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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 18  |  Issue : 3  |  Page : 205-207

Combined retinal vascular occlusion in a recovered case of COVID-19


Department of Vitreo-Retina, Aditya Jyot Eye Hospital Pvt. Ltd., Mumbai, Maharashtra, India

Date of Submission15-May-2021
Date of Decision21-Jun-2021
Date of Acceptance30-Jun-2021
Date of Web Publication11-Aug-2021

Correspondence Address:
Jaydeep Avinash Walinjkar
Aditya Jyot Eye Hospital Pvt. Ltd., Plot No. 153, Major Parameshwaran Road, Opp. SIWS College, Wadala (West), Mumbai - 400 031, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_38_21

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  Abstract 


Hypercoagulability in COVID-19 can be described as a “sepsis-induced coagulopathy” and may be a precursor for thromboembolic events. There are other reported milder ocular manifestations of COVID-19 disease such as conjunctivitis, as well as a few reported central retinal vein occlusions (CRVOs), combined retinal vascular occlusion has never been reported. We report the case of a 66-year-old male, who presented to us with combined central retinal artery occlusion and CRVO with proven COVID-19 infection, diagnosed after presentation.

Keywords: Central retinal artery occlusion, central retinal vein occlusion, COVID-19, ocular manifestations of COVID-19, thromboembolic phenomena in COVID-19


How to cite this article:
Walinjkar JA. Combined retinal vascular occlusion in a recovered case of COVID-19. Apollo Med 2021;18:205-7

How to cite this URL:
Walinjkar JA. Combined retinal vascular occlusion in a recovered case of COVID-19. Apollo Med [serial online] 2021 [cited 2021 Dec 6];18:205-7. Available from: https://www.apollomedicine.org/text.asp?2021/18/3/205/323676




  Introduction Top


October 2019 saw the emergence of a new betacoronavirus, the SARS-CoV-2, which rapidly evolved into a global pandemic. Initially and primarily touted as a respiratory illness, there is evidence to prove that it should be considered as a systemic pathology involving several systems and organs.[1] Literature on ocular manifestations of COVID-19 is quite scarce, and out of that, largely comprises reports of conjunctivitis and ocular surface disease.[2],[3] However, the fact that COVID-19 is implicated as an etiologic factor in thromboembolic events leads us to believe that it is a causative factor for retinal vascular occlusion as well.[4]

We report a case of combined central retinal artery and vein occlusion (CRAO and CRVO) – in a 66-year-old male with a proven history of COVID-19 disease being the possible etiology. We performed a thorough literature search and to the best of our knowledge, no other case of combined CRAO and CRVO has been reported in COVID-19 positive patients in literature.


  Case Report Top


A 66-year-old gentleman with no significant past medical systemic history presented to us for a second opinion. He had developed sudden profound diminution of vision in the right eye (oculus dexter [OD]) 1 week before coming to our institute. He was diagnosed with OD CRAO with macular edema elsewhere after which he received one intravitreal injection antivascular endothelial growth factor (VEGF) 5 days before visiting us. OD had apparently normal vision before this episode, and there was no history of any past ocular illness in OD. His vitals were stable and best-corrected visual acuity was perception of hand movements in OD and no light perception in the left eye (OS). Intraocular pressure (Perkins) was 9 mmHg in both eyes (OU). Examination of anterior segment with slit lamp showed a relative afferent papillary defect in OD and nonreactive, mid-dilated pupil in the OS, bilateral pseudophakia with rest of the findings within normal limits in OU. Indirect ophthalmoscopy [Figure 1] in OD showed optic disc swelling with splinter hemorrhages, multiple flame shaped, and blot intraretinal hemorrhages in all quadrants of the retina. The retinal veins appeared grossly dilated and tortuous while the arteries were severely attenuated. There were also areas of retinal whitening with a faint cherry-red spot.
Figure 1: Fundus photograph (oculus dexter) showing optic disc edema with splinter hemorrhages. Retina appears pale with grossly dilated veins and attenuated arteries. There is a faint cherry-red spot seen, with multiple hemorrhages in all quadrants of the retina

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OS revealed the presence of a closed funnel retinal detachment with proliferative vitreoretinopathy which had occurred few years ago, and no treatment was sought then by the patient then. OS was in an inoperable state with very poor to nil visual prognosis.

