Central Retinal Vein Occlusion after COVID-19 Infection.

INTRODUCTION: Central retinal vein occlusions are not well-known complications of SARS-CoV-2 infection. We describe a case of central retinal vein occlusion secondary to COVID-19, and a review of the literature was performed. HISTORY AND SIGNS: A 47-year-old woman with no underlying ocular or medical condition presented to the hospital complaining about sudden onset of multiple scotomas in her left eye. A COVID-19 infection was confirmed 2 days previously by a PCR test that was performed 2 days after the onset of symptoms. Medical history revealed no risk factors and no oral contraception. Her best-corrected visual acuity was 1.0 in the right eye and 0.04 in the left eye. Clinical exam showed a left relative afferent pupillary defect and a nasally localized papilledema on fundoscopy of the left eye. Multiple dot and blot hemorrhages were also present. Optical coherence tomography revealed cystoid macular edema and paracentral acute middle maculopathy. The results of the fluoresceine angiography were consistent with central retinal vein occlusion. Laboratory workup later revealed an elevated fibrinogen level, corresponding to the COVID-19-induced hypercoagulable state. No other prothrombotic conditions were found. The patient immediately received an intravitreal injection of Lucentis (ranibizumab) after diagnosis. Complete resolution of the retinal hemorrhages and papilledema was observed 1.5 months after treatment and the final visual acuity was 1.25 in the left eye. CONCLUSION: Coagulation abnormalities are frequently observed in infectious diseases such as COVID-19 infection and the resulting prothrombotic state can sometimes lead to retinal vascular complications, including central retinal vein occlusion, irrespective of the presence of other classical risk factors. The consideration of this information could help clinicians establish a prompt diagnosis and therefore appropriate treatment, which could hopefully lead to complete healing of retinal lesions.

Time course study of optical coherence tomography angiography in patients with methanol induced optic neuropathy.

INTRODUCTION: In countries where alcoholic beverages are legally prohibited, methanol toxicity usually occurs due to ingesting homemade alcoholic drinks. The initial ophthalmologic symptoms of methanol toxicity typically appear 6-48 h after ingestion, and the severity of symptoms varies widely from mild and painless decreased vision to no-light perception vision. METHODS: This prospective study examines 20 patients with acute methanol poisoning within 10 days of use. Patients underwent ocular examinations, BCVA (Best Corrected Visual Acuity) recording, and OCTA (Optical Coherence Tomography Angiography) of the macula and optic disc. BCVA measurement and imaging were repeated one month and three months after intoxication. RESULTS: There was a statistically significant reduction in superficial parafoveal vascular density (P-value = 0.026), inner retinal thickness (P-value = 0.022), RNFL (Retinal Nerve Fiber Layer) thickness (P-value = 0.031), and an increase in cup to disc ratio (P-value < 0.001), and central visual acuity (P-value = 0.002) in this time course. However, there was no statistically significant difference in FAZ (Foveal Avascular Zone) area (P-value = 0.309), FAZ perimeter (P-value = 0.504), FD-300 (Foveal density, vascular density within a 300 µm wide region of the FAZ) (P-value = 0.541), superficial vascular density (P-value = 0.187), deep foveal vascular density (P-value = 0.889), deep parafoveal vascular density (P-value = 0.830), choroidal flow area (P-value = 0.464), total retinal thickness (P-value = 0.597), outer retinal thickness (P-value = 0.067), optic disc whole image vascular density (P-value = 0.146), vascular density inside the disc (P-value = 0.864), or peripapillary vascular density (P-value = 0.680) at different times. CONCLUSION: Over time, methanol poisoning can cause changes in retinal layers thickness, vasculature, and optic nerve head. The most important changes include cupping of the optic nerve head, reduction in RNFL thickness, and inner retinal thickness.

Purtscher-like retinopathy following coronary artery bypass grafting in an antiphospholipid syndrome patient: a case report.

