Bilateral central retinal vein occlusion following COVID-19 vaccination: Cause or coincidence?

AIM

To report a case of sequential bilateral ischemic central retinal vein occlusion (CRVO) following the third dose of anti-COVID 19 vaccination.

METHODS

Observational case report.

RESULTS

A 73-year-old Caucasian male patient, with no known medical history, complained of sudden vision loss in his right eye (RE) 18 days following the third dose of Pfizer-BioNTech anti-COVID 19 vaccination. Ten days later, he suffered from sudden vision loss in his left eye (LE).Best-corrected visual acuity was limited to counting fingers at 50cm in both eyes.Fundus examination of both eyes revealed signs of ischemic central retinal vein occlusion (CRVO) with diffuse superficial and deep retinal hemorrhages in all four quadrants. Diagnosis was confirmed of fluorescein angiography.Optical coherent tomography (OCT) showed an ischemic hyperreflectivity and disorganization of the inner retinal layers in both eyes with significantly increased central macular thickness, associated to intraretinal fluid accumulation in LE.An urgent systemic assessment was requested. A mild hypertension was discovered and the rest of the work up was unremarkable.

CONCLUSION

To our knowledge, we report the first case of bilateral CRVO in a healthy patient after anti-COVID 19 vaccination. CRVO occurred few days following third shot of vaccine followed by a sequential CRVO in the fellow eye in a patient with recently diagnosed very mild hypertension and no thrombo-embolic risk factors, strongly suggesting a relationship between both events. Nowadays, CRVO should be kept in mind as a potential side effect of Covid-19 vaccination and should be added to the spectrum of their ophthalmic complications.

COMBINED CENTRAL RETINAL VASCULAR OCCLUSION AS THE PRESENTING FEATURE IN β-THALASSEMIA WITH IRON DEFICIENCY ANEMIA

PURPOSE

To report a case of β-thalassemia trait with iron deficiency anemia presenting as a combined central retinal vein and artery occlusion.

METHODS

Case report. A 22-year-old woman presented with sudden-onset blurry vision in the left eye of 3-day duration.

RESULTS

Best-corrected visual acuity was 20/20 and 20/1000 in right and left eyes, respectively. Fundus examination of the left eye revealed optic disk edema, macular whitening with a cherry-red spot, markedly dilated and tortuous retinal veins, and hemorrhages both around the disk and extending into the macula and the periphery. Fundus fluorescein angiography showed delayed filling of retinal vasculature, dilated and tortuous retinal veins, and blocked fluorescence around and beyond the optic disk. Optical coherence tomography scan at presentation showed hyperreflective inner retinal layers with neurosensory detachment. Optical coherence tomography angiography showed that the vessel densities of superficial and deep capillary plexus were remarkably reduced. A diagnosis of β-thalassemia trait combined with iron deficiency anemia was made after hematologic workup. The patient was treated with a course of oral iron supplements, vasodilator (compound Xueshuantong), inhalation of a mixture of 5% carbon dioxide and 95% oxygen, and a nutritional agent (compound anisoine). Six months later, her visual acuity improved to 20/60 in the left eye with complete resolution of all clinical signs.

CONCLUSION

Combined central retinal vein and artery occlusion is a rare emergency leading to acute vision loss and can manifest in patients with β-thalassemia trait with iron deficiency anemia. Prompt diagnosis and early management is important to treat underlying systemic disorders and to prevent occurrence of a similar episode in fellow eye.

Retinal Artery and Vein Occlusion Risks after Coronavirus Disease 2019 or Coronavirus Disease 2019 Vaccination

PURPOSE

To evaluate the incidence of new retinal artery occlusion (RAO) and retinal vein occlusion (RVO) after the diagnosis of coronavirus disease 2019 (COVID-19) or vaccination against COVID-19 and compare the incidences with the population with neither.

DESIGN

Nationwide population-based cohort study.

PARTICIPANTS

From a nationwide population-based cohort, 8 418 590 patients were categorized into control (group 1), COVID-19 infection (group 2), and COVID-19 vaccination (group 3) groups.

METHODS

The cumulative incidence of RAO and RVO was calculated in groups 1, 2, and 3 using the Kaplan-Meier method. We calculated hazard ratios (HRs) and 95% confidence intervals (CIs) based on the Poisson distribution for RAO and RVO according to each group and subgroup using Cox proportional hazards models, with group 1 as the reference. We conducted univariable and multivariable analyses for the risk factors of RAO and RVO according to each subgroup.

MAIN OUTCOME MEASURES

Cumulative incidence and risks of incidence of RAO and RVO from the index date to day 60.

RESULTS

In multivariable analysis, no significant increase in RAO and RVO risks after COVID-19 or COVID-19 vaccination were observed in either men or women. These results were observed consistently across various conditions in sensitivity analyses. In subgroup analysis, individuals who were vaccinated before infection showed no significant increase in RAO or RVO risks in both sexes compared with the control group. In the subgroup analysis of vaccinated patients, the HRs of RAO and RVO for different vaccine types did not show an increase compared with the control group; however, an exception was observed in women who received mRNA-1273 vaccines, who showed a higher RAO HR (4.65; 95% CI, 1.27-17.03; P = 0.021).

CONCLUSIONS

Within 60 days of COVID-19 diagnosis or vaccination, RAO and RVO occurred rarely. We observed no increase in the HR of RVO and RAO relative to COVID-19 or COVID-19 vaccination except for a possible increase in the RAO HR in women who received mRNA-1273, for which the raw incidence was extremely low. Further investigation is required to validate this result.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Hypertension, hyperlipidaemia and thrombophilia as the most common risk factors for retinal vein occlusion in patients under 50 years

BACKGROUND AND AIMS

Cardiovascular (CV) diseases are the most common risk factors (RFs) for retinal vein occlusion (RVO) development in general. The aim of this study was to identify the most frequent causes of RVO in patients under 50.