A diagnosis of combined retinal vascular occlusion – CRAO and CRVO – was made after clinical examination and fundus fluorescein angiography (FFA) and optical coherence tomography (OCT). OCT showed evidence of macular edema, hyperreflective and distorted inner retinal layers [Figure 2]. FFA showed normal choroidal filling with late arterial filling and delayed arteriovenous filling time in the early phase. There was arteriolar attenuation and dilated and tortuous veins with multiple filling defects in the venous phase and staining of vessels in the late phase. Cystoid macular edema was noted in the late phase with diffuse staining of the posterior pole retina.
Figure 2: Optical coherence tomography (oculus dexter) - distortion of all inner retinal layers, with pockets of intra retinal edema

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As part of retinal vascular occlusion workup, following investigations were done: complete blood count with erythrocyte sedimentation rate and C-reactive protein, peripheral smear, fasting lipid profile, blood sugar profile, antinuclear antibody (screen), rheumatoid factor (rheumatoid arthritis), urine routine and micro-albumin, serum angiotensin-converting enzyme, serum homocysteine, blood urea nitrogen, serum osmolality, renal function and liver function tests, and serum D-dimer. All the reports were found to be within normal limits. Bilateral carotid Doppler imaging showed very minimal intimal thickening of internal carotids bilaterally, consistent with his age. Although the patient was asymptomatic systemically, in view of recent reports citing retinal vascular occlusions associated with recent COVID-19 infection, we asked for a high-resolution chest computed tomography scan (chest scan) which showed ground-glass opacities consistent with COVID-19-associated pneumonia and a serum antigen detection test for COVID-19 which turned out to be positive. The patient refused to do a reverse transcriptase-polymerase chain reaction test for detection of active COVID-19 infection.

On follow-up after 3 weeks, OD showed signs of clinical improvement, having received intravitreal anti-VEGF elsewhere earlier. However, there was marginal improvement in OD vision up to counting fingers at 1 m. He was advised further doses of intravitreal anti-VEGF ranibizumab 0.05 ml of 10 mg/ml concentration with due precautions and is maintained on close follow-up. After another two doses of injection anti-VEGF 1 month apart in OD, there was no further improvement in vision even though the macular edema resolved completely possibly due to ischemic changes secondary to CRAO.


  Discussion Top


Intraocular manifestations of COVID-19 are not widely reported. Almost, all the case reports that have been reported are those of conjunctivitis. Increasingly, there have been reports of thromboembolic phenomena associated with COVID-19.[4],[5] The retinal circulation being an end arterial system has potentially blinding consequences due to vascular occlusions. Sheth et al.[5] reported a case of vasculitic retinal vein occlusion secondary to COVID-19 in a 52-year-old patient who presented with the diminution of vision in the left eye 10 days after he tested positive for SARS-CoV-2. All investigations for ocular inflammation were negative, as in our case. Their case supports the mechanism of thromboinflammatory state secondary to the “cytokine storm” as the pathogenesis for systemic manifestations of COVID-19.

Marinho et al.[6] reported the cases of 12 adults from 25 to 69 years who presented with sudden decrease of vision and had cotton wool spots and hemorrhages along the retinal arcade on examination. OCT showed the presence of hyperreflective lesions at the level of ganglion cell and inner plexiform layers more prominently at the papillomacular bundle, done 11–33 days after COVID-19 onset, and a provisional diagnosis of retinitis was made. Unlike their report, however, our patients did not have an inflammatory component. Bikdeli et al.[7] have suggested that COVID-19 may predispose patients to thromboembolic phenomena. Case reports of three patients, <41 years of age, proven COVID-19 positive, presenting with cerebral venous thrombosis were reported by Cavalcanti et al.[8] At present, the incidence of venous thromboembolic phenomena is estimated at around 25% of patients hospitalized in the intensive care unit for COVID-19 even under anticoagulant treatment at prophylactic doses. Ocular manifestations have been reported to be the first sign of COVID-19.[9] Apart from conjunctivitis, coronaviruses are reported to cause granulomatous anterior uveitis, choroiditis with retinal detachment, and retinal vasculitis[2] but our case had no positive inflammatory markers. COVID-19 is now being understood also as a thromboembolic disease affecting multiple organs.[10] D-dimer has been observed to be very high in patients with COVID-19 with a 10-fold increase in D-dimer compared to interleukin-6 reflecting true thrombotic disease, possibly induced by cellular activation triggered by the virus. Many different studies have shown a strong association between elevated D-dimer levels vis-à -vis severity and prognosis of disease with specific concerns about thrombotic complications of COVID-19 such as pulmonary embolism, stroke, disseminated intravascular coagulation, limb, and digit infarcts.[11] To the best of our knowledge, there has been no reported case of combined retinal vascular occlusion in an asymptomatic patient recovered from COVID-19. We present this as a first case report of combined retinal vascular occlusion presenting as a first sign in a case of COVID-19 infection with no other known possible etiology. This has implications in terms of the ophthalmologists being aware of COVID-19 as a possible etiology of combined retinal vascular occlusions with a need for a different therapeutic approach to such cases-in terms of hospitalization, alerting the proper authorities, and following the protocol for COVID suspects along with the usual ocular vascular occlusion workup.[12] There is also an emphasis further, for protocols for personal protection of ophthalmologists even in so called “non-COVID” patients presenting with combined retinal vascular occlusion who could have a possible underlying undiagnosed active or past COVID-19 infection which might be missed altogether.