BACKGROUND: Purtscher retinopathy is a rare occlusive microangiopathy comprising a constellation of retinal signs including cotton wool spots, retinal hemorrhages and Purtscher flecken. While classical Purtscher must be antedated by a traumatic incident, Purtscher-like retinopathy is used to refer to the same clinical syndrome in the absence of trauma. Various non-traumatic conditions have been associated with Purtscher-like retinopathy e.g. acute pancreatitis, preeclampsia, parturition, renal failure and multiple connective tissue disorders. In this case study, we report the occurrence of Purtscher-like retinopathy following coronary artery bypass grafting in a female patient with primary antiphospholipid syndrome (APS). CASE PRESENTATION: A 48-year-old Caucasian female patient presented with a complaint of acute painless diminution of vision in the left eye (OS) that occurred approximately two months earlier. Clinical history revealed that the patient underwent coronary artery bypass grafting (CABG) two months earlier and that visual symptoms started 4 days thereafter. Furthermore, the patient reported undergoing percutaneous coronary intervention (PCI) one year before for another myocardial ischemic event. Ophthalmological examination revealed multiple yellowish-white superficial retinal lesions i.e. cotton-wool spots, exclusively in the posterior pole and predominantly macular within the temporal vascular arcades only OS. Fundus examination of the right eye (OD) was normal and the anterior segment examination of both eyes (OU) was unremarkable. A diagnosis of Purtscher-like retinopathy was made based on clinical signs, suggestive history and consolidated by fundus fluorescein angiography (FFA), spectral domain optical coherence tomography (SD-OCT) and optical coherence tomography angiography (OCTA) of macula, optic nerve head (ONH) according to the diagnostic guidelines of Miguel. The patient was referred to a rheumatologist to identify the underlying systemic cause and was diagnosed with primary antiphospholipid syndrome (APS). CONCLUSIONS: We report a case of Purtscher-like retinopathy complicating primary antiphospholipid syndrome (APS) following coronary artery bypass grafting. This conveys a message to clinicians that patients presenting with Purtscher-like retinopathy should undergo meticulous systemic work-up in order to identify potentially life-threatening underlying systemic diseases.

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.

Evaluation of the retina with optical coherence tomography angiography (OCTA) in patients with coronavirus (COVID-19) infection.

PURPOSE: The goal of this study is to compare the optical coherence tomography angiography (OCTA) findings in Coronavirus (COVID-19) positive adult and pediatric patients with those of healthy volunteers with the same demographic characteristics. METHODS: The right eye of 157 adults infected with covid, 168 healthy adult volunteers, 40 children (6-18 years of age) infected with covid, and 44 healthy children (6-18 years of age) were included in this prospective study. All participants underwent ophthalmological examination and OCTA. The OCTA findings were evaluated. RESULTS: Deep nasal density (DND), deep inferior density (DID), and deep parafoveal density (DPD) were significantly lower in the pediatric covid-affected group (PCAG) than in the pediatric healthy control group (PHCG) (P=0.034, P=0.029, P=0.022 respectively). On the other hand, radial peripapillary capillary vessel density (RPCVD) intra-disc measurements were significantly higher in the PCAG compared to the PHCG (P=0.025). There was no significant difference between the OCTA measurements of the adult covid-affected group (ACAG) and the adult healthy control group (AHCG). CONCLUSION: In our study, significant differences were found in OCTA measurements between the covid group and the healthy control group in children. Retinal microvascular changes may occur in patients with covid infection, and these patients might be followed for long-term retinal changes.

Morphovascular changes after anti-VEGF intravitreal injection for a choroidal neovascularization secondary to COVID-19 infection in a pediatric patient.

Choroidal neovascularization (CNV) is a common pathologic lesion that occurs in various chorioretinopathy. Although the incidence of CNV is quite rare in children and adolescents, these lesions have a severe impact on visual acuity and quality of life over patients' lifetime. The management of CNV in pediatric patients is challenging, clear guidelines are limited due to a lack of randomized clinical trials. However, the more promising option is the use of vascular endothelial growth factor (VEGF) inhibitors. We reported a case of recurrent idiopathic choroidal neovascularization in a healthy pediatric patient after COVID 19 infection. Optical coherence tomography angiofraphy (OCTA) showed, in a non invasive way, a choroidal neovascularization at the posterior pole including macula and superior temporal arcade in the right eye, while the left eye was unaffected. In order to inactivate the neovascularization, intravitreal injections of anti-VEGF (Lucentis-Ranibizumab 0.3 mL) were performed in the right eye. Six months after the injections BCVA of the right eye was improved from 0.7 logMAR to 0.2 logMAR. OCT-A examination did not detect any signs of attivation of the preexistent neovascularization. It is reasonable to assert that Anti-VEGF could be the main treatment in case of choroidal neovascularization in young patients after COVID 19 infection due to the high chorioretinal level of VEGF-A described in these diseases.