METHODS

We retrospectively evaluated a group of patients with RVO under 50 years. The parameters of interest included age and sex, RVO type, presence of arterial hypertension (HT), hyperlipidaemia (HLD), diabetes mellitus (DM), congenital thrombophilic disorder (TD), obstructive sleep apnoea syndrome (OSAS), thyroid eye disease (TED), use of hormone contraception (HC) or hormone replacement therapy (HRT), glaucoma and other potential RFs. Patients with central RVO (CRVO), hemi-central RVO (HRVO), branch RVO (BRVO), impending CRVO and combined arterial-venous (AV) occlusion were included.

RESULTS

The group consisted of 110 eyes of 103 patients. CV disease was the most common systemic abnormality. 55.3% patients had HT, 17.5% had HLD. TD was the third most frequent RF (12.6%). The cohort also included patients with DM (6.8%), glaucoma (6.8%) and women using HC/HRT (26.2% of female patients). There were isolated cases of RVO due to retinal vasculitis, intense exercise, antiphospholipid syndrome and COVID-19 pneumonia. None of the patients had OSAS, TED or a haemato-oncological disease. The etiology remained unexplained in 20.4% patients. No difference was observed in RF occurrence between patients with CRVO and HRVO and those with BRVO.

CONCLUSION

The most common systemic abnormality in our cohort was CV disease, especially HT and HLD. The risk factors for central, hemi-central and branch RVOs were similar.

Hemicentral retinal vein occlusion in a patient with a history of coronavirus disease 2019 infection: a case report and review of the literature

BACKGROUND

Considering the various manifestations of coronavirus disease 2019 and its imperative importance in terms of the right clinical approach and early management, we sought to present a hemicentral retinal vein occlusion case, with a history of heterozygosity of methylenetetrahydrofolate reductase (MTHFR) genes and potential for clotting complications as a late manifestation of coronavirus disease 2019, and provide a brief review of reported retinal vein occlusion cases in patients with coronavirus disease 2019.

CASE PRESENTATION

A 35-year-old Iranian patient presented with a visual impairment in the left eye 4 months after recovering from coronavirus disease 2019. He reported a mild blurring of vision in the same eye a few days after admission due to coronavirus disease 2019. The ophthalmic evaluation was compatible with hemicentral retinal vein occlusion. Systemic and laboratory workups were negative except for borderline protein C activity, homocysteine levels, and heterozygosity of MTHFR genes. The patient was scheduled to receive three monthly intravitreal antivascular endothelial growth factor injections.

CONCLUSION

We present a case of inferior hemicentral retinal vein occlusion case with an MTHFR mutation with sequential loss of vision 4 months after coronavirus disease 2019 to make clinicians aware of the possibility of late ocular coronavirus disease 2019 manifestations.

RETINAL VASCULAR OCCLUSION AND COVID-19 DIAGNOSIS: A Multicenter Population-Based Study

BACKGROUND

Several ocular diseases have been reported in patients with coronavirus disease 2019 (COVID-19), especially retinal vascular occlusion. This study aimed to examine the risk of retinal vascular occlusion after COVID-19 diagnosis.

METHODS

This retrospective cohort study was based on 46 health care organizations in the United States using the TriNetX network. Individuals who had laboratory confirmation of COVID-19 from January 1, 2020, to December 31, 2021, were included. Multivariate analysis was adjusted on age, sex, race, and comorbidities, and hazard ratio was calculated using the Cox proportional hazard regression model.

RESULTS

A total of 1,460,634 paired individuals were enrolled for analysis. Patients with COVID-19 had a significantly higher risk of branch retinal vein occlusion (hazard ratio 1.27, 95% confidence interval [CI] 1.04-1.52) than those without COVID-19. The cumulative incidence rate of branch retinal vein occlusion was also significantly higher in patients with COVID-19 compared with those without COVID-19 (log-rank P = 0.014). Within 12 weeks after COVID-19 diagnosis, the transient effect of central retinal vein occlusion (hazard ratio 1.59, 95% confidence interval 1.15-2.17) and branch retinal vein occlusion (hazard ratio 2.11, 95% confidence interval 1.51-2.95) were observed.

CONCLUSION

This large-scale multicenter study demonstrated that retinal vein occlusion may be associated with COVID-19.

PSORIASIS INCREASES RETINAL VEIN OCCLUSION RISK IN DIABETIC PATIENTS: A Nationwide Population-Based Study

PURPOSE

The objective of this research was to explore how psoriasis is linked to the occurrence of retinal vein occlusion (RVO) in diabetic population.

METHODS

This was a retrospective, nationwide, population-based cohort study that examined medical records from January 2009 to December 2012. The study focused on patients ≥20 years of age who had been diagnosed with Type 2 diabetes mellitus (DM). The authors compared the incidence rate of RVO between a group of patients with psoriasis and a group of patients without psoriasis until December 2018 in all subjects.

RESULTS

Of the 2,745,689 Type 2 DM patients, 23,725 patients were classified in the psoriasis group and the rest of the 2,547,121 individuals in the control group. A total of 497 RVO cases occurred in the psoriasis group (3.14/1,000 person-years) and 42,388 RVO cases in the control group (2.44/1,000 person-years). According to multivariable Cox proportional hazard models, individuals with psoriasis had a significantly greater risk of developing RVO compared with control subjects (hazard ratio: 1.216, 95% confidence interval: 1.11-1.33) after adjustments for covariates.