  Conclusion Top


When it comes to the ocular manifestations of COVID-19 much is still unknown. We believe that for the 1st time, to the best of our knowledge, this case of combined retinal vascular occlusion secondary to COVID-19 will help us to increase our knowledge about the various ocular manifestations and be vigilant about this vision-threatening ocular disease caused by a potentially life-threatening virus.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Temgoua MN, Endomba FT, Nkeck JR, Kenfack GU, Tochie JN, Essouma M. Coronavirus disease 2019 (COVID-19) as a multi-systemic disease and its impact in low- and middle-income countries (LMICs). SN Compr Clin Med 2020:1-11.  Back to cited text no. 1
    
2.
Seah I, Agrawal R. Can the coronavirus disease 2019 (COVID-19) affect the eyes? A review of coronaviruses and ocular implications in humans and animals. Ocul Immunol Inflamm 2020;28:391-5.  Back to cited text no. 2
    
3.
Hu K, Patel J, Patel BC. Ophthalmic Manifestations of Coronavirus (COVID-19) 8 August 2020. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2020.  Back to cited text no. 3
    
4.
Allegra A, Innao V, Allegra AG, Musolino C. Coagulopathy and thromboembolic events in patients with SARS-CoV-2 infection: Pathogenesis and management strategies. Ann Hematol 2020;99:1953-65.  Back to cited text no. 4
    
5.
Sheth JU, Narayanan R, Goyal J, Goyal V. Retinal vein occlusion in COVID-19: A novel entity. Indian J Ophthalmol 2020;68:2291-3.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Marinho PM, Marcos AA, Romano AC, Nascimento H, Belfort R Jr. Retinal findings in patients with COVID-19. Lancet 2020;395:1610.  Back to cited text no. 6
    
7.
Bikdeli B, Madhavan MV, Jimenez D, Chuich T, Dreyfus I, Driggin E, et al. COVID-19 and thrombotic or thromboembolic disease: implications for prevention, antithrombotic therapy, and follow-up: JACC state-of-the-art review. J Am Coll Cardiol 2020;75:2950-73.  Back to cited text no. 7
    
8.
Cavalcanti DD, Raz E, Shapiro M, Dehkharghani S, Yaghi S, Lillemoe K, et al. Cerebral venous thrombosis associated with COVID-19. AJNR Am J Neuroradiol 2020;41:1370-6.  Back to cited text no. 8
    
9.
Daruich A, Martin D, Bremond-Gignac D. Ocular manifestation as first sign of coronavirus disease 2019 (COVID-19): Interest of telemedicine during the pandemic context. J Fr Ophtalmol 2020;43:389-91.  Back to cited text no. 9
    
10.
Oudkerk M, Büller HR, Kuijpers D, van Es N, Oudkerk SF, McLoud T, et al. Diagnosis, prevention, and treatment of thromboembolic complications in COVID-19: Report of the National Institute for Public Health of the Netherlands. Radiology 2020;297:E216-22.  Back to cited text no. 10
    
11.
Zhang Y, Xiao M, Zhang S, Xia P, Cao W, Jiang W, et al. Coagulopathy and antiphospholipid antibodies in patients with COVID-19. N Engl J Med 2020;382:e38.  Back to cited text no. 11
    
12.
Walinjkar JA, Makhija SC, Sharma HR, Morekar SR, Natarajan S. Central retinal vein occlusion with COVID-19 infection as the presumptive etiology. Indian J Ophthalmol 2020;68:2572-4.  Back to cited text no. 12
[PUBMED]  [Full text]  


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