Macular optical coherence tomography angiography analysis in diabetes mellitus patients with a history of Covid-19.

PURPOSE: There is evidence of decreased vessel density in optical coherence tomography angiography (OCTA) after Covid-19. We aimed to investigate whether the outcome of retinal vasculopathy would be worse if patients with diabetes mellitus (DM) were infected with coronavirus using OCTA to assess retinal vessels. METHODS: One eye of each subject was included in the study. Diabetic patients without retinopathy and non-diabetic controls were divided into four groups according to their Covid-19 history: group 1=DM(-)Covid-19(-); group 2=DM(+)Covid-19(-); group 3=DM(-)Covid-19(+); and group 4=DM(+)Covid-19(+). All Covid-19 patients were not hospitalised. Macular OCTA scans were performed in a 6 × 6 mm area. RESULTS: Diabetes had no effect on the area of the foveal avascular zone (FAZ), but Covid-19 caused an increase in FAZ area. Diabetes and Covid-19 had an effect on both the superficial capillary plexus (SCP) and the deep capillary plexus (DCP) in the fovea. Eta squared (ƞ2) is a measure of effect size. The effect size of Covid-19 (ƞ2=0.180) was found to be greater than that of diabetes (ƞ2=0.158) on the SCP, whereas the effect size of diabetes (ƞ2=0.159) was found to be greater than that of Covid-19 (ƞ2=0.091) on the DCP. CONCLUSIONS: The percentage of vessel density was lower in the fovea and the FAZ area was enlarged in the diabetic patients who recovered from Covid-19. In diabetic patients Covid-19 may lead to deterioration of vascular metrics.

Retinal microvascular changes in patients recovered from COVID-19 compared to healthy controls: A meta-analysis.

PURPOSE: To investigate changes in retinal microcirculation in patients recovered from COVID-19 infection compared to healthy controls, using optical coherence tomography-angiography. METHODS: Meta-analysis of eligible studies comparing retinal microcirculation between patients recovered from COVID-19 infection and healthy controls up to 7th of September 2022 was performed, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 guidelines. The following search algorithm was used: (COVID-19 OR coronavirus) AND (retina OR optical coherence tomography OR optical coherence tomography angiography OR vessel density OR foveal avascular zone). Standardized Mean Difference (SMD) with 95% confidence interval (CI) was calculated to compare continuous variables. Revman 5.3 was used for the analysis. RESULTS: 12 studies were included in our analysis. Foveal avascular zone (FAZ) area was larger in patients recovered from COVID-19 infection compared to healthy controls, while there was no statistically significant difference in FAZ perimeter between the two groups. The foveal, parafoveal and whole image vessel density in the superficial capillary plexus showed no significant difference between the two groups. The foveal, parafoveal and whole image vessel density in the deep capillary plexus was statistically lower in patients recovered from COVID-19 compared to healthy controls. CONCLUSION: FAZ area was enlarged and foveal, parafoveal and whole image vessel density in deep capillary plexus were reduced in patients recovered from COVID-19 infection compared to healthy controls, suggesting that COVID-19 infection may induce long-term retinal microvascular changes in patients recovered from the virus infection.

Retinal tissue and microvasculature loss in COVID-19 infection.