CONCLUSION

This study demonstrated that psoriasis was an independent risk factor for developing RVO in DM patients. Therefore, physicians need to be vigilant for the occurrence of RVO in DM patients who also have psoriasis.

Ocular manifestations of obstructive sleep apnea: a systematic review and meta-analysis

BACKGROUND

The association of obstructive sleep apnea (OSA) with development of eye diseases is unclear. This current systematic review and meta-analysis attempts to summarize and analyze associations between OSA and ocular disorders in the literature.

METHODS

PubMed, EMBASE, Google Scholar, Web Of Science, and Scopus databases were searched from 1901 to July 2022 in accordance with the Preferred Reporting in Systematic Review & Meta-Analysis (PRISMA). Our primary outcome assessed the association between OSA and the odds of developing floppy eyelid syndrome (FES), glaucoma, non-arteritic anterior ischemic optic neuropathy (NAION), retinal vein occlusion (RVO), keratoconus (KC), idiopathic intracranial hypertension (IIH), age-related macular degeneration (AMD), and central serous chorioretinopathy (CSR) through odds ratio calculated at the 95% confidence interval.

RESULTS

Forty-nine studies were included for systematic review and meta-analysis. The pooled OR estimate was highest for NAION [3.98 (95% CI 2.38, 6.66)], followed by FES [3.68 (95% CI 2.18, 6.20)], RVO [2.71(95% CI 1.83, 4.00)], CSR [2.28 (95% CI 0.65, 7.97)], KC [1.87 (95% CI 1.16, 2.99)], glaucoma [1.49 (95% CI 1.16, 1.91)], IIH [1.29 (95% CI 0.33, 5.01)], and AMD [0.92 [95% CI 0.24, 3.58] All observed associations were significant (p < 0.001) aside from IIH and AMD.

CONCLUSION

OSA is significantly associated with NAION, FES, RVO, CSR, KC, and glaucoma. Clinicians should be informed of these associations so early recognition, diagnosis, and treatment of eye disorders can be addressed in at-risk groups, and early referral to ophthalmic services is made to prevent vision disturbances. Similarly, ophthalmologists seeing patients with any of these conditions should consider screening and referring patients for assessment of possible OSA.

Neurofibromatosis Type 1 Vasculopathy Presenting as Branch Retinal Vein Occlusion: Case Report and Review of the Literature

Systemic vascular occlusive disease associated with neurofibromatosis type 1 (NF1) has been reported in the aortic, cerebral, renal, celiac, and mesenteric vessels and is referred to as NF1 vasculopathy. Although retinal vascular involvement in patients with NF1 usually manifests as retinal capillary hemangiomatosis, a few cases of NF1 with retinal vascular occlusive disease have also been described. Here, we report a 2-year-old girl with NF1 who presented with branch retinal vein occlusion and peripheral retinal ischemia secondary to NF1. This case demonstrates that NF1-related retinal occlusive vasculopathy may occur in very young patients and that detailed fundus examination with fluorescein angiography is necessary in all patients with NF1.

Risk factors in developing retinal vein occlusion in subject with obstructive sleep apnea

BACKGROUND

Patients with obstructive sleep apnea (OSA) have a higher risk of developing vascular diseases. In this study, we evaluated the clinical profile of patients with OSA who develop retinal vein occlusion (RVO) compared with a population of OSA patients without RVO.

METHODS

We analyzed patients with OSA diagnosed with RVO (21 cases; mean of age 61 years. range 44-87 years. 67% men), belonging to a large cohort of people with long-term follow-up for RVO (up to 12 years). We compared them with 21 patients with OSA, without RVO, matched by age and gender, selected from the Sleep Unit Registry (control group).

RESULTS

There were no differences in the prevalence of arterial hypertension (AHT) or Diabetes mellitus (DM), but the RVO patients presented a higher diastolic blood pressure compared to controls (87.6±12.6 mmHg vs. 77.9±10.1 mmHg respectively). The polygraphic parameters were similar in both groups. The Apnea-Hypopnea Index (IHA) similar in both groups (30.4±20.9 RVO vs. 33.7±22.1 controls). In addition, RVO patients had a less favorable lipid profile, with higher total cholesterol (218±52 mg/dL vs. 179±41 mg/dL), higher LDL cholesterol (139±47 mg/dL vs. 107±32 mg/dL) and higher atherogenic indices: LDL/HDL (2.78±0.95 RVO vs. 2.03±0.67 controls) and total cholesterol/HDL (4.37±1.08 vs. 3.45±0.84). Among the cases, 81% had peripheral RVO (superior temporal branch in 20 out of 21 cases) and 19% had central RVO. A percentage of 62% of the cases received intravitreal antiangiogenic therapy and dexamethasone implants and 33% received argon laser photocoagulation.

CONCLUSIONS

Poor control of cardiovascular risk factors, particularly dyslipidemias, in patients with OSA may lead to the development of this ocular complication.

Case Report: Branch Retinal Vein Occlusion Post-mRNA SARS-CoV-2 (COVID-19) Vaccination

SIGNIFICANCE

Systemic thromboembolic complications are well documented to be associated with coronavirus disease 2019 (COVID-19); however, there have been a growing number of reports regarding ocular complications stemming from COVID-19 vaccinations. This case illustrates a clear temporal and possible causal relationship of COVID-19 vaccination with an ocular microvascular disorder, namely, retinal vein occlusion.

PURPOSE

This study aimed to report a case of inferotemporal branch retinal vein occlusion after messenger RNA Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination.

