MYTHS AND TRUTHS OF THE ASSOCIATION OF RETINAL VASCULAR OCCLUSION WITH COVID-19

Retinal venous occlusion and its association with atherosclerotic vascular disease

Retinal venous occlusion (RVO) is the second most frequent cause of decreased visual acuity due to retinal vascular, after diabetic retinopathy. Its etiology is not completely clear. Current scientific evidence suggests that it is related to the atherosclerotic process given the high number of cardiovascular risk factors and the higher incidence of cardiovascular events in these patients. In fact, RVO implies a 45% higher risk of stroke, 26% of acute myocardial infarction and peripheral vascular disease, 53% of heart failure and 36% of overall mortality, compared to the general population adjusted for age, sex and the different cardiovascular risk factors. However, no increase in cardiovascular mortality has been detected. Therefore, a multidisciplinary clinical approach to this pathology is essential.

Retinal vascular occlusion risks during the COVID-19 pandemic and after SARS-CoV-2 infection

The coronavirus disease 2019 (COVID-19) has been reported to affect vascular networks including the eye. However, evidence on the causal relationship between COVID-19 infection and retinal vascular occlusions remains limited. This study aimed to determine the change in retinal vascular occlusion incidence during COVID-19 era and whether severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection induces retinal vascular occlusion. Retinal vein occlusion (RVO) and retinal artery occlusion (RAO) incidences during 2018-2019 and 2020-July 2021 were compared, those in confirmed and suspected COVID-19 patients diagnosed from 2020 to January 2021 were calculated, and those in COVID-19 patients during 180 days prior and 180 days after diagnosis were assessed. Additionally, the standardized incidence ratio of RVOs in COVID-19 patients was analyzed. Incidence rates per 100,000 people/year of RVO during 2018-2019 and 2020-2021 was 102.0 and 98.8, respectively. RAO incidence rates during 2018-2019 and 2020-2021 were 11.7 and 12.0, respectively. In both confirmed and suspected COVID-19 patients, the incidence of RVO and RAO did not change significantly from 180 days before to after diagnosis in the adjusted model. RVO incidence slightly decreased while RAO incidence increased during the COVID-19 pandemic. SARS-CoV-2 infection did not significantly increase RVO or RAO incidence.

Central retinal artery occlusion in a young child affected by COVID-19: a first case report

BACKGROUND

Central retinal artery occlusion (CRAO) is an ophthalmic emergency, and its etiology is generally ascribed to vessel occlusion by a thrombus or embolus, eventually due to a hypercoagulable state. CRAO occurrence is described even in the pediatric population, but its incidence is very rare. SARS-CoV-2 infection has a multitude of presentations, and almost any organ may be involved including the ocular district. Cases of CRAO in patients affected by COVID-19 are reported in the literature in the adult population, but not in the pediatric one.

CASE PRESENTATION

We describe the case of a six-year-old otherwise healthy girl, who presented a sudden and complete bilateral vision loss after a one-day fever. All the clinical, ophthalmological, laboratory and instrumental investigations led to the diagnosis of a right CRAO and the suspicion of a contralateral posterior optic nerve affection. These manifestations could not be ascribed to any etiological condition apart from the documented ongoing mild SARS-CoV-2 infection. Treatment with anticoagulants and steroids was tried but the visual outcome was poor during the one-month hospitalization and at the last follow-up.

CONCLUSIONS

To the best of our knowledge, this is the first report of CRAO in the course of SARS-CoV-2 infection in the pediatric age. In our review of the literature, we found few cases of CRAO in adults with COVID-19; we highlighted differences in anamnestic, clinical, and interventional aspects and therefore we tried to summarize the state of the art on this topic to facilitate further studies. Even if rare, the prognosis of CRAO is poor and the thrombolytic treatment could be effective only if rapidly administered, so the disease suspicion should be high in a patient with sudden vision loss, also in pediatric age.

Central Retinal Vein Occlusion after COVID-19 Infection

INTRODUCTION

Central retinal vein occlusions are not well-known complications of SARS-CoV-2 infection. We describe a case of central retinal vein occlusion secondary to COVID-19, and a review of the literature was performed.

