Retinal Manifestations of COVID-19

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Article initiated by:

Jessica Randolph, M.D.

All contributors:

Meagan Shinbashi, Stephanie Saadeh-Jackson, Leo A. Kim, MD, PhD, Koushik Tripathy, MD (AIIMS), Jessica Randolph, M.D., Aneesha M Ichlangod

Assigned editor:

Koushik Tripathy, MD (AIIMS)

Review:

Assigned status Up to Date

 by Koushik Tripathy, MD (AIIMS) on June 17, 2026.

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Contributing Editors:	add

Introduction

The coronavirus disease 2019 (COVID-19) pandemic was a global health crisis caused by coronavirus 2 (SARS-CoV-2). According to the World Health Organization (WHO) on 28 June 2023, there have been over 767 million confirmed cases of COVID-19 and over 6.9 million deaths around the world. On 5 May 2023, the WHO declared an end to COVID-19 as a global health emergency. According to the WHO, as of the declaration ending the COVID-19 global health emergency on May 5, 2023, there had been over 767 million confirmed cases and over 6.9 million deaths worldwide; ongoing surveillance continues under routine infectious disease monitoring frameworks.. Li Wenliang (12 October 1986 – 7 February 2020), the Chinese Ophthalmologist who warned his colleagues about this infection on 30 December 2019, seemingly contracted the infection from a patient (a storekeeper at Wuhan Huanan Seafood Wholesale Market) with acute angle closure glaucoma. Although most research and therapeutic efforts are directed toward the respiratory complications of the disease, COVID-19 can also lead to significant ophthalmic manifestations. The most commonly reported of these is conjunctivitis, may be the only manifestation of SARS-CoV-2 infection in some patients. While eyelid, ocular surface, and anterior segment manifestations of COVID-19 are well documented, posterior segment involvement is less common. It has mainly been described in the form of case reports. This article provides 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 patients have preserved visual acuity and pupillary reflexes,, but there have also been instances where patients developed visual field defects. The SARS-CoV-2 infection has also been associated with new-onset paracentral acute middle maculopathy (PAMM) and acute macular neuroretinopathy (AMN). However, a true relationship between these conditions and COVID-19 is yet to be established. Increased tortuosity of retinal vessels is another finding documented in patients with COVID-19. 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. Optical coherence tomography angiography (OCTA) has provided subclinical insights beyond what is visible on fundus photography. A 2024 longitudinal study using swept-source OCTA in patients with mild primary COVID-19 infection found a transient increase in macular vessel density during early recovery that returned to baseline by two months; ganglion cell–inner plexiform layer thickness and central macular thickness also showed transient decreases that normalized within the same period, and the foveal avascular zone (FAZ) area remained stable throughout. This suggests that mild infection may produce reversible subclinical microvascular changes without permanent structural sequelae. In contrast, in patients with severe COVID-19, reduced vessel density of the superficial capillary plexus and an enlarged FAZ area were still detectable at 12 months after the acute phase, with the degree of microvascular impairment correlating with inflammatory markers and renal dysfunction during hospitalization. Clinicians using OCTA in post-COVID patients should interpret findings in the context of disease severity, as the chronicity and magnitude of changes appear to be severity-dependent.

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. 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. Although CRVO is classically associated with risk factors like age, hypertension, glaucoma, and diabetes, COVID-19 may be associated with CRVO irrespective of patient age or comorbidities. Because timely diagnosis and management are crucial for vision preservation, clinicians should be vigilant about monitoring signs of CRVO in patients with a history of COVID-19. Retinal vein occlusion has also been reported as a rare adverse event following COVID-19 vaccination. Large-scale population-based studies have produced conflicting results, with some reporting no excess risk and others suggesting a modestly increased risk in the weeks following vaccination. The proposed mechanisms include vaccine-induced immune thrombotic thrombocytopenia and transient endothelial inflammatory responses. Despite these reports, the absolute risk is low and the benefit-risk balance of COVID-19 vaccination remains strongly favorable.

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 onset of COVID-19 symptoms. They were found to have mild-to-significant retinal whitening on the fundus exam. 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. Central retinal artery occlusion has similarly been described following COVID-19 vaccination across multiple vaccine platforms, though as with infection-associated cases, confounding comorbidities are common and a definitive causal relationship has not been established in most reported instances.

Acute Macular neuroretinopathy

Acute Macular Neuroretinopathy is a rare condition marked by a wedge-shaped reddish-brown lesion reaching toward the fovea and resulting in a rapid onset of one or more paracentral scotomas. There are reports of a surge in the incidence of AMN during the COVID-19 pandemic. In some cases, AMN was detected as the first sign of COVID-19 infection, and the patient later developed fever and cough while testing positive for COVID-19. Etiology is unconfirmed. One theory is that microvascular ischemia of the choriocapillaris leads to hypoxic insult to the middle and outer retinal layers. This mechanism is particularly pertinent to recent reports of microthrombi found in patients with COVID-19. AMN has also been reported following COVID-19 vaccination across multiple vaccine platforms including mRNA and adenoviral vector types, in some cases after the first dose. This finding has been included in systematic reviews of post-vaccination ocular adverse events.

