Progressive Central Artery Occlusion, Ophthalmic Artery Occlusion, and Hemispheric Intracranial Thrombosis after COVID-19 mRNA Vaccine Application: Case Report.

Thromboembolic events as a result of COVID-19 mRNA vaccination are a rare, though life-threatening complication. In this case report, we describe a 40-year-old female patient who developed central retinal artery and ophthalmic artery occlusion progressing to intracranial thrombosis 3 weeks after vaccination with the Pfizer-BioNTech COVID-19 vaccine. Initially, she presented with progressive acute and painless unilateral vision loss in her left eye. Dilated fundoscopy of left eye showed macular whitening with sparing of the area of cilioretinal artery distribution. Labs revealed a normal erythrocyte sedimentation rate, C-reactive protein, and platelet count. Computerized tomography angiography of the head and neck showed an occlusion of the entire left cervical internal carotid artery and occlusion of the origin of the left external carotid artery. Despite treatment with heparin, her vision declined to no light perception. Ten days later, the patient presented with right peripheral vision loss and was found to have a new left posterior cerebral artery/posterior inferior cerebellar artery stroke. Seventeen days later, she presented to the hospital with nausea and vertigo and was found to have a subacute infarction in the left parietal lobe corresponding to left anterior communicating artery/middle cerebral artery watershed territory. Hypercoagulable disorders, vasculitis, cardiac arrhythmias, and intraventricular thrombi were excluded. Fundus fluorescein angiography confirmed central retinal artery occlusion and ophthalmic artery occlusion with impressive retina and choroid changes in fluorescein angiography patterns. This complication of mRNA COVID-19 vaccination has not been previously described in the literature and should be considered even weeks after initial presentation.

Spectral Domain Optical Coherence Tomography Findings in Vision-Threatening Rhino-Orbital Cerebral Mucor Mycosis-A Prospective Analysis.

Rhino-orbital cerebral mucor mycosis is a rare disease entity, where retinal involvement is described in the literature mostly as CRAO. However, pathological studies have shown mucor invading the choroid and retina with a neutrophilic reaction. So, it is pertinent that retinal inflammation secondary to invading mucor has some role in microstructural changes seen in the vitreous and retina of these patients. This novel study aims to describe the vitreal and retinal features of patients with vision-threatening rhino-orbital cerebral mucor mycosis and how they evolve on spectral domain optical coherence tomography (SD-OCT). This study shall also provide insight into the pathophysiology of these vitreoretinal manifestations by in vitro analysis of the exenterated orbital content. Fifteen eyes of fifteen patients with vision-threatening ROCM treated with standard care were enrolled in this study and underwent complete ophthalmic examination, serial colour fundus photography, and SD-OCT for both qualitative and quantitative analysis, at baseline and follow-up visits. SD-OCT on serial follow-up revealed thickening and increased inner-retinal reflectivity at presentation followed by thinning of both, other features such as the loss of the inner-retinal organized layer structure, external limiting membrane (ELM) disruption, necrotic spaces in the outer retina, and hyperreflective foci. Vitreous cells with vitreous haze were also seen. There was a significant reduction in CMT, inner and outer retinal thickness, total retinal thickness (all p < 0.05) with time, the quantum of reduction concentrated primarily to the inner retina. In summary, in vivo and in vitro analysis revealed that early microstructural changes were primarily a result of retinal infarctions secondary to thrombotic angioinvasion. With the late microstructural changes, there was possible sequelae of retinal infarction with some contribution from the inflammation, resulting from mucor invading the choroid and retina.

Point-of-care ultrasound in the detection of central retinal artery occlusion in a patient with recent COVID-19.

Ocular emergencies are a frequent occurrence in the emergency setting. Fortunately, point-of-care ultrasound (POCUS) lends itself exceptionally well to ocular evaluation. Here, we present a unique case of central retinal artery occlusion rapidly diagnosed with POCUS in a patient with a recent COVID-19 diagnosis.

