Eye Disorders and Neuro-ophthalmic Manifestations of COVID-19

Growing data are confirming the association between the novel coronavirus disease (COVID-19) and eye disorders, including ocular alterations and neuro-ophthalmic manifestations. The main pathophysiological mechanisms considered included a direct infection through the ocular surface, a post-viremia secretion of the virus from the lacrimal glands, and a viral dissemination through the bloodstream. According to the different ways of contagion, different structures could be involved.The most common ocular symptoms reported in COVID-19 patients were dry eye, redness, tearing, itching and pain. Among symptomatic patients, most of them presented conjunctivitis. Considering the posterior chamber, retinal artery and vein occlusions were described in few clinical reports;moreover, some studies presented cases of paracentral acute middle maculopathy occurring in COVID-19 patients. The involvement of the choroid seems to be rare, and a single case of atypical choroiditis was currently described. Between neuro-ophthalmic manifestations, optic neuritis appear to be relatively frequent and generally not associated with magnetic resonance imaging abnormalities. Some reports showed the involvement of the ocular motor nerves, often presenting with palsy. Miller Fisher syndrome has been showed in rare cases;however, this association could be corroborated by the several reports describing Guillain-Barré syndrome occurrence in COVID-19 patients.In line with well-known previous viral infection, COVID-19 seems to be associated with eye involvement. Thus, ocular and neuro-ophthalmic symptoms and signs should be carefully assessed and monitored in these patients. To reach this purpose, it is critical to implement remote diagnostic techniques. Moreover, the comprehension of the pathogenetic mechanisms is still scarce and no standardized diagnostic protocol was established for these patients, making necessary further studies to improve current understandings. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

Eye damage in COVID-19. Part 2: posterior segment complications, neuro-ophthalmic manifestations, vaccination and risk factors

Posterior eye segment involvement in COVID-19 has varied manifestations: vascular, inflammatory, and neuronal. All of them are triggered by SARS-CoV-2 virus but they cannot be viewed as exclusively specific to COVID-19. According to the literature, the mean age of the patients varies from 17 to 75 with the median of 50 years. The median duration between the appearance of ophthalmic symptoms and the detection of COVID-19 was 12 days. The disease affects both men and women equally. Direct exposure to the virus, immune-mediated tissue damage, activation of the coagulation system, the prothrombotic state caused by a viral infection, concomitant diseases and medications used in the treatment contribute to the development of eye pathologies. Ophthalmologists should be aware of the possible relations of posterior eye segment pathologies, orbit and neuro-ophthalmic disorders with SARS-CoV-2, as well as the possible exacerbation of chronic forms of inflammatory eye diseases and autoimmune disorders due to anti-COVID-19 vaccination. © 2023, Real Time LLC. All rights reserved.

Late PAMM-Like Lesions in a Patient with HIV Retinopathy

This report describes a case of a newly diagnosed 49-year-old HIV patient, who presented with decreased visual acuity and retinal lesions characterized by ischemia at the level of the deep retinal capillary plexus, documented with optical coherence tomography (OCT), OCT angiography, fluorescein angiography, and visual fields testing. These lesions closely resembled the morphologic and clinical characteristics of late paracentral acute middle maculopathy. The presence of these lesions suggests that HIV microangiopathy can potentially affect both superficial and deep retinal capillary plexuses.

Coincident Acute Macular Neuroretinopathy and Paracentral Acute Middle Maculopathy in COVID-19.

An ophthalmology consultation was requested for a 29-year-old woman complaining of visual field defects. The patient had presented to the emergency department with cough and high fever one day earlier. Chest computed tomography demonstrated pneumonia and two severe acute respiratory syndrome coronavirus 2 polymerase chain reaction tests were positive. The patient had undergone renal transplantation 11 years ago due to glomerulonephritis. Best-corrected visual acuity (BCVA) was 20/40 in the right eye and 20/30 in the left eye. Fluorescein angiography showed macular hypoperfusion, and optical coherence tomography (OCT) showed hyperreflectivity in the inner nuclear, outer plexiform, and outer nuclear layers, as well as discontinuity of the ellipsoid zone. Perimetry confirmed bilateral central scotoma. Levels of D-dimer and fibrinogen were 0.86 g/mL and 435.6 g/mL, respectively. The patient was diagnosed as having concurrent acute macular neuroretinopathy and paracentral acute middle maculopathy and was given low-molecular-weight heparin treatment for one month. Her BCVA improved to 20/20 in both eyes, and regression was observed in the retinal findings, hyperreflectivity and ellipsoid zone disruption on OCT, and scotoma in perimetry. Inflammation, thrombosis, and glial involvement may play a role in the pathogenesis of retinal microvascular impairment in COVID-19.

