Central Retinal Vein Occlusion in a 46-Year-Old Man with COVID-19: Case Report and Review of the Literature

Ocular manifestations of COVID-19

There is an increasing body of knowledge regarding how COVID-19 may be associated with ocular disease of varying severity and duration. This article discusses the literature on the ocular manifestations associated with COVID-19, including appraisal of the current evidence, suggested mechanisms of action, associated comorbidities and risk factors, timing from initial infection to diagnosis and clinical red flags. The current literature primarily comprises case reports and case series which inevitably lack control groups and evidence to support causality. However, these early data have prompted the development of larger population-based and laboratory studies that are emerging. As new data become available, a better appraisal of the true effects of COVID-19 on the eye will be possible. While the COVID-19 pandemic was officially declared no longer a "global health emergency" by the World Health Organization (WHO) in May 2023, case numbers continue to rise. Reinfection with different variants is predicted to lead to a growing cumulative burden of disease, particularly as more chronic, multi-organ sequelae become apparent with potentially significant ocular implications. COVID-19 ocular manifestations are postulated to be due to three main mechanisms: firstly, there is a dysregulated immune response to the initial infection linked to inflammatory eye disease; secondly, patients with COVID-19 have a greater tendency towards a hypercoagulable state, leading to prothrombotic events; thirdly, patients with severe COVID-19 requiring hospitalisation and are immunosuppressed due to administered corticosteroids or comorbidities such as diabetes mellitus are at an increased risk of secondary infections, including endophthalmitis and rhino-orbital-mucormycosis. Reported ophthalmic associations with COVID-19, therefore, include a range of conditions such as conjunctivitis, scleritis, uveitis, endogenous endophthalmitis, corneal graft rejection, retinal artery and vein occlusion, non-arteritic ischaemic optic neuropathy, glaucoma, neurological and orbital sequelae. With the need to consider telemedicine consultation in view of COVID-19's infectivity, understanding the range of ocular conditions that may present during or following infection is essential to ensure patients are appropriately triaged, with prompt in-person ocular examination for management of potentially sight-threatening and life-threatening diseases.

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.

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.

Ophthalmic Presentations and Manifestations of COVID-19: A Systematic Review of Global Observations

As the presentations and complications of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continue to surface, the ocular manifestations have emerged as an area of interest. Research and reports conveyed the presence of several ophthalmic conditions observed in Coronavirus disease 2019 (COVID-19) patients. These publications documented a range of presentations varying from asymptomatic to serious impairments. The aim of this study is to characterize the ophthalmic pathologies and their frequencies observed due to COVID-19 in patients across different regions of the world. The goal is that the paper assists primary care physicians and healthcare providers. A systematic review of 31 articles published between January 1, 2021 to January 13, 2022, explored the presenting ocular symptoms of COVID-19, diagnosis, duration of ophthalmic complications, as well as pre-existing comorbidities. A total of 816 patients, 427 (52.3%) males and 389 (47.7%) females, from various regions of the world were investigated. Studies focusing on patients with a history of ocular pathologies, non-COVID-19 infections, complications associated with the COVID-19 vaccine, and pediatric patients were excluded from this study. Ocular complications were most commonly reported one to two weeks following the initial COVID-19 diagnosis. Analysis suggests that the "red" eye is the most prevalent presenting ophthalmologic symptom, followed by temporary vision loss. Conjunctivitis was also the most common clinical diagnosis reported, followed by neuro-retinal affection in the form of cotton wool spots (n=127 and n=9, respectively). This study summarizes ocular manifestations in COVID-19 patients and serves to help healthcare providers recognize common symptoms and their severity. This may lead to early diagnosis, treatment, and intervention of these manifestations.