Rapid Onset Neovascular Glaucoma due to COVID-19-related Retinopathy.

Aim: To present a case of rapid onset on neovascular glaucoma following the Coronavirus disease 2019 (COVID-19). Background: COVID-19 has various ocular manifestations such as conjunctivitis, uveitis, retinal vasculitis, and so on. However, to date, the development of neovascular glaucoma has not been reported in COVID-19. Case description: A 50-year-old male with a history of COVID-19 3 weeks ago presented with left eye (OS) central retinal artery occlusion (CRAO) and right eye (OD) cystoid macular edema with disc and microvascular leakage on multimodal imaging. After being managed conservatively for 2 weeks, the patient developed OD neovascular glaucoma with intraocular pressure (IOP) of 44 mm Hg and angle neovascularization (NVA) on gonioscopy. The patient was started on topical antiglaucoma medications (AGM) with panretinal photocoagulation (PRP) and responded well with complete regression of NVA, CME, and normal IOP after 3 weeks. Conclusion: This is the first reported case of rapid onset of NVG secondary to COVID-19-induced retinal vasculitis. COVID-19-associated prothrombotic state with secondary retinal vascular involvement can potentially trigger such NVG. Such NVG responds well with topical AGM and PRP therapy. Clinical significance: Given the global COVID-19 pandemic, it is imperative to be vigilant regarding the various vision-threatening manifestations associated with the disease such as the NVG. How to cite this article: Soman M, Indurkar A, George T, et al. Rapid onset Neovascular Glaucoma due to COVID-19-related Retinopathy. J Curr Glaucoma Pract 2022;16(2):136-140.

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.

Retrospective diagnosis of COVID-19 following the detection of central retinal artery occlusion.

Thromboembolic complications are being increasingly reported in patients with COVID-19 due to the associated hypercoagulability and are an important cause for morbidity and mortality. Retinal vascular occlusions especially arterial occlusions are one of the gravest ocular complications reported. This complication may occur in severe cases with cytokine storm or even in mild or asymptomatic patients and presentation can be anytime from few days to weeks after the onset of symptoms. Ophthalmologists should be aware of this new etiology when dealing with patients having features of retinal vascular occlusions and should investigate for the same in this pandemic situation. Although reverse transcriptase polymerase chain reaction is the diagnostic test for COVID-19, serological assays have a role in patients with delayed presentation. We describe the clinical features and multimodal imaging findings in a patient who presented with features of central retinal artery occlusion with cilioretinal artery sparing wherein his ophthalmic condition led to the diagnosis of previously undetected COVID-19 through serology. To the best of our knowledge, this is the first documentation of a case of isolated central retinal artery occlusion leading to a retrospective diagnosis of COVID-19.

Bilateral blindness in a young male of rhino-orbital-cerebral mucormycosis: A case report.

The storm of COVID-19-associated mucormycosis (CAM) has not yet settled, and it has proven itself a disfiguring and potentially life-threatening disease, complicating the course of COVID-19 infection. Mucormycosis is a rare but devastating fungal infection caused by filamentous fungi of the family Mucoraceae. We report a rare case of a 37-year-old diabetic male with bilateral rhino-orbital-cerebral mucormycosis (ROCM) where it leads to bilateral central retinal artery occlusion (CRAO) as manifestation of the disease. Bilateral CRAO secondary to ROCM is extremely rare. A strong suspicion of CAM in uncontrolled diabetics can result in early diagnosis and management.