Acute macular neuroretinopathy as the first stage of SARS-CoV-2 infection.

INTRODUCTION: To report two cases of Acute Macular Neuroretinopathy (AMN) presented as the first stage of SARS-CoV-2 infection in two European countries during the third wave of pandemic viral infection in the early months of 2021. OBSERVATIONS: A unilateral case of type 1 AMN in a man and a bilateral case of type 2 AMN in an otherwise heathy patients were reported. Sudden onset of paracentral scotoma characterized the cases with no systemic symptoms. Structural optical coherence tomography (OCT) shows multifocal middle and inner retinal hyperreflective infarctions. OCT-Angiography showed the presence of hypoperfusion of the deep capillary plexus (DCP) corresponding to the hyperreflective lesions visible on structural OCT, confirming the diagnosis. CONCLUSIONS AND IMPORTANCE: Type 1 and type 2 AMN may be the first stage of SARS-CoV-2 infection. We suggest testing all patients with AMN for SARS-CoV-2. In our cases, the natural history of AMN associated with SARS-CoV-2 infection was similar to already described cases of AMN.

Acute Macular Neuroretinopathy and Paracentral Acute Middle Maculopathy during SARS-CoV-2 Infection and Vaccination.

Purpose: To review the demographic and clinical profile of patients developing acute macular neuroretinopathy (AMN) or paracentral acute middle maculopathy (PAMM) after receiving coronavirus disease-2019 (COVID-19) vaccination or infection. Methods: In this review article, the published literature was searched to determine cases developing either AMN or PAMM after COVID-19 vaccinations or infections. Data, including demographic profile, presenting features, symptoms, diagnosis, and clinical outcomes, were extracted from the selected publications. These parameters were compared between the two groups, i.e., patients developing AMN/PAMM either after vaccination or infection. Results: After the literature review, 57 patients developing either AMN (n = 40), PAMM (n = 14), or both (n = 3) after COVID-19 infection (n = 29) or vaccination (n = 28) were included (mean age: 34.9 ± 14.4 years; n = 38; 66.7% females). In 24.6% patients, the diagnosis of COVID-19 infection was preceded by the development of ocular disease. There were no significant differences in the age or gender between the patients developing AMN or PAMM after vaccination or infection (p > 0.13). Among the vaccination group, the highest number of patients developing AMN/PAMM were after the Oxford-AstraZeneca (n = 12; 42.9%). Patients with vaccination had a significantly early onset of AMN/PAMM compared to those with infection (11.5 ± 17.6 days versus 37.8 ± 43.6 days; p = 0.001). Conclusions: Both AMN and PAMM are reported to be associated with COVID-19 infections and in persons receiving vaccination against COVID-19. While COVID-19 infections and vaccinations may have a contributory role, other risk factors such as oral contraceptive pills may also play a role in the development of the disease.

Paracentral Acute Middle Maculopathy Associated With Cilioretinal Artery Insufficiency Following COVID-19 Vaccination in a Young Patient.

We aim to present a unique case of unilateral paracentral acute middle maculopathy (PAMM) associated with cilioretinal artery insufficiency following the coronavirus disease 2019 (COVID-19) vaccination. A 28-year-old male complained of a sudden blurring of vision in his left eye 40 days after receiving the second dose of COVID-19 immunization. The optical coherence tomography revealed a diffuse paracentral area of hyper-reflective change in the inner plexiform layer and an increase in the inner nuclear layer volume, consistent with PAMM along the course of the cilioretinal artery. PAMM has been connected to an assortment of retinal vasculature anomalies. Considering COVID-19 vaccination, we hypothesize that the immunogenic cascade following vaccination dysregulated coagulation and led to retinal vascular thrombosis. However, the link between COVID-19 vaccination and retinal vascular occlusion disease remains unknown.

Multitarget microangiopathy in a young healthy man with COVID-19 disease: A case report.

A 41-year-old man presented to the emergency department complaining of decrease of vision in his left eye. Initial examination was consistent with retrobulbar optic neuritis, and an intravenous drip of methylprednisolone was started. On the third day, the fundus examination revealed the appearance of multiple Purtscher-like cotton-wool spots in the posterior pole and nasally to the optic disc, slight retinal whitening around the fovea, and cherry-red spot. The patient reported flu-like symptoms, and he tested positive at PCR (polymerase chain reaction) test for 2019-nCoV (2019 novel coronavirus) infection. Assuming possible 2019-nCoV-related vascular damage, we prescribed low-molecular-weight heparin. The lesions were regressing at follow-up, and we registered a complete visual recovery.

Branch Retinal Artery Occlusions, Paracentral Acute Middle Maculopathy and Acute Macular Neuroretinopathy After COVID-19 Vaccinations.