COVID-19, post-acute COVID-19 syndrome (PACS, "long COVID") and post-COVID-19 vaccination syndrome (PCVS, "post-COVIDvac-syndrome"): Similarities and differences

Worldwide there have been over 760 million confirmed coronavirus disease 2019 (COVID-19) cases, and over 13 billion COVID-19 vaccine doses have been administered as of April 2023, according to the World Health Organization. An infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can lead to an acute disease, i.e. COVID-19, but also to a post-acute COVID-19 syndrome (PACS, "long COVID"). Currently, the side effects of COVID-19 vaccines are increasingly being noted and studied. Here, we summarise the currently available indications and discuss our conclusions that (i) these side effects have specific similarities and differences to acute COVID-19 and PACS, that (ii) a new term should be used to refer to these side effects (post-COVID-19 vaccination syndrome, PCVS, colloquially "post-COVIDvac-syndrome"), and that (iii) there is a need to distinguish between acute COVID-19 vaccination syndrome (ACVS) and post-acute COVID-19 vaccination syndrome (PACVS) - in analogy to acute COVID-19 and PACS ("long COVID"). Moreover, we address mixed forms of disease caused by natural SARS-CoV-2 infection and COVID-19 vaccination. We explain why it is important for medical diagnosis, care and research to use the new terms (PCVS, ACVS and PACVS) in order to avoid confusion and misinterpretation of the underlying causes of disease and to enable optimal medical therapy. We do not recommend to use the term "Post-Vac-Syndrome" as it is imprecise. The article also serves to address the current problem of "medical gaslighting" in relation to PACS and PCVS by raising awareness among the medical professionals and supplying appropriate terminology for disease.

Central Retinal Vein Occlusion after mRNA COVID-19 Vaccination

A 47-year-old man presented with visual loss in the right eye 8 h after the first dose of a coronavirus disease 2019 (COVID-19) vaccine developed by Pfizer/BioNTech (BNT162b2). The best corrected visual acuity (BCVA) was 20/200. Fundus examination showed dilated and tortuous retinal veins at the posterior pole, retinal hemorrhages throughout the fundus, and macular edema. Fluorescein angiography showed multiple hypofluorescent spots that appeared to be fluorescent block due to retinal hemorrhages and hyperfluorescent leakage from the retinal veins. The eye was diagnosed with central retinal vein occlusion (CRVO). For the treatment of macular edema, intravitreal injection of aflibercept (IVA) was administered and treated with one plus pro re nata regimen. Five IVAs were performed over a 10-month follow-up period, with resolution of macular edema, and the BCVA recovered to 20/20. The patient was young and had no history of diabetes mellitus, hypertension, or atherosclerotic diseases, and his blood tests showed no abnormal findings. Both antigen test and polymerase chain reaction test for COVID-19 were negative, and the antibody test was positive due to vaccination. The development of CRVO in this patient may have been related to COVID-19 vaccination, and the appropriate IVA treatment resulted in a good visual prognosis.

Possible COVID-19 MRNA Vaccine-Induced Case of Unilateral Central Retinal Vein Occlusion

PURPOSE

To report a case of a patient with central retinal vein occlusion (CRVO), 2 weeks after the first dose of a COVID-19 mRNA vaccine.

RESULTS

A 35-year-old man presented with decreased vision on his right eye, 2 weeks after receiving the first dose of COVID-19 mRNA vaccine. During examination, signs of right CRVO were found. We started general checkup of the patient, extended with laboratory tests specific for VIPIT. No exact cause of the thromboembolic episode could be documented. With the applied therapy, symptoms resolved completely.

CONCLUSION

CRVO after COVID-19 mRNA vaccination is reported only in one case in the literature. In our case, the young age of the patient, the close onset of the symptoms to the vaccination and the negative systemic, immunologic and hematologic tests are suggesting a vaccine-induced thrombotic mechanism. We propose further investigation of vaccine-induced thrombotic mechanisms and also close follow of the reported cases.

Hemi- and Central Retinal Vein Occlusion Associated with COVID-19 Infection in Young Patients without Known Risk Factors

PURPOSE

Venous thromboembolic complications have been reported in association with coronavirus disease 2019 (COVID-19) infection. We raised awareness regarding a potential temporal association between COVID-19 infection and retinal vein occlusion (RVO).