A CLINICAL CASE OF CENTRAL RETINAL ARTERY OCCLUSION AFTER PNEUMONIA CAUSED BY SARS-COV-2 (COVID-19)

In domestic and foreign medical periodical literature, highlighting the problem of ophthalmopathology against the background of coronavirus infection, the lesion of the anterior segment of the eye is most often described. It is extremely hard to find reports about pathology of the retina, optic nerve or central parts of the visual analyzer. However, it is widely acknowledged that there is a high risk of developing coagulopathy against the background of COVID-19 infection, which leads to occlusion and thrombosis of retinal vessels, ischemic neuropathies. The problem of irreversible loss of vision due to circulatory disorders of the retinal vessels was urgent even before the wide spread of coronavirus infection due to the high prevalence of atherosclerosis, hypertension and type 1 and 2 diabetes in the population. Also, it is widely known that occlusions and thrombosis of retinal vessels can be formidable harbingers of the developing life-threatening conditions. Knowledge about the high risk of vascular ophthalmopatology against the background of a previous COVID-19 infection by the primary echelon ophthalmologists, early diagnostics and treatment of ischemic conditions of the posterior segment of the eye will reduce the frequency of irreversible vision loss due to these diseases, secondary neovascular glaucoma cases, and will also help to send patients to the multidisciplinary hospitals in a timely manner for the prevention of fatal complications of coagulopathy. The article provides a brief overview of foreign literary sources regarding the history of outbreaks of coronavirus infection in the world, as well as possible ways of damage to the organ of vision by the coronavirus. A clinical case of damage to the vascular bed of the retina in both eyes due to coagulopathy against the background of pneumonia caused by COVID-19 is presented, which is actual due to the low illumination of similarly cases. © 2021 Uchenye Zapiski Kazanskogo Universiteta. Seriya Estestvennye Nauki. All rights reserved.

A Case of Bilateral Central Retinal Artery Occlusion in a Post-COVID Rhino-Orbital-Cerebral Mucormycosis Patient.

Central retinal artery occlusion (CRAO) is a multifactorial disease, where inflammation and hypercoagulability are the major risk factors. It is a rare occurrence in this geographical area in patients diagnosed with sinus mucormycosis infection, which has emerged as one of the most fulminant, opportunistic secondary infection during post-COVID era. We report a case of a bilateral CRAO, in a 66-year-old, post-COVID, diabetic patient. A complete eye examination followed by radiological imaging of brain, orbit, and paranasal sinuses were done. Multidisciplinary approach was contemplated to reach a diagnosis of bilateral rhino-orbital-cerebral mucormycosis (ROCM). Intravenous liposomal amphotericin-B injection was started as a part of systemic management and an aggressive sinus debridement of both sides with amphotericin-B wash was also done. Despite an early diagnosis and intervention, the patient succumbed to her illness. All post-COVID patients presenting with the complaints of blurring of vision should be meticulously examined for the presence of any retinal abnormality in both the eyes as this may be a manifestation of an underlying secondary fungal infection. Early diagnosis of ROCM and management will help in reducing complications.

Acute Ischemic Stroke With Central Retinal Artery Occlusion as a Rare Presentation of COVID-19 Disease.

In this report, we present a case where the patient developed a border-zone ischemic stroke with central retinal artery occlusion (RAO) following coronavirus disease 2019 (COVID-19) disease. The COVID-19 disease has been described to induce inflammatory changes that predispose to thrombotic disease in both venous and arterial circulation. Angiotensin-converting enzyme 2 (ACE2) receptor expression in the blood vessel with which severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) binds is the cornerstone of inflammation although the pathogenesis of central RAO is multifactorial. The effects of COVID-19 inflammatory and pro-coagulant state on cerebral and retinal vascular systems are still inadequately understood. Combined presentation of central RAO with ischemic stroke has not been documented in the literature yet. As of now, no guidelines exist regarding treatment modalities to be employed in such instances. Hence, further research is warranted regarding the treatment of this condition with respect to the association with COVID-19.

Post COVID-19 Ophthalmic Manifestations in an Asian Indian Male.