This cross-sectional study aimed to investigate the hypothesis that permanent capillary damage may underlie the long-term COVID-19 sequela by quantifying the retinal vessel integrity. Participants were divided into three subgroups; Normal controls who had not been affected by COVID-19, mild COVID-19 cases who received out-patient care, and severe COVID-19 cases requiring intensive care unit (ICU) admission and respiratory support. Patients with systemic conditions that may affect the retinal vasculature before the diagnosis of COVID-19 infection were excluded. Participants underwent comprehensive ophthalmologic examination and retinal imaging obtained from Spectral-Domain Optical Coherence Tomography (SD-OCT), and vessel density using OCT Angiography. Sixty-one eyes from 31 individuals were studied. Retinal volume was significantly decreased in the outer 3 mm of the macula in the severe COVID-19 group (p = 0.02). Total retinal vessel density was significantly lower in the severe COVID-19 group compared to the normal and mild COVID-19 groups (p = 0.004 and 0.0057, respectively). The intermediate and deep capillary plexuses in the severe COVID-19 group were significantly lower compared to other groups (p < 0.05). Retinal tissue and microvascular loss may be a biomarker of COVID-19 severity. Further monitoring of the retina in COVID-19-recovered patients may help further understand the COVID-19 sequela.

OCTA evaluation of posterior ocular blood flow in patients after COVID-19 infection without pneumonia.

INTRODUCTION: We aimed to demonstrate the changes in optic nerve and retinal microvascular structures with Optical Coherence Tomography Angiography (OCTA) in patients who had COVID-19 infection. METHODS: Prospective study. Retina, choroid and optic nerve head microvascular flow and vascular densities of both groups were measured by OCTA. RESULTS: OCTA measurements of 122 right eyes of a total of 122 patients, including 72 patients in the COVID-19 group and 50 patients in the control group, were included in the study. The Deep Capillary Plexus (DCP) Flow Area (FA) in the COVID-19 group was 1.42±0.23 mm2, in the control group was 1.50±0.15 mm2, Choriocapillary Plexus FA was 1.89±0.04 mm2 in the COVID-19 group, was 1.91±0.05 mm2 in the control group, and a statistically significant difference was found between the two groups (respectively; P=0.03; P=0.02). DCP Whole Vascular density (VD) values were 56.76±4.16% in the COVID-19 group, 58.28±3.88% in the control group; difference between the values was statistically significant (P=0.04). There was no statistically significant difference between the two groups in terms of optic nerve head flow areas and other parameters examined according to quadrants. CONCLUSIONS: Results show that the retinal microcirculation in subjects with mild disease is affected. Even if the disease is mild, patients may need to be followed up for retinal changes that may develop in the future.

Retinal vascular occlusion and SARS-CoV-2 vaccination.

PURPOSE: To assess the clinical and retinal imaging features of patients in whom retinal vascular occlusion (VO) had developed in temporal associations with COVID-19 vaccination. METHODS: In this retrospective case series, all consecutive adult patients with new onset VO within 6 weeks of vaccination against COVID-19 were included in the study between May 1 and October 31, 2021. All patients had a systemic medical health assessment, full ophthalmic evaluation, and complete fundus imaging. RESULTS: Fifteen eyes of VO (14 patients) after COVID-19 vaccinations were identified. The median time between vaccination and symptoms onset was 14 days (range 7-42 days). The mean best-corrected visual acuity (BCVA) was 20/55 with a range of 20/20 to 20/200. Eleven of 15 eyes (73.3%) had visual acuity improvement after intravitreal treatment at 60-90 days (range, 45-105 days) from the presentation. Four of 5 cases without systemic risk factors for VO had a mean BCVA > 20/32 at presentation and > 20/25 at the latest evaluation. Between May 1 and October 31, 2021, a temporal association was found between the 15 reported cases and COVID-19 vaccination out of a total of 29 VO (p = 0.05). The incidence of VO was higher in the considered period compared to the equivalent 6-month period in 2019 (1.17% vs 0.52%, respectively; p = 0.0134). CONCLUSIONS: Retinal vascular occlusion with different grades of severity are reported in temporal association with COVID-19 vaccination. The exact pathogenic mechanism needs to be further studied. No certain causal relationship can be established from this case series.

The effect of various types of COVID-19 vaccines on the retinal microvasculature.