CASE REPORT

A middle-aged woman developed right eye central scotoma 2 days after COVID-19 vaccination. She had transient hypertension during the first 2 days post-vaccination. A decrease in visual acuity (6/18) was documented. Initial retinal findings included flame-shaped hemorrhages and cotton-wool spots along inferotemporal branch retinal vessels. Optical coherence tomography revealed right eye cystoid macular edema. Laboratory investigation revealed mildly raised erythrocyte sedimentation rate and C-reactive protein. Other systemic examinations were unremarkable. She was treated for right eye inferotemporal branch retinal vein occlusion with cystoid macular edema and was given intravitreal anti-vascular endothelial growth factor monthly in three doses. Her visual acuity improved to 6/6 with resolved cystoid macular edema.

CONCLUSIONS

This case illustrates a clear temporal and possible causal relationship between COVID-19 vaccination and retinal vein occlusion. Post-vaccination transient hypertension or the immunological and inflammatory response to the vaccine may have contributed to the venous occlusive event in this case. Eye care providers should remain aware of this possibility. The effectiveness of intravitreal anti-vascular endothelial growth factor for the treatment of macular edema secondary to branch retinal vein occlusion was demonstrated in this patient.

CENTRAL RETINAL VEIN OCCLUSION IN 12-YEAR-OLD GIRL WITH METHYLENETETRAHYDROFOLATE REDUCTASE MUTATION: A CASE REPORT AND REVIEW OF THE LITERATURE

PURPOSE

This case report describes a central retinal vein occlusion in a healthy 12-year-old girl who developed retinal neovascularization at 24 years of age. To the knowledge of the authors, this is the longest time between a reported pediatric central retinal vein occlusion event and neovascularization.

METHODS

The patient underwent a full history, physical examination, and laboratory workup to determine potential risk factors contributing to the vascular event. Fundus photographs, optical coherence tomography, and fluorescein angiography were performed throughout the patient's treatment course.

RESULTS

Family history was noncontributory, but laboratory testing revealed a mildly elevated homocysteine level and homozygous C677T mutation in methylenetetrahydrofolate reductase. As a result, she was started on folate supplementation. The patient has had no further ocular or systemic thrombotic events to date.

CONCLUSION

Pediatric patients presenting with central retinal vein occlusion should undergo a systemic workup and require long-term follow-up to avoid complications, such as intraocular hemorrhage, tractional retinal detachments, and neovascular glaucoma.

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.

Risk of retinal vein occlusion following COVID-19 vaccination: a self-controlled case series

BACKGROUND

To evaluate the association between COVID-19 vaccination and retinal vein occlusion (RVO).

METHODS

This multicentre self-controlled case series included patients with RVO seen in five tertiary referral centres in Italy. All adults who received at least one dose of the BNT162b2, ChAdOx1 nCoV-19, mRNA-1273 or Ad26.COV2.S vaccine and had a first diagnosis of RVO between January 01, 2021, and December 31, 2021 were included. Incidence rate ratios (IRRs) of RVO were estimated using Poisson regression, comparing rates of events in a 28-day period following each dose of vaccination and in the unexposed control periods.

RESULTS

210 patients were included in the study. No increased risk of RVO was observed after the first dose (1-14 days IRR: 0.87, 95% CI: 0.41-1.85; 15-28 days IRR: 1.01, 95% CI: 0.50-2.04; 1-28 days IRR: 0.94, 95% CI: 0.55-1.58) and second dose of vaccination (1-14 days IRR: 1.21, 95% CI: 0.62-2.37; 15-28 days IRR: 1.08, 95% CI: 0.53-2.20; 1-28 days IRR: 1.16, 95% CI: 0.70-1.90). No association between RVO and vaccination was found in subgroup analyses by type of vaccine, gender and age.

CONCLUSIONS

This self-controlled case series found no evidence of an association between RVO and COVID-19 vaccination.

Retinal vein occlusion in the general population after COVID-19 vaccination and infection

INTRODUCTION

Retinal vein occlusion (RVO) is mostly a consequence of vascular risk factors (VRF). COVID-19 vaccines have been related to vascular and thrombotic events (VTE).

OBJECTIVE

To assess the RVO incidence in the general population in our health area and the possible relation with COVID-19 infection and vaccination.

METHODS

Demographic features, classic VRF, thrombophilia data, COVID-19 status, and Framingham risk score were collected prospectively.

RESULTS

472 consecutive patients studied over 13 years with RVO were included (Valdecilla Cohort). Classic VRFs were present in 90%, antiphospholipid syndrome in 12.3%, and genetic thrombophilia in 13.5%. Ninety-one percent of RVO patients were vaccinated and 6.8% suffered COVID-19 infection. In the cohort, no patient had a new RVO after vaccination or infection. In the general population, 20 subjects had RVO after receiving the vaccine (0.006%). Overall, 8 cases occurred in the first-month post-vaccination and 12 after 30 days. In the early and late groups, there are 3 and 4 patients respectively, with a low-intermediate risk Framingham score. Twenty-nine patients in the cohort suffered SARS-CoV-2 infection, twenty-seven of them had RVO before infection. Two patients with low-risk Framingham scores had RVO after infection, one of them early (<1 month).

CONCLUSIONS

Vaccination and COVID-19 might be involved in the development of RVO in some cases, mainly in patients without VRF, thrombophilia, or chronic inflammatory conditions and with a lower Framingham score, especially in the first month after vaccination or infection.

Branch retinal vein occlusion following ChAdOx1 nCoV-19 (Oxford-AstraZeneca) vaccine

PURPOSE

To present a case of branch retinal vein occlusion (BRVO) following ChAdOx1 nCoV-19 (Oxford-AstraZeneca) Vaccine.