HISTORY AND SIGNS

A 47-year-old woman with no underlying ocular or medical condition presented to the hospital complaining about sudden onset of multiple scotomas in her left eye. A COVID-19 infection was confirmed 2 days previously by a PCR test that was performed 2 days after the onset of symptoms. Medical history revealed no risk factors and no oral contraception. Her best-corrected visual acuity was 1.0 in the right eye and 0.04 in the left eye. Clinical exam showed a left relative afferent pupillary defect and a nasally localized papilledema on fundoscopy of the left eye. Multiple dot and blot hemorrhages were also present. Optical coherence tomography revealed cystoid macular edema and paracentral acute middle maculopathy. The results of the fluoresceine angiography were consistent with central retinal vein occlusion. Laboratory workup later revealed an elevated fibrinogen level, corresponding to the COVID-19-induced hypercoagulable state. No other prothrombotic conditions were found. The patient immediately received an intravitreal injection of Lucentis (ranibizumab) after diagnosis. Complete resolution of the retinal hemorrhages and papilledema was observed 1.5 months after treatment and the final visual acuity was 1.25 in the left eye.

CONCLUSION

Coagulation abnormalities are frequently observed in infectious diseases such as COVID-19 infection and the resulting prothrombotic state can sometimes lead to retinal vascular complications, including central retinal vein occlusion, irrespective of the presence of other classical risk factors. The consideration of this information could help clinicians establish a prompt diagnosis and therefore appropriate treatment, which could hopefully lead to complete healing of retinal lesions.

Difference in characteristics and lesion reactivation between type 3 macular neovascularization with and without subretinal fluid at baseline

PURPOSE

To compare the characteristics and incidence rates of lesion reactivation after anti-vascular endothelial growth factor (VEGF) treatment in type 3 macular neovascularization (MNV) with and without subretinal fluid (SRF) at baseline.

METHODS

This retrospective study included 95 patients diagnosed with type 3 MNV. After the initial loading injections, re-treatment was performed when lesion reactivation occurred defined as the re-accumulation of subretinal or intraretinal fluid or the new development of a retinal/subretinal hemorrhage. The differences in the baseline characteristics and the incidence rates of lesion reactivation were compared between patients with SRF (SRF group, n = 42) and those without SRF (non-SRF group, n = 53).

RESULTS

At diagnosis, the mean visual acuity was worse (0.68 ± 0.41 vs 0.50 ± 0.36; P = 0.032), mean central retinal thickness was greater (515.4 ± 145.9 μm vs 383.8 ± 105.5 μm; P < 0.001), and the incidence of focal retinal hemorrhages was higher (90.5% vs 66.0%; P = 0.005) in the SRF group than in the non-SRF group. In the SRF group, the first lesion reactivation was noted in 89.7% at a mean of 5.8 ± 4.4 months after the third injection. In the non-SRF group, the first lesion reactivation was noted in 70.6% at a mean of 6.1 ± 3.8 months. There was a significant difference in lesion reactivation between the two groups (P = 0.019).

CONCLUSIONS

The difference in the baseline characteristics and incidence of lesion reactivation between type 3 MNV with and without SRF suggests that the presence of SRF may be indicative of more advanced disease with a high risk of visual deterioration. This result also suggests the need for more active treatment to preserve vision in patients with SRF.

[Ophthalmic manifestations of COVID-19]

In March 2020 the World Health Organization (WHO) declared a pandemic of the novel coronavirus infection (COVID-19) caused by the SARS-CoV-2 respiratory virus. The high spread rate of the virus and the severity of the course of the disease are of great clinical and epidemiological significance, making it relevant for ophthalmologists to study the mechanisms of how SARS-CoV-2 infects ocular structures, as well as possible clinical manifestations of the infection in the organ of vision. This review contains analysis, systematization, and generalization of epidemiological and clinical data on SARS-CoV-2 ocular lesions and was carried out with the data found in scientific abstract databases. The article presents main clinical ophthalmic manifestations of COVID-19, lists the utilized schemes of etiotropic and symptomatic therapy, recommended preventive measures, and considers the possible ophthalmic complications after vaccination against COVID-19.