Purpose: Potential retinal adverse events after COVID-19 vaccinations reported previously include paracentral acute middle maculopathy (PAMM), acute macular neuroretinopathy (AMN), and central serous chorioretinopathy. We report four cases of branch retinal artery occlusion (BRAO), one case of PAMM, and one case of AMN that occurred after administration of the Pfizer-BioNTech COVID-19 vaccine. Patients and Methods: We retrospectively reviewed the medical records of six patients who presented to Yame General Hospital or Oita University Hospital from July through October 2021. Results: Four patients (2 males) presented with visual field defects associated with BRAO, one male patient with PAMM, and one female patient with AMN after receiving the Pfizer-BioNTech COVID-19 vaccine. The mean age was 59.3 years; the mean best-corrected visual acuity was 20/21. The mean time from the last vaccination to the onset of visual field defect was 22.8 days. Five patients had received two doses of the vaccine and one patient one dose. Patients' medical history included diabetes mellitus in case 2, hypertension in cases 2, 3 and 6, and Alport syndrome and end-stage renal disease in case 6 for which the patient was undergoing regular hemodialysis. Conclusion: Although rare, retinal adverse events may occur after COVID-19 vaccinations. Further studies with a larger sample size should determine whether these retinal abnormalities are causally associated with COVID-19 vaccinations or just coincidental. Potential risks of BRAO/PAMM/AMN after COVID-19 vaccinations must be carefully weighed against the substantial benefit of COVID-19 vaccinations.

Paracentral acute middle maculopathy and COVID-19 vaccination: Causation versus coincidence finding.

The current report is a rare case of paracentral acute middle maculopathy (PAMM) in a previously healthy man following COVID-19 vaccination.

Differentiation between acute macular neuroretinopathy and paracentral acute middle maculopathy in elderly persons: two case reports.

BACKGROUND: We report one case of rare acute macular neuroretinopathy (AMN) in an elderly patient with hypertension and one case of common paracentral acute middle maculopathy (PAMM) in a patient with diabetes mellitus to illustrate the difference between the two diseases. CASE PRESENTATION: This report describes two cases, one involving AMN and the other PAMM. The first patient was a 70-year-old man complaining of blurred vision for 3 days. He was examined with fundus photography, optical coherence tomography angiography (OCTA) and optical coherence tomography (OCT); a diagnosis of AMN was established. The second patient was a 50-year-old woman who complained of decreased vision during the past month. She had had diabetes mellitus for 6 years. From the ophthalmic imaging examination, the patient was diagnosed with PAMM and non-proliferative diabetic retinopathy (NPDR). Both patients were treated with drugs for improving microcirculation and neurotrophic drugs; however, there was no significant improvement in visual acuity. CONCLUSIONS: AMN is more common in young patients and is rarely observed in elderly patients with systemic diseases. The OCTA examination has an auxiliary diagnostic value for deep retinal capillary network ischaemia. Meanwhile, OCT examination has important imaging value in differentiating AMN from PAMM and can help avoid missed diagnoses.

Bilateral paracentral acute middle maculopathy and acute macular neuroretinopathy following COVID-19 vaccination.

A 35-year-old male patient presented with blurring and black spots in vision after 1 month of the second dose of Covishield vaccination. His visual acuity was 6/6; both eyes and anterior and posterior segment examinations were normal. The optical coherence tomography (OCT) showed multiple hyperreflective lesions involving the nerve fiber layer with back shadowing. In addition, there were hyperreflective spots in the ganglion cell layer and outer plexiform layer with focal loss of external limiting membrane and an intact inner segment/outer segment junction involving the posterior pole in both eyes. The patient was diagnosed with paracentral acute middle maculopathy (PAMM) and acute macular neuroretinopathy (AMN) and advised observation. PAMM and AMN are unreported manifestations following the COVID-19 vaccination.

Cilioretinal artery occlusion with paracentral acute middle maculopathy associated with COVID-19.

The purpose of the study is to describe cilioretinal artery (CILRA) occlusion that is presumed to be associated with COVID-19 without severe respiratory distress and inform ophthalmologists of unusual ocular presentations of COVID-19. Here, we present the first case of a patient with isolated CILRA occlusion and paracentral acute middle maculopathy (PAMM) after recently polymerase chain reaction-proven COVID-19. A 26-year-old female patient presented with a visual field defect in her left eye for 2 days and decreased vision compared to her right eye. It was learned that the patient had a laboratory-proven COVID-19 infection with mild respiratory symptoms that did not require hospitalization 2 weeks ago. Fundus examination revealed retinal edema in the left eye area supplied by the CILRA. Spectral-domain optical coherence tomography revealed a prominent hyperreflective band at the inner nuclear layer level. These findings led us to the diagnosis of isolated CILRA occlusion and PAMM associated with recent COVID-19. CILRA occlusion and PAMM could be associated with the inflammatory and procoagulant condition caused by the SARS-CoV-2 infection.