METHODS

Case report.

RESULTS

A 60-year old otherwise healthy Caucasian male, presented to the ophthalmology emergency clinic complaining of sudden, painless vision loss in his right eye of 24 h" duration. The patient had received Vaxveria seven days prior. The clinical and fundus examination of the right eye established the diagnosis of BRVO.

CONCLUSION

The present case descibes the occurrence of BRVO soon after the vaccination with the Oxford-AstraZeneca vaccine. The close temporal relationship between the BRVO incidence and the vaccination is reinforced by the lack of othe subjective cause to justify the episode.

DeepDrRVO: A GAN-auxiliary two-step masked transformer framework benefits early recognition and differential diagnosis of retinal vascular occlusion from color fundus photographs

Retinal vascular occlusion (RVO) are common causes of visual impairment. Accurate recognition and differential diagnosis of RVO are unmet medical needs for determining appropriate treatments and health care to properly manage the ocular condition and minimize the damaging effects. To leverage deep learning as a potential solution to detect RVO reliably, we developed a deep learning model on color fundus photographs (CFPs) using a two-step masked SwinTransformer with a Few-Sample Generator (FSG)-auxiliary training framework (called DeepDrRVO) for early and differential RVO diagnosis. The DeepDrRVO was trained on the training set from the in-house cohort and achieved consistently high performance in early recognition and differential diagnosis of RVO in the validation set from the in-house cohort with an accuracy of 86.3%, and other three independent multi-center cohorts with the accuracy of 92.6%, 90.8%, and 100%. Further comparative analysis showed that the proposed DeepDrRVO outperforms conventional state-of-the-art classification models, such as ResNet18, ResNet50d, MobileNetv3, and EfficientNetb1. These results highlight the potential benefits of the deep learning model in automatic early RVO detection and differential diagnosis for improving clinical outcomes and providing insights into diagnosing other ocular diseases with a few-shot learning challenge. The DeepDrRVO is publicly available on https://github.com/ZhouSunLab-Workshops/DeepDrRVO.

The Incidence, Time to Development, and Risk Factors for Fellow Eye Retinal Vein Occlusions

BACKGROUND AND OBJECTIVE

Little is known about factors affecting risk or time to development of fellow eye retinal vein occlusion (RVO). The purpose of this study was to examine the incidence and risk factors for fellow eye RVO.

PATIENTS AND METHODS

This was a retrospective case-control study comparing unilateral and fellow eye RVO patients. This study was exempt by the Cleveland Clinic Institutional Review Board.

RESULTS

Out of 1,083 patients, fellow eye RVO had a cumulative incidence of 3.6% (95% CI 2.61, 4.94) with a median time to development of 18 months (95% CI 6.0, 28.0). Fellow eye disease was associated with multiple characteristics including chronic kidney disease (odds ratio [OR] 3.78, 95% CI 1.89 to 7.55) and diabetic retinopathy (3.18, 1.57 to 6.44).

CONCLUSION

While fellow eye RVO is relatively rare, it typically occurs within the first few years following initial diagnosis. Multiple characteristics were associated with fellow eye disease and time to onset. [Ophthalmic Surg Lasers Imaging Retina 2023;54:471-476.].

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.

Update on Retinal Vein Occlusion

Retinal vein occlusion represents the second leading cause of retinal vascular disorders, with a uniform sex distribution worldwide. A thorough evaluation of cardiovascular risk factors is required to correct possible comorbidities. The diagnosis and management of retinal vein occlusion have changed tremendously in the last 30 years, but the assessment of retinal ischemia at baseline and during follow-up examinations remains crucial. New imaging techniques have shed light on the pathophysiology of the disease and laser treatment, once the only therapeutic option, is now only one of the possible approaches with antivascular endothelial growth factors and steroid injections being preferred in most cases. Nowadays long-term outcomes are better than those achievable 20 years ago and yet, many new therapeutic options are under development, including new intravitreal drugs and gene therapy. Despite this, some cases still develop sight-threatening complications deserving a more aggressive (sometimes surgical) approach. The purpose of this comprehensive review is to reappraise some old but still valid concepts and to integrate them with new research and clinical data. The work will provide an overview of the disease's pathophysiology, natural history, and clinical features along with a detailed discussion on the advantages of multimodal imaging and of the different treatment strategies with the aim of providing retina specialists with the most updated knowledge in the field.

Red Blood Cells: A Newly Described Partner in Central Retinal Vein Occlusion Pathophysiology?

Central retinal vein occlusion (CRVO) is a frequent retinal disorder inducing blindness due to the occlusion of the central vein of the retina. The primary cause of the occlusion remains to be identified leading to the lack of treatment. To date, current treatments mainly target the complications of the disease and do not target the primary dysfunctions. CRVO pathophysiology seems to be a multifactorial disorder; several studies did attempt to decipher the cellular and molecular mechanisms underlying the vessel obstruction, but no consensual mechanism has been found. The aim of the current review is to give an overview of CRVO pathophysiology and more precisely the role of the erythroid lineage. The review presents emerging data on red blood cell (RBC) functions besides their role as an oxygen transporter and how disturbance of RBC function could impact the whole vascular system. We also aim to gather new evidence of RBC involvement in CRVO occurrence.