Paracentral Acute Middle Maculopathy (PAMM)

Paracentral acute middle maculopathy (PAMM) is an optical coherence tomography (OCT) finding characterized by the parafoveal hyper‐reflective band at the level of the inner nuclear layer (INL). Although the exact etiopathogenesis of PAMM is not completely understood, ischemia of the retinal intermediate and deep capillary plexus has been shown to have a significant role. Physicians must recognize the signs and symptoms for an accurate diagnosis. Optical coherence tomography angiography shows perivascular hyper‐reflectivity and hyper‐reflective spots in the retinal deep capillary layer.

Long COVID and Retinal Neurodegeneration

There is growing evidence that SARS-CoV-2 infection may cause structural changes in the posterior segment that persist well beyond the acute phase of illness. Several studies using spectral-domain OCT in recovered patients have identified thinning of the macular retinal nerve fiber layer, ganglion cell–inner plexiform layer, and outer nuclear layer compared to age-matched healthy controls, with some abnormalities persisting at 12 months post-infection. A 2025 comparative study found that recovered COVID-19 patients had measurably reduced ganglion cell layer thickness and altered subfoveal choroidal thickness on spectral-domain OCT, raising concern about a potential neurodegenerative impact on the posterior segment. A one-year prospective study using swept-source OCT and OCTA before and after infection found quantifiable changes in vessel density across the superficial, intermediate, and deep capillary plexuses, with some parameters still abnormal at one year. These findings suggest that the retina may serve as an accessible biomarker for long COVID-related neurovascular injury, though interpretation is complicated by the heterogeneity of disease severity, vaccination status, and pre-existing comorbidities across studies. Prospective longitudinal studies with standardized imaging protocols and control for confounders are needed before firm conclusions can be drawn.

Central serous chorioretinopathy (CSCR)

COVID-19 infection could be established as a risk factor for CSCR, although the relationship remains ambiguous. A proposed mechanism can be mediated by the proven link between COVID-19 and the activation of the sympathetic system, leading to choroidal leak and predisposing to CSCR. Such patients usually presented with a sudden blurring of vision in one eye; symptoms started two weeks to several months following COVID-19 infection. The diagnosis was confirmed using OCT. Most of the cases resolved spontaneously. It is important to distinguish between CSCR arising in the context of COVID-19 infection, where autonomic dysregulation has been proposed as the mechanism, and CSCR reported after COVID-19 vaccination, which represents a separate and less well-characterized association. Both contexts have been described in the literature.

Fungal endogenous endophthalmitis (EE)

Various hypotheses have been proposed for the sudden surge of endogenous endophthalmitis cases in COVID-19 patients. Many of the patients had diabetes and required a high dose of systemic corticosteroid and/or further immunomodulation to combat the “cytokine storm.” Thus, a state of immunosuppression and systemic comorbidity was the prime suspect in such patients with EE. A decrease in the peripheral distribution of CD4+ T and CD8+ T cells has been reported in COVID-19 patients. Diagnosis of fungal EE requires a high index of suspicion. Irrespective of immune status, the ophthalmologist should investigate and explore the possibilities of dissemination of fungus in the bloodstream of patients with fungal EE. The contaminated intravenous fluid remains an important source of fungal EE in India. Microbiological investigation of the vitreous aspirates showed Aspergillus fumigatus, Aspergillus niger, Candida albicans, and Mucor. Timely diagnosis and management with intravitreal antifungals could salvage the eye in such patients.

Candida retinitis

Candida retinitis has been reported after COVID-19. Its diagnosis can be challenging in the initial stage with only chorioretinal involvement. The best-corrected visual acuity in such patients can be as bad as counting fingers close to the face. Fundus examination may reveal clear vitreous, with multiple, yellowish-white, fluffy lesions, predominantly across the posterior pole. The foveal center can also be involved with the retinitis lesion. The diagnosis was confirmed by vitreous tap and blood culture. In most cases, an intravitreal voriconazole injection (100 micrograms in 0.1 ml) was given. Retinitis lesions and choroidals had regressed significantly, and OCT showed regression of lesions. For this reason, candidemia should prompt a thorough evaluation of patients, including an ophthalmologic exam.

Conclusion

While many case reports document 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 vision-threatening complications. Future studies are warranted to investigate whether these retinal changes are truly attributable to COVID-19 or represent incidental findings in the setting of intercurrent comorbidities. The emerging literature on long COVID retinal sequelae and on vaccine-associated retinal complications represents two additional domains that require dedicated prospective study, with careful adjustment for disease severity, vaccination status, and pre-existing systemic disease.