Inner retinal layer ischemia and vision loss after COVID-19 infection: A case report.

INTRODUCTION: COVID-19 infection may also occur with ocular manifestations. Paracentral acute middle maculopathy(PAMM) is a condition that causes ischemia in the inner retinal layers characterized by disruptions in capillary plexus flow. Also, ischemia in inner retinal layers secondary to COVID-19 infection has not yet been reported. CASE REPORT: The case, presented with the complaint of gradually decreasing visual acuity in the right eye after COVID-19 infection. PAMM was suspected, however, ischemia was detected in all inner retinal layers with Optical coherence tomography angiography. DISCUSSION: We showed that it should be kept in mind that atypical retinal involvement of COVID-19 infection could present, with this case.

Retinal manifestations in patients following COVID-19 infection: A consecutive case series.

PURPOSE: To describe retinal manifestations seen in patients associated with COVID-19 infection at a multi-specialty tertiary care hospital in Southern India. METHODS: In this retrospective chart review, all consecutive cases presenting to the Retina-Uveitis service from May 2020 to January 2021 with retinal manifestations associated with COVID-19 infection or its sequelae or as a result of treatment given for COVID-19 were included. RESULTS: : Of the 7 patients, 3 were female, and 4 were male. Four patients had onset of symptoms during the active phase of COVID-19 infection. Four had bilateral and three had unilateral involvement. The manifestations ranged from mild to vision threatening. Vision threatening manifestations included infections: endogenous endophthalmitis, candida retinitis and tubercular choroidal abscess and bilateral pre-foveal hemorrhages. Milder manifestations included paracentral acute middle maculopathy, central serous chorio-retinopathy and voriconazole induced visual symptoms. Final visual acuity was 6/36 or better in the four severe cases and 6/9 or better in the mild cases. CONCLUSION: This study highlights the retinal manifestations associated with COVID-19 infection and its sequelae. As these patients presented with an association with COVID-19 (either during or after recovery), ophthalmologists should be vigilant and screen for such entities in case of complaints of visual symptoms or in the presence of systemic sepsis. The outcomes can be good with prompt and aggressive management.

Paracentral acute middle maculopathy in the setting of central retinal artery occlusion following COVID-19 diagnosis.

BACKGROUND: Since its emergence in Wuhan, China, COVID-19 has disseminated across many other countries worldwide. In this report, we firstly presented a patient with mild COVID-19 disease who developed paracentral acute middle maculopathy (PAMM) due to CRAO. CASE PRESENTATION: A 54-year-old male patient who reported a contact with a COVID-19 patient applied to the hospital and tested positive for SARS-CoV-2 by polimerase chain reaction testing. He had no significant past medical history. Chest computed tomography was not notable. He had a mild COVID-19 course during hospitalization. Two weeks following COVID-19 diagnosis, he reported profund vision loss (counting fingers) in his right eye where central retinal artery occlusion (CRAO) was detected on fundoscopic examination. Coagulation profile was within normal limits. Hypercoagulable work up was also not notable. Treatment was given for CRAO. Visual acuity was counting fingers at 30 cm. Five days following treatment. Optical coherence tomography analysis showed increased diffuse reflectance and thickening at the level of inner nuclear layer consistent with PAMM. Fluorescein angiography illustrated no perfusion defect. CONCLUSION: This is the first case that reports PAMM in the setting of CRAO following COVID-19 diagnosis. Viral induced microangiopathy may involve in the development of CRAO in our patient without a hypercoagulable state and additional risk factors. Physicians should be vigilant to seek for retinal evaluation in patients with significant visual loss even after a mild COVID-19 history.

Covid-19-Associated Retinopathy: A Case Report.

A 53-year-old man presented with acute loss of vision, negative scotoma and dyschromatopsia in his left eye. He reported contact with people with severe respiratory syndrome - coronavirus-2 (SARS-CoV-2) 8 days prior symptoms. Funduscopic examination revealed several retinal hemorrhages. Spectral-domain optical coherence tomography showed lesions consistent with acute macular neuroretinopathy and paracentral acute middle maculopathy. Quickly after his presentation, SARSCov-2 was confirmed by chest computed tomography-scan and RT-PCR in this patient. Thrombotic complications associated with Covid-19 infection have high incidence and may involve the retina. We described a case of retinal involvement associated with Covid-19 infection. PRÉCIS: Funduscopic examination revealed retinal hemorrhages in a man with loss of vision. Optical coherence tomography showed an acute macular neuroretinopathy and paracentral acute middle maculopathy. Coronavirus disease was confirmed by chest computed tomography-scan and RT-PCR.