Aldosterone as a Possible Contributor to Eye Diseases

Aldosterone, an effector molecule of the renin-angiotensin-aldosterone system (RAAS), has been receiving more attention in the field of ophthalmology because of its possible role in the pathogenesis of various eye diseases or abnormalities; it may even become a target for their treatment. Primary aldosteronism, a typical model of a systemic aldosterone excess, may cause vision loss due to various ocular diseases, such as retinal vein occlusion, central serous chorioretinopathy, and, possibly glaucoma. RAAS components are present in various parts and types of cells present in the eye. Investigations of the local RAAS in various animal models of diabetic macular edema, retinal vein occlusion, retinopathy of prematurity, central serous chorioretinopathy, and glaucoma have found evidence that aldosterone or mineralocorticoid receptors may exacerbate the pathology of these disorders. Further studies are needed to elucidate whether the modulation of aldosterone or mineralocorticoid receptors is an effective treatment for preventing vision loss in patients with eye diseases.

Association between Retinal Vein Occlusion and Life's Simple 7 Cardiovascular Health Metrics: A Large Claims Database Study

PURPOSE

Cardiovascular diseases and retinal vein occlusion (RVO) have many risk factors in common. We aimed to investigate the associations between RVO occurrence and each of the cardiovascular health (CVH) metrics known as Life's Simple 7, which are indicators of an unhealthy lifestyle.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Individuals in the JMDC Claims Database (JMDC Inc) who underwent health checkups between 2005 and 2020.

METHODS

We set the following exposures: (1) each component of the CVH metrics (body mass index, blood pressure [BP], fasting blood glucose, total cholesterol, smoking, dietary habits, and physical activity) and (2) the number of nonideal CVH metrics (nonideal CVH score, ranging from 0 [healthiest] to 7 [unhealthiest]). The study outcomes were RVO and central RVO (CRVO) occurrence, which were identified on the first date of diagnosis. We performed Cox regression analyses, with covariates including age, sex, and glaucoma.

MAIN OUTCOME MEASURES

The hazard ratios for RVO and CRVO occurrence for (1) each component of the CVH metrics and (2) the nonideal CVH score.

RESULTS

We included 2 093 536 individuals. During a mean follow-up period of 1070 ± 884 days, there were 3265 RVO and 789 CRVO events. An increased risk of RVO occurrence was most strongly associated with a nonideal BP (hazard ratio [HR], 2.25; 95% confidence interval [CI], 2.06-2.46), followed by a nonideal body mass index (HR, 1.31; 95% CI, 1.21-1.41). Individuals with nonimprovement in BP within 1 year showed a higher risk of RVO occurrence than those with improvement (HR, 2.07; 95% CI, 1.70-2.52). The adjusted HRs of the groups with nonideal CVH scores of 6 to 7, 5, 4, 3, 2, and 1 were 3.76 (2.66-5.30), 2.87 (2.06-4.00), 2.57 (1.85-3.57), 2.22 (1.60-3.08), 1.79 (1.29-2.48), and 1.39 (0.99-1.95), respectively, compared with the group with a score of 0. Similar results were observed for CRVO.

CONCLUSIONS

The strongest risk factor for RVO was nonideal BP, followed by nonideal body mass index. There was a dose-dependent positive association between a nonideal CVH score and RVO occurrence. These findings are important with respect to the identification of individuals at higher risk of RVO.

Retinal vein occlusion in patients under 50 years. Analysis of vascular risk factors, thrombophilia, carotid ultrasound findings and uncommon aetiologies

INTRODUTION

Retinal vein occlusion (RVO) has been related to vascular risk factors and thrombophilia.

METHODS

This is a prospective cohort study of all patients diagnosed with RVO and referred to an Internal Medicine clinic of a tertiary teaching hospital during a 10-year period. Clinical, laboratory and supra-aortic trunks ultrasound variables were analysed and compared according to age.

RESULTS

Some 309 patients diagnosed with RVO were included, 25 of them younger than 50 years. The prevalence of high blood pressure, dyslipidaemia, diabetes mellitus, hyperhomocysteinemia, and carotid plaque was significantly higher in patients >50 years than in those below. However, the prevalence of inherited thrombophilia was higher in the younger group (32.0% vs 11.4%; p = 0.005). Uncommon diseases related to RVO such as hepatitis C, thalassemia minor, Lyme disease, vasculitis, and periphlebitis were observed in young patients without vascular risk factors.

CONCLUSION

We suggest performing a genetic thrombophilia study in RVO patients younger than 50 years, while an exhaustive control of vascular risk factors is always recommended in all RVO patients. Moreover, we suggest bearing in mind uncommon diseases related to RVO, especially in young patients without vascular risk factors.

Retinal vein and artery occlusion as the first manifestation of primary antiphospholipid syndrome in a pediatric patient

Antiphospholipid syndrome is an acquired autoimmune disease characterized by hypercoagulability associated with recurrent venous and arterial thromboembolism in the presence of antiphospholipid antibodies. Herein, we report a case of rapid sequential retinal vein and artery occlusion as the first manifestation of a primary antiphospholipid syndrome triggered by an acute Mycoplasma infection in a previously healthy 11-year-old patient. On day 1, ophthalmoscopy revealed a central retinal vein occlusion. The patient developed temporal branch retinal artery occlusion the next day. On day 3, a central retinal artery occlusion was observed. Serum lupus anticoagulant, immunoglobulin (Ig) G anticardiolipin, IgG anti-β2-glycoprotein 1 antibody, and Mycoplasma pneumoniae IgM antibody levels were increased. Thus, retinal vascular occlusions can be the first manifestation of primary antiphospholipid syndrome. Although it may not improve visual prognosis, prompt diagnosis and treatment are essential to avoid further significant morbidity.

