ABSTRACT
Purpose of Study: Severe COVID-19 infection has been associated with a hypercoagulable state, contributing to the formation of clots. Retinal vascular occlusion (RVO) is a common cause of vision impairment and is due to blockage of the retinal arteries and veins. There have been reported cases of patients with previous history of COVID-19 presenting with new RVO. Given the minimal research delving into this relationship, the purpose of this study was to investigate the short-term prevalence and risk for RVO following infection by COVID-19 compared to Influenza A. Methods Used: Two cohorts were created using TrinetX, a national federated electronic health record (EHR). The two cohorts consisted of patients with a history of COVID-19 (n=2,352,475) and patients with a history of Influenza A (n=67,065). Both cohorts were balanced using 1:1 propensity score matching (PSM) addressing demographics and medical comorbidities. Outcomes between the two cohorts were compared using adjusted risk ratios (aRR), with a confidence interval of 95%. Summary of Results: After PSM, two cohorts of 67,063 patients each were compared. Patients in the COVID-19 cohort had an average age of 41.4+/-23.0 years compared to 34.4+/-27.7 years in the Influenza cohort. Between the two cohorts, there was no significant difference in risk of developing retinal vascular occlusion (aRR [95% CI] = 0.72 [0.49,1.06];p=0.097) and patients with COVID-19 had a significantly lower risk for developing retinal vein occlusion (aRR [95% CI] = 0.45 [0.27,0.77];p=0.03). Incidence of retinal vascular occlusion was 0.1% between both cohorts. Retinal artery occlusion was excluded from analysis due to obfuscation of the data by the EHR. Conclusion(s): Between the two cohorts, there was no significant difference in risk for developing RVO within 120 days. However, while there was no significant difference, vascular occlusions were found at a relatively younger age than the general population. Although incidence of RVO was low between the two cohorts, both viruses could be considered a risk factor for development of RVO, particularly in younger patients lacking classic risk factors for the disease.
ABSTRACT
Purpose : SARS-CoV-2, the viral infection that causes COVID-19, is known to induce a hypercoagulable state in patients. While there have been isolated reports of retinal vascular occlusion among patients with a pre-existing COVID-19 infection, research into this topic remains scant. Therefore, the purpose of this study is to investigate the shortterm prevalence and risk for retinal vascular occlusion between COVID-19 and influenza A patients. Methods : TrinetX is a national, federated database that was utilized in this retrospective cohort analysis. At the time of the study, electronic medical records from over 80 million patients across 57 healthcare organizations were analyzed to create two cohorts of patients. At the time of the analysis, 1,224,770 patients with a previous history for COVID19 were compared to 61,555 patients with a previous history for influenza A. Then, 1:1 propensity score matching (PSM) was utilized to balance each cohort by demographics and comorbidities (age, sex, BMI, history of hypertension, chronic lower respiratory disease, diabetes mellitus, nicotine dependence, heart failure, and alcohol related disorders). Adjusted risk ratios (aRR) using 95% confidence intervals (CI) were used to assess risk of retinal vascular occlusion 120 days after initial diagnosis for COVID-19 or influenza A. Results : Before PSM, COVID-19 patients were at significantly lesser risk for retinal vascular occlusion within 120 days of initial diagnosis than influenza A patients (aRR [95% CI] = 0.58 [0.42,0.8];p<0.001). However, the incidence for influenza patients to develop retinal vascular occlusion was very small (0.1%). After PSM, two balanced cohorts of 61,555 patients were compared to one another and revealed that there is no significant difference in developing a retinal vascular occlusion after a previous diagnosis of COVID19 or influenza A (0.92 [0.58,1.46];p=0.725). Likewise, the incidence for retinal vascular occlusion remained very small (0.1% between both cohorts) (Table 1). Conclusions : This is the first large-scale study investigating the risk of retinal vascular occlusion among COVID-19 and influenza A patients. We found that each cohort was at similar risk for developing retinal vascular occlusion within 120 days. Likewise, the incidence for retinal vascular occlusion was miniscule among patients in this study.
ABSTRACT
CASE: A 48-year-old female with no medical history presented with 2 days of decreased vision in the right eye. She reported painless blurry vision that progressed to near complete vision loss. The vision loss was accompanied by one month of progressively worsening cough, body aches, and subjective fevers. She denied smoking and reported no sick contacts. Physical exam was notable for submandibular lymphadenopathy, bilateral conjunctival injection, and grossly decreased vision of the right eye. She also endorsed decreased sensation in bilateral lower extremities distally. Her initial labs showed leukocytosis (13), thrombocytosis (754), and elevated inflammatory markers (ESR 105 and CPR 359). A chest CT showed bilateral upper lobe consolidations and scattered mass like opacities bilaterally. Ophthalmic exam of the right eye revealed multiple small retinal infarctions consistent with paracentral acute middle maculopathy. A CT head was negative and TTE showed no vegetation. Additional testing revealed negative TB, COVID, and normal complements. Initial ANCA testing was negative, however a repeat test was strongly positive for ANCA with PR3 significantly elevated to 428. She was diagnosed with granulomatosis with polyangiitis (GPA) vasculitis and treated with prednisone and started induction therapy of Rituximab. IMPACT/DISCUSSION: GPA is a small-medium vessel necrotizing vasculitis and the most common anti-neutrophil- cytoplasmic-antibody (ANCA) associated vasculitis. GPA classically involves the upper respiratory tract, lungs, and kidneys referenced by the ELK criteria (ENT, Lung, Kidney) commonly used for diagnosis. ENT findings are present in 70-100% of cases with the nasal cavity and paranasal sinuses most commonly involved. Roughly 50% have pulmonary involvement on presentation, as in this patient, while only 10-20% have initial renal involvement. A prodrome of systemic symptoms including body aches and fevers is often present. GPA is closely associated with c-ANCA, with autoantibodies to proteinase 3 (PR3) positive in over 80% of cases. This patient did have prodromal symptoms yet her primary presenting symptom of vision loss was atypical. Eye involvement is not part of the diagnostic triad yet it can occur in GPA. When it does present, it usually manifests as scleritis, conjunctivitis, or uveitis. Retinal infarctions, as seen in this patient, are uncommon and make this case an atypical presentation of GPA. Additionally, ANCA positivity is related to disease activity and a negative ANCA should not exclude GPA from a differential. Not all patients will be ANCA positive on initial presentation and 10% of patients with GPA will remain ANCA negative. CONCLUSION: Providers should consider atypical presentations of GPA in addition to the classic triad of ENT, Lungs, and Kidneys. Renal manifestations are often missing initially and involvement of other systems, such as ocular, can take place. With a positive c-ANCA and high clinical suspicion, treatment should not be delayed.