabetic control cases and 11 diabetic retinopathy cases were analyzed for the expression of ACE2. To compare the vascular ACE2 expression between different organs that involve in diabetes, the expression of ACE2 was investigated in renal specimens from nondiabetic and diabetic nephropathy patients. Expression of TMPRSS2, a cell-surface protease that facilitates SARS-CoV-2 entry, was also investigated in human nondiabetic retinas. Primary human retinal endothelial cells (HRECs) and primary human retinal pericytes (HRPCs) were further used to confirm the vascular ACE2 expression in human retina.

Results

We found that ACE2 was expressed in multiple nonvascular neuroretinal cells, including the retinal ganglion cell layer, inner plexiform layer, inner nuclear layer, and photoreceptor outer segments in both nondiabetic and diabetic retinopathy specimens. Strikingly, we observed significantly more ACE2 positive vessels in the diabetic retinopathy specimens. By contrast, in another end-stage organ affected by diabetes, the kidney, ACE2 in nondiabetic and diabetic nephropathy showed apical expression of ACE2 tubular epithelial cells, but no endothelial expression in glomerular or peritubular capillaries. Western blot analysis of protein lysates from HRECs and HRPCs confirmed expression of ACE2. TMPRSS2 expression was present in multiple retinal neuronal cells, vascular and perivascular cells, and Müller glia.

Conclusions

Together, these results indicate that retina expresses ACE2 and TMPRSS2. Moreover, there are increased vascular ACE2 expression in diabetic retinopathy retinas.

Retinopathy and Systemic Disease Morbidity in Severe COVID-19

PURPOSE

To assess the prevalence of retinopathy and its association with systemic morbidity and laboratory indices of coagulation and inflammatory dysfunction in severe COVID-19.

DESIGN

Retrospective, observational cohort study.

METHODS

Adult patients hospitalized with severe COVID-19 who underwent ophthalmic examination from April to July 2020 were reviewed. Retinopathy was defined as one of the following: 1) Retinal hemorrhage; 2) Cotton wool spots; 3) Retinal vascular occlusion. We analyzed medical comorbidities, sequential organ failure assessment (SOFA) scores, clinical outcomes, and laboratory values for their association with retinopathy.

RESULTS

Thirty-seven patients with severe COVID-19 were reviewed, the majority of whom were female (n = 23, 62%), Black (n = 26, 69%), and admitted to the intensive care unit (n = 35, 95%). Fourteen patients had retinopathy (38%) with retinal hemorrhage in 7 (19%), cotton wool spots in 8 (22%), and a branch retinal artery occlusion in 1 (3%) patient. Patients with retinopathy had higher SOFA scores than those without retinopathy (8.0 vs. 5.3, p = .03), higher rates of respiratory failure requiring invasive mechanical ventilation and shock requiring vasopressors (p < .01). Peak D-dimer levels were 28,971 ng/mL in patients with retinopathy compared to 12,575 ng/mL in those without retinopathy (p = .03). Peak CRP was higher in patients with cotton wool spots versus those without cotton wool spots (354 mg/dL vs. 268 mg/dL, p = .03). Multivariate logistic regression modeling showed an increased risk of retinopathy with higher peak D-dimers (aOR 1.32, 95% CI 1.01-1.73, p = .04) and male sex (aOR 9.6, 95% CI 1.2-75.5, p = .04).

CONCLUSION

Retinopathy in severe COVID-19 was associated with greater systemic disease morbidity involving multiple organs. Given its association with coagulopathy and inflammation, retinopathy may offer insight into disease pathogenesis in patients with severe COVID-19.

Retinal manifestations in patients following COVID-19 infection: A consecutive case series

Purpose

To describe retinal manifestations seen in patients associated with COVID-19 infection at a multi-specialty tertiary care hospital in Southern India.

Methods

In this retrospective chart review, all consecutive cases presenting to the Retina-Uveitis service from May 2020 to January 2021 with retinal manifestations associated with COVID-19 infection or its sequelae or as a result of treatment given for COVID-19 were included.

Results

: Of the 7 patients, 3 were female, and 4 were male. Four patients had onset of symptoms during the active phase of COVID-19 infection. Four had bilateral and three had unilateral involvement. The manifestations ranged from mild to vision threatening. Vision threatening manifestations included infections: endogenous endophthalmitis, candida retinitis and tubercular choroidal abscess and bilateral pre-foveal hemorrhages. Milder manifestations included paracentral acute middle maculopathy, central serous chorio-retinopathy and voriconazole induced visual symptoms. Final visual acuity was 6/36 or better in the four severe cases and 6/9 or better in the mild cases.

Conclusion

This study highlights the retinal manifestations associated with COVID-19 infection and its sequelae. As these patients presented with an association with COVID-19 (either during or after recovery), ophthalmologists should be vigilant and screen for such entities in case of complaints of visual symptoms or in the presence of systemic sepsis. The outcomes can be good with prompt and aggressive management.

Low Visual Acuity Due to Acute Macular Neuroretinopathy Associated with COVID-19: A Case Report

Patient: Female, 71-year-old

Final Diagnosis: Acute macular neuroretinopathy

Symptoms: Anosmia • loss of vision

Medication: —

Clinical Procedure: —

Specialty: Ophthalmology

How to Manage COVID-19 Vaccination in Immune-Mediated Inflammatory Diseases: An Expert Opinion by IMIDs Study Group

Since March 2020, the outbreak of Sars-CoV-2 pandemic has changed medical practice and daily routine around the world. Huge efforts from pharmacological industries have led to the development of COVID-19 vaccines. In particular two mRNA vaccines, namely the BNT162b2 (Pfizer-BioNTech) and the mRNA-1273 (Moderna), and a viral-vectored vaccine, i.e. ChAdOx1 nCoV-19 (AstraZeneca), have recently been approved in Europe. Clinical trials on these vaccines have been published on the general population showing a high efficacy with minor adverse events. However, specific data about the efficacy and safety of these vaccines in patients with immune-mediated inflammatory diseases (IMIDs) are still lacking. Moreover, the limited availability of these vaccines requires prioritizing some vulnerable categories of patients compared to others. In this position paper, we propose the point of view about the management of COVID-19 vaccination from Italian experts on IMIDs and the identification of high-risk groups according to the different diseases and their chronic therapy.

Ophthalmic Screening in Patients with Coronavirus Disease 2019: A Prospective Cohort Study

Postmortem pathological examinations, animal studies, and anecdotal reports suggest that coronavirus disease 2019 (COVID-19) could potentially affect intraocular tissue. However, published evidence is scarce and conflicting. In our study, we screened 100 eyes of 50 patients hospitalized for COVID-19. Relevant medical and ophthalmological history was assessed as well as symptoms, laboratory results, specific treatments, clinical course, and outcome. Ophthalmic exams including assessment of best corrected visual acuity (BCVA), intraocular pressure (IOP), color perception, ocular motility, ophthalmoscopy as well as optical coherence tomography (OCT) of the macula and the optic disc was performed at hospital admission and 29 to 192 days later. Of the 50 patients included, 14 (28%) were female. Median age was 64.5 (range 29–90) years. COVID-19 severity was mild in 15 (30%), severe in 30 (60%), and critical in five cases (10%). At baseline, median BCVA was 0.1 (0–1.8) Logarithm of the Minimum Angle of Resolution (LogMAR) and median IOP was 16 (8–22) mmHg. At follow-up, no relevant changes in BCVA and IOP were documented. No signs of active intraocular inflammation or optic nerve affection were found and OCT findings were widely stable during the observation period. Our findings suggest that COVID-19 does not regularly affect intraocular tissue.