Case Report: Recurrent retinal vein occlusion as the first clinical manifestation of systemic lupus erythematosus in a male patient

Systemic lupus erythematosus (SLE) is a chronic, autoimmune disease characterized by widespread clinical manifestations and immunological disorders. A myriad of ocular manifestations can be seen in patients with SLE. The most vision-threatening complication is vaso-occlusive retinopathy including retinal vein occlusion (RVO). RVO associated with SLE is well described in the literature and its association with antiphospholipid antibodies is recognized. However, RVO as the initial manifestation of SLE is scarcely reported.

Herein, we report the first case of recurrent RVO as the revealing manifestation of SLE in a 40-year-old male patient. He had two consecutive episodes of decreased vision. Ophthalmologic examination disclosed a branch retinal vein occlusion the first time and a central retinal vein occlusion the second time. The diagnosis of SLE was established based on clinical and immunological criteria. He was prescribed antiplatelet therapy, hydroxychloroquine at 5.5 mg/kg/day, and intravitreal anti-vascular endothelial growth factor (VEGF) antibodies regimen. He slowly improved under treatment.

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.

ENDOTHELIN-1 AS A RISK FACTOR IN RETINAL VEIN OCCLUSION

PURPOSE

Retinal vein occlusion (RVO) risk factors largely coincide with cardiovascular risk factors. Endothelin-1 (ET-1), the most potent vasoconstrictor with proinflammatory properties, is a known cardiovascular risk factor. In this study, we explore the role of serum ET-1 as a potential risk factor for RVO.

METHODS

Endothelin-1 serum levels were measured in patients with RVO and control subjects. Samples were measured using the sandwich enzyme-linked immunosorbent assay for the quantitative determination of human big endothelin-1 (Biomedica Group, Austria).

RESULTS

The study consisted of 147 RVO patients and 150 control subjects. Median serum ET-1 was significantly higher in RVO patients (0.26 pmol/L; range, 0.19-0.37 pmol/L) compared with control subjects (0.10 pmol/L; range, 0.05-0.22 pmol/L) (P < 0.0001) independent of the occlusion site. The difference remained significant after adjusting for arterial hypertension, diabetes mellitus, history of stroke, history of myocardial infarction, history of venous thromboembolism, glomerular filtration rate, and c-reactive protein.

CONCLUSION

In conclusion, our results suggest that ET-1 is a potential risk factor for all types of RVO.

Combined central retinal artery and vein occlusion associated with antiphospholipid syndrome

A female patient in early 50s presented to us several months after developing severe visual loss in her right eye. The patient was diagnosed with resolved central retinal vein occlusion (CRVO) based on the clinical picture at the time of presentation, however, retroactive evaluation of fundus imaging and further multi-disciplinary workup led to the rare diagnosis of combined central retinal artery and vein occlusion associated with antiphospholipid syndrome (APS). Only a few cases reporting retinal arterial and venous occlusions in patients with APS are found in the literature. To the best of our knowledge, no case of simultaneous CRAO and CRVO has been reported with APS. The patient was started on lifelong warfarin therapy to prevent a similar episode in the left eye. It is important to properly evaluate patients presenting with retinal vascular occlusions, as a missed diagnosis of APS can lead to recurrent and more devastating vascular events.

CLINICAL SIGNIFICANCE OF RETINAL VASCULAR OCCLUSION IN MOYAMOYA DISEASE: Case Series and Systematic Review

PURPOSE

Although moyamoya disease primarily affects the carotid artery in the ophthalmic artery bifurcation area, retinal vascular abnormalities in moyamoya disease have rarely been reported. The purpose of this report is to describe clinical findings of patients with retinal vascular occlusion in patients with moyamoya disease and present its clinical significance.

METHODS

We reviewed and analyzed patients with moyamoya disease with retinal vascular occlusions. For this, a retrospective medical chart review was performed in a tertiary medical center and a literature search was performed using PubMed and EMBASE until September 2020.

RESULTS

Patients with retinal artery occlusion (RAO) were significantly younger than patients with retinal vein occlusion (25.0 vs. 40.1 years, P = 0.023). Of 14 patients, retinal vascular occlusion was the presenting sign of moyamoya disease in 8 (57.1%) patients. The occlusion site at the carotid artery was proximal to the ophthalmic artery bifurcation area in 8 (57.1%) patients. Legal blindness occurred in 8 (57.1%) patients at final visits.

CONCLUSION

Retinal vascular occlusion is a rare but sight-threatening ocular complication in patients with moyamoya disease. Overall, younger age may be a risk factor for RAO, whereas older age for retinal vein occlusion. Retinal vascular occlusion can be an important indicator of moyamoya disease screening, especially in relatively younger and healthy patients.

Is retinal vein occlusion associated with depression symptoms?: A nationwide cohort study

Retinal vessels share similar anatomical and physiological characteristics with the cerebral microvasculature, and abnormal cerebral blood flow is reportedly associated with depressive disorder. However, there is limited evidence regarding the relationship between depression and the risk of retinal vein occlusion (RVO). This study aimed to investigate the association between depression and the prospective risk of RVO using nationally representative longitudinal data. This retrospective, nationwide, population-based cohort study included 9,178,222 people aged 20 years or older who underwent the Korean National Health Screening Program examination in 2009. The depression group consisted of subjects whose initial diagnoses were made between 2009 and 2010 (n = 128,700). The predictive value for RVO was analyzed using multivariate Cox proportional hazard regression models.From the Kaplan-Meier curves, the depression group showed significantly higher RVO incidence probability, relative to the comparison group (P < .0001). After all confounding variables were adjusted, the hazard ratio of RVO in the depression group with or without recurrence was 1.2 (95% confidence interval [CI]: 1.076-1.338) and 1.087 (95% CI: 1.012-1.167), respectively, relative to the comparison group. This is the first nationwide, population-based, epidemiologic study that evaluated the association between depression and the risk of RVO development. The presence of depression was significantly associated with increased risks of RVO, and the recurrence of depression showed a higher RVO incidence probability.