Introduction: The Ocular manifestations of coronavirus disease 2019 (COVID-19) reported include conjunctivitis, conjunctival hyperemia, chemosis, epiphora, episcleritis, retinal manifestations included cotton wool spots (CWS), micro-hemorrhages, papillophlebitis and neuro-ophthalmic manifestations.Purpose: To report post COVID-19 ophthalmic manifestations using multimodal imaging.Results: A 66-year-old Asian Indian male presented to us with bilateral blurring of vision, RE>LE, of 3 days following a diagnosis of COVID-19 disease. Corrected distance visual acuity were 20/2666 and 20/25 in the right (RE) and left (LE) eyes respectively. He had bilateral anterior chamber inflammation with a relative afferent pupillary defect in the RE. RE showed central retinal artery occlusion(CRAO) with CWS, few flame-shaped retinal hemorrhages and disc edema and hyperemia. LE had disc edema and hyperemia, few flame-shaped retinal hemorrhages, cystoid changes and CWS. A diagnosis of bilateral panuveitis and papillitis with CRAO in the RE was made.Conclusion: Our patient developed a vascular occlusion with panuveitis, which possibly represents an immune mediated event following COVID-19. Patients should be warned about possible ophthalmic sequelae even after recovery.

COVID-19 and Eye: A Review of Ophthalmic Manifestations of COVID-19.

The pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has had health implications of unprecedented magnitude. The infection can range from asymptomatic, mild to life threatening respiratory distress. It can affect almost every organ of the body. Ophthalmologists world over are reporting various manifestations of the infection in the eye. This review was undertaken to help ophthalmologists recognize the possible manifestations and the stage of the viral disease when they commonly appear. Literature search was performed for the publications on ophthalmic manifestations of coronavirus disease-19 (COVID-19) between January 1, 2020 and January 31, 2021. 46 case reports, 8 case series, 11 cross sectional/cohort observational studies, 5 prospective interventional studies, 3 animal models/autopsy studies and 6 reviews/meta-analysis were included. Conjunctivitis is the most common manifestation and can develop at any stage of the disease. Direct effect due to virus, immune mediated tissue damage, activation of the coagulation cascade and prothrombotic state induced by the viral infection, the associated comorbidities and drugs used in the management are responsible for the findings in the eye. The viral ribonucleic acid (RNA) has been isolated from ocular tissues but the role of eye as a route for infection is yet to be substantiated. Ophthalmic manifestations may be the presenting feature of COVID-19 infection or they may develop several weeks after recovery. Ophthalmologists should be aware of the possible associations of ocular diseases with SARS-CoV-2 in order to ask relevant history, look for specific signs, advise appropriate tests and thereby mitigate the spread of infection as well as diagnose and initiate early treatment for life and vision threatening complications.

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.

Monocular visual loss as the presenting symptom of COVID-19 infection.

BACKGROUND AND IMPORTANCE: Additional time is needed to determine the exact impact of COVID-19 on acute cerebrovascular disease incidence, but recently published data has correlated COVID-19 to large vessel occlusion strokes. CLINICAL PRESENTATION: We report the first case of central retinal artery occlusion (CRAO) as the initial manifestation of COVID-19 infection. Subsequent neuroimaging revealed a large thrombus extending into the internal carotid artery. CONCLUSION: This case illustrates the need to suspect COVID-19 infection in patients presenting with retinal arterial occlusion, including individuals who are asymptomatic or minimally symptomatic for COVID-19 infection.

Case Report: Central Retinal Artery Occlusion in a COVID-19 Patient.

We report a case of central retinal artery occlusion (CRAO) in a patient with a previous history of severe COVID-19 disease. This disease has been associated with inflammatory-induced homeostasis changes leading to endothelial dysfunction and a procoagulant state with multi-organ involvement, but the burden of thromboembolic complications in COVID-19 patients is currently unknown. The pathogenesis of retinal artery occlusions is a multifactorial process where inflammation and hypercoagulation state are established risk factors. Even if our experience may represent a coincidental relationship, it is likely that COVID-19 patients could be at risk of developing retinal vascular occlusions. A focused ophthalmological surveillance is advisable to prevent and manage this possible cause of severe vision loss that has an important impact in health care system.