DESIGN

Multicenter, retrospective, nonconsecutive case series.

SUBJECTS

Patients presenting with hemi-RVO (HRVO) or central RVO (CRVO) between March 2020 and March 2021, with confirmed COVID-19 infection, were included. The exclusion criteria were as follows: age >50 years, hypertension, diabetes, glaucoma, obesity, underlying hypercoagulable states, and those requiring intubation during hospitalization.

METHODS

This was a multicenter, retrospective, nonconsecutive case series including patients presenting with hemi-RVO (HRVO) or central RVO (CRVO) between March 2020 and March 2021, with confirmed COVID-19 infection. The exclusion criteria were as follows: age >50 years, hypertension, diabetes, glaucoma, obesity, underlying hypercoagulable states, and those requiring intubation during hospitalization.

MAIN OUTCOME MEASURES

Ophthalmic findings, including presenting and final visual acuity (VA), imaging findings, and clinical course.

RESULTS

Twelve eyes of 12 patients with CRVO (9 of 12) or HRVO (3 of 12) after COVID-19 infection were included. The median age was 32 years (range, 18-50 years). Three patients were hospitalized, but none were intubated. The median time from COVID-19 diagnosis to ophthalmic symptoms was 6.9 weeks. The presenting VA ranged from 20/20 to counting fingers, with over half (7 of 12) having a VA of ≥20/40. OCT revealed macular edema in 42% of the eyes; of these, 80% (4 of 5) were treated with anti-VEGF injections. Ninety-two percent (11 of 12) had partial or complete resolution of ocular findings at final follow-up. Four eyes (33%) had retinal thinning, as determined using OCT, by the end of the study interval. The final VA ranged from 20/20 to 20/60, with 11 of the 12 (92%) eyes achieving a VA of ≥20/40 at a median final follow-up period of 13 weeks (range, 4-52 weeks).

CONCLUSIONS

Although we acknowledge the high seroprevalence of COVID-19 and that a causal relationship cannot be established, we reported this series to raise awareness regarding the potential risk of retinal vascular events due to a heightened thromboinflammatory state associated with COVID-19 infection.

Retinal vasoocclusive spectrum following COVID-19

The coagulation abnormalities and thromboembolic complications of coronavirus 2 (SARS-CoV-2) are now a well-established fact. The hypercoagulable state, the tendency for thromboembolism, and a cytokine surge state have been the exclusive reasons for multiorgan failure and other morbidities that have been regularly reported in COVID-19 patients. Ocular involvement in patients with active disease and those who have recovered is uncommon but not rare. We report a case series of four patients with CRVO, BRVO, CRAO, and vitreous hemorrhage in patients with proven COVID-19 infection and no other systemic ailments. The case series also tries to correlate the elevated D-dimer values, which signify a plausible prothrombotic state with the vaso-occlusive phenomenon in the retina leading to significant visual morbidity.

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.

Retinal Vein Occlusion with COVID-19: A Case Report and Review of Literature

OBJECTIVES

To provide a case report of Retinal Vein Occlusion (RVO) with COVID-19 infection.

CASE

A 15-year-old healthy male presented with blurring of vision, 2+ vitreous cells, retinal haemorrhages and dilated and tortuous retinal vessels in the left eye within 28 days of a positive COVID-19 reverse transcriptase polymerase chain reaction (RT-PCR) assay. He was diagnosed with left non-ischaemic CRVO, with a suspected aetiology of COVID-19.

DISCUSSION

A literature review found 12 reported cases of RVO associated with COVID-19. All but one patient was younger than 60, with a mean age of 42 years. Management varied, but in the majority (8/12), visual acuity (VA) improved with follow-up, and five (42%) had a final VA of 20/20.

CONCLUSION

In the absence of other known aetiological factors, ophthalmologists should consider COVID-19 as a cause of RVO. The outcome can vary, but the majority can expect improvement in VA with time.