The Nationwide Incidence of Retinal Vein Occlusion Following Dialysis due to End-stage Renal Disease in Korea, 2004 through 2013

BACKGROUND

We investigated the incidence and risk of retinal vein occlusion (RVO) in end-stage renal disease (ESRD) patients on dialysis in Korea.

METHODS

In this nationwide cohort study, we used Korean National Health Insurance Service data between 2004 and 2013 for analysis. ESRD patients who started dialysis from 2004 to 2013 and an equal number of controls were selected through propensity score matching. RVO incidence in both cohorts were calculated for 2004-2013 using washout data from 2003. The multivariable Cox proportional hazards model was used to assess the risk of RVO in dialysis cohort. The Kaplan-Meier method was used to generate the cumulative RVO incidence curve. Whether the dialysis modality affects the development of RVO was also evaluated.

RESULTS

In this study, 74,551 ESRD patients on dialysis and the same number of controls were included. The incidence of RVO was significantly higher in the dialysis cohort than in the control cohort (dialysis = 7.3/1,000 person-years [PY]; control = 1.9/1,000 PY; P < 0.001). The cumulative-incidence of RVO was also significantly higher in the dialysis cohort than in the control cohort (P < 0.001; log-rank test). However, there was no significant difference in the incidence of RVO between the two dialysis methods (P = 0.550; log-rank test).

CONCLUSION

This study provided epidemiological evidence that receiving dialysis for ESRD could increase the risk of developing RVO. We also found a rapid increase in the incidence of RVO with a longer dialysis period. These results strengthen the relationship between retinal vascular disease and renal function.

Diabetic and Retinal Vascular Eye Disease

The retinal vasculature is the only neurovascular system directly visible to the human eye, easily evaluated by fundoscopy and many imaging modalities. This window allows physicians to diagnose and treat retinal pathologies and detect systemic diseases including diabetes, hypertension, hypercoagulable/hyperviscosity syndromes, and vasculitis. Diabetic retinopathy is the most common retinal vascular disease, followed by retinal vein and artery occlusion. Patients with these conditions require medical optimization to prevent further damage to the eyes and to the other organs. Both the internists and medical subspecialists play a crucial role in the prevention, detection, evaluation, and management of vision-threatening retinal vascular diseases.

Risk of retinal vein occlusion in patients with diabetes mellitus: A retrospective cohort study

AIMS

To investigate the risk of retinal vein occlusion (RVO) in new-onset diabetes mellitus (DM) patients.

METHODS

This nationwide, retrospective, matched cohort study included 240,761 DM patients registered between January 2003 and December 2005 in the Longitudinal Cohort of Diabetes Patients database. An age- and sex-matched control group comprising 240,761 non-DM patients (case: control = 1:1) was selected from the Taiwan Longitudinal Health Insurance Database 2000. Information for each patient from the index date until December 2013 was collected. The incidence and risk of RVO were compared between the two groups. Cox proportional hazard regression analysis was performed to calculate the adjusted hazard ratio (HR) for RVO after adjustment for potential confounders. The RVO cumulative incidence rate was obtained using Kaplan-Meier analysis.

RESULTS

During the follow-up period, 1,456 DM patients developed RVO (491, central retinal vein occlusion; 965, branch retinal vein occlusion). There was a significantly elevated risk of RVO in DM patients compared with the controls (incidence rate ratio = 1.91, 95% confidence interval [CI] = 1.75-2.08). Patients with DM showed significant risk of RVO after adjustment for potential confounders (hypertension, hyperlipidemia, congestive heart failure, coronary artery disease, and chronic renal disease) in the full cohort (adjusted HR = 1.76, 95% CI = 1.61-1.93). Additionally, patients with hypertension had a significantly higher risk of RVO than patients without hypertension after adjustment for other confounders in the cohort (adjusted HR = 1.50, 95% CI = 1.36-1.65).

CONCLUSIONS

We found that patients with DM have increased risks of RVO. In addition to blood pressure control, we recommend educating patients with DM about RVO, to prevent its subsequent occurrence.

Anti-VEGF Therapy and Retinal Photocoagulation to Prevent Recurrence of Central Retinal Vein Occlusion: Two Case Reports of Young Patients

Case 1: An 18-year-old man. On initial examination, he was diagnosed with central retinal vein occlusion (CRVO) due to optic papillitis. He had no previous systemic and ocular medical history. His best corrected visual acuity was 20/20 for the right eye, but macular edema accompanied by serous retinal detachment was observed about 2 months after the initial examination. Intravitreal anti-VEGF injection was performed, and the symptoms improved. Then, additional photocoagulation was applied to the retinal nonperfusion area, to maintain its normal state. Case 2: A 36-year-old man. He was diagnosed with neovascular glaucoma associated with CRVO in the right eye by his previous physician. Panretinal photocoagulation and intravitreal anti-VEGF injection were performed under maximum-tolerated medical therapy for the right eye. He had diabetes. On initial examination, his visual acuity was 20/100 and his intraocular pressure was 19mmHg. Macular edema and iris neovascularization recurred half a year later, so intravitreal anti-VEGF injection and additional photocoagulation were applied to nonperfusion area. After that, both macular edema and iris neovascularization have settled down. Conclusions: Intravitreal anti-VEGF injection is effective in young patients with CRVO. Also, photocoagulation to nonperfusion area in addition to the continuous treatment with intravitreal anti-VEGF injection seems effective for preventing recurrence.