Retinal Manifestations of Covid 19

From EyeWiki


Introduction

The coronavirus disease 2019 (COVID-19) pandemic is an ongoing global health crisis that is caused by the acute respiratory syndrome coronavirus 2 (SARS-CoV-2).[1] As of March 12, 2022, there have been over 450 million confirmed cases of COVID-19 and over 6 million deaths around the world. Although most research and therapeutic efforts are directed toward the respiratory complications of the disease, COVID-19 can also lead to significant ophthalmic manifestations.[2] The most commonly reported of these is conjunctivitis,[3] which in some patients may be the only manifestation of SARS-CoV-2 infection.[4] While eyelid, ocular surface, and anterior segment manifestations of COVID-19 are well documented, posterior segment involvement is less common and has mainly been described in the form of case reports.[5] In this article, we will provide an overview of the most commonly reported retinal manifestations of COVID-19.

Retinal Manifestations of COVID-19

Microvascular Changes

The most common retinal manifestations of COVID-19 are microvascular changes like cotton wool spots and retinal microhemorrhages. Many of these patients had preserved visual acuity and pupillary reflexes,[6] but there have also been instances where patients developed visual field defects.[7] The SARS-CoV-2 infection has also been associated with new-onset paracentral acute middle maculopathy (PAMM) and acute macular neuroretinopathy (AMN), although a true relationship between these conditions and COVID-19 has yet to be established.[8] Increased tortuosity of retinal vessels is another finding that has been documented in patients with COVID-19.[9] However, many of these retinal findings can also be seen in septic patients and patients with conditions like diabetic retinopathy, making it difficult to establish a true causal relationship between SARS-CoV-2 infection and microvascular retinal changes.[10]

Retinal Vein Occlusion

Central retinal vein occlusion (CRVO) has been identified as an important complication of COVID-19, as early detection and treatment are necessary for improved prognosis. SARS-CoV-2 infection is known to cause endothelial disruption, complement activation, and inflammation, leading to a hypercoagulable state that increases the risk of thrombus formation.[11] Decreased vision and blurred vision are the most common presenting symptoms of CRVO and can start anytime from 5 days to 6 weeks after the initial onset of fever.[12] Although CRVO is classically associated with risk factors like age, hypertension, glaucoma, and diabetes, COVID-19 has been shown to have a causal relationship with CRVO irrespective of patient age or comorbidities.[12] Because timely diagnosis and management are crucial for vision preservation, clinicians should be vigilant about monitoring for signs of CRVO in patients with a history of COVID-19.

Retinal Artery Occlusion

Central retinal artery occlusion (CRAO) is a medical emergency that can lead to complete vision loss if not treated promptly and has also been documented in the context of SARS-CoV-2 infection. In case reports, patients developed sudden, unilateral, and painless vision loss two to six weeks after the initial onset of COVID-19 symptoms and were found to have mild-to-significant retinal whitening on fundus exam.[13] However, it is important to note that most of these patients had additional underlying conditions like hypertension, obesity, and coronary artery disease, which may have placed them at a higher risk of developing CRAO. Regardless, because rapid identification and treatment are necessary to restore visual acuity, clinicians should consider CRAO in patients with a history of COVID-19 who present with sudden and painless vision loss.

Acute Macular neuroretinopathy

Conclusion

While there are many case reports documenting retinal changes in the setting of COVID-19, the presence of additional comorbidities and their effects on the retina cannot be excluded. Despite this, clinicians should still be aware of and assess for the retinal manifestations of SARS-CoV-2 infection to prevent any vision-threatening complications. Future studies to investigate whether these documented retinal changes are truly attributable to COVID-19 or are incidental findings in the setting of clinical intercurrences are warranted.

References

  1. Cascella M, Rajnik M, Aleem A, et al. Features, Evaluation, and Treatment of Coronavirus (COVID-19) [Updated 2022 Oct 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554776/
  2. WHO Coronavirus (COVID-19) Dashboard. Accessed March 12, 2022. https://covid19.who.int
  3. Sen M, Honavar SG, Sharma N, Sachdev MS. COVID-19 and Eye: A Review of Ophthalmic Manifestations of COVID-19. Indian J Ophthalmol. 2021;69(3):488-509. doi:10.4103/ijo.IJO_297_21
  4. Bertoli F, Veritti D, Danese C, et al. Ocular Findings in COVID-19 Patients: A Review of Direct Manifestations and Indirect Effects on the Eye. J Ophthalmol. 2020;2020:4827304. doi:10.1155/2020/4827304
  5. Zhang Y, Stewart JM. Retinal and choroidal manifestations of COVID-19. Curr Opin Ophthalmol. 2021;32(6):536-540. doi:10.1097/ICU.0000000000000801
  6. Invernizzi A, Torre A, Parrulli S, et al. Retinal findings in patients with COVID-19: Results from the SERPICO-19 study. EClinicalMedicine. 2020;27:100550. doi:10.1016/j.eclinm.2020.100550
  7. Gonzalez-Lopez JJ, Felix Espinar B, Ye-Zhu C. Symptomatic Retinal Microangiopathy in a Patient with Coronavirus Disease 2019 (COVID-19): Single Case Report. Ocul Immunol Inflamm. 2021;29(4):642-644. doi:10.1080/09273948.2020.1852260
  8. Virgo J, Mohamed M. Paracentral acute middle maculopathy and acute macular neuroretinopathy following SARS-CoV-2 infection. Eye. 2020;34(12):2352-2353. doi:10.1038/s41433-020-1069-8
  9. Hernandez M, González-Zamora J, Recalde S, et al. Evaluation of Macular Retinal Vessels and Histological Changes in Two Cases of COVID-19. Biomedicines. 2021;9(11):1546. doi:10.3390/biomedicines9111546
  10. Lani-Louzada R, Ramos C do VF, Cordeiro RM, Sadun AA. Retinal changes in COVID-19 hospitalized cases. PLoS One. 2020;15(12):e0243346. doi:10.1371/journal.pone.0243346
  11. Abou-Ismail MY, Diamond A, Kapoor S, Arafah Y, Nayak L. The hypercoagulable state in COVID-19: Incidence, pathophysiology, and management. Thromb Res. 2020;194:101-115. doi:10.1016/j.thromres.2020.06.029
  12. 12.0 12.1 Ullah I, Sohail A, Shah MUFA, et al. Central Retinal Vein Occlusion in patients with COVID-19 infection: A systematic review. Ann Med Surg (Lond). 2021;71:102898. doi:10.1016/j.amsu.2021.102898
  13. Ucar F, Cetinkaya S. Central retinal artery occlusion in a patient who contracted COVID-19 and review of similar cases. BMJ Case Reports CP. 2021;14(7):e244181. doi:10.1136/bcr-2021-244181
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