PURPOSE: To detect the effect of various types of COVID-19 vaccine on macular and optic disc microvasculature. METHOD: One hundred subjects receiving various types of COVID-19 vaccine (AstraZeneca, Sinopharm, Sinovac, Pfizer, and Moderna) were included in this study. A complete ophthalmic examination was done which included best-corrected visual acuity measurement, slit-lamp biomicroscopy, intraocular pressure measurement with Goldmann applanation tonometry, and fundus examination. Optical coherence tomography angiography (OCT-A) was done before and 1 week after receiving the vaccine. Superficial and deep macular capillary densities were measured in the form of the whole image, fovea, parafoveal, and perifoveal capillary density. Optic disc vessel density in the form of the whole disc, inside disc, and peripapillary were also measured. RESULTS: The superficial macular vessel densities, (whole image, fovea, parafoveal, and perifoveal) showed statistically non-significant changes with P-values (0.269, 0.167, 0.346, and 0.476) respectively. Also, the deep macular vessel densities showed statistically non-significant changes with P-values (0.491, 0.096, 0.724, and 0.386) for the whole image, fovea, parafoveal, and perifoveal respectively. Moreover, RPC (radial peripapillary capillary) density showed no significant changes either (the whole disc, inside disc, or peripapillary) with P-values (0.807, 0.141, 0.883) respectively. CONCLUSION: Various types of COVID-19 vaccines had no statistically significant effects on macular or optic disc microvasculature.

Investigation of changes in retinal vascular parameters and choroidal vascular index values during the early recovery period of COVID-19: The COVID-OCTA study.

BACKGROUND: COVID-19 effects microvasculature in many tissues. This study investigated whether the choroidal structure is also affected. METHODS: This cross-sectional study included 80 patients with COVID-19 and the same number of age- and gender-matched healthy individuals. All participants' right eye measurements were examined. Optical coherence tomography angiography (OCTA) was used for imaging. Otherwise, two independent researchers used the Choroidal vascular index (CVI) for choroidal parameters calculation. RESULTS: Superior and deep flow values were lower in the COVID-19 group than in the control group, and vascular density (VD) values were lower in all regions in this group. Except for the superior mean VD, there was no statistically significant difference (p = 0.003). However, the COVID-19 group had significantly lower subfoveal choroidal thickness (SFChT) measurements than the control group (p = 0.001). In addition, no significant difference was observed between the groups in evaluating mean CVI values (p>0.05). CONCLUSION: Noninvasive diagnostic tools such as OCTA and EDI-OCT can be used to monitor early changes in diseases affecting microvessels, such as from COVID-19.

Bilateral Purtscher-Like Retinopathy Associated With COVID-19 Infection.

This case report describes a 37-year-old female individual who presented with sudden-onset blurred vision in both eyes 4 days after testing positive for COVID-19.

Evaluation of retinal and optic disc vascular structures in individuals before and after Pfizer-BioNTech vaccination.

INTRODUCTION: We conducted this study to detect possible changes in posterior segment structures using the optical coherence tomography angiography (OCTA) in individuals vaccinated with the Pfizer-BioNTech vaccine. MATERIALS AND METHODS: The study included healthcare professionals who presented to the Ophthalmology Clinic of Health Sciences University Antalya Training and Research Hospital, who were scheduled to receive the first dose of the Pfizer-BioNTech vaccine. The exclusion criteria were any eye pathology (e.g., glaucoma, uveitis, diabetic retinopathy, amblyopia), myopia with the absolute value of refractive error >6, axial length >26 mm, history of eye surgery, and presence of systemic disease.OCTA was performed to 40 healthcare professionals before vaccination and on the third day after vaccination. RESULTS: After Pfizer-BioNTech vaccination, there was a statistically significant decrease in the total vascular, foveal vascular, parafoveal vascular and perifoveal vascular density of the superficial capillary plexus and the perifoveal vascular density of the deep capillary plexus and a statistically significant increase in the retinal foveal thickness and total retinal parafoveal thickness compared to the pre-vaccination values (p < 0.0001, p = 0.009, p < 0.0001, p = 0.001, p = 0.04, p = 0.03, and p = 0.05, respectively). CONCLUSION: We consider that the decrease in the retinal vascular density may be due to vascular endothelial damage and inflammation in vaccinated people. It can be suggested that increased inflammation plays a role in the retinal thickness in vaccinated people similar to patients with a history of COVID-19. We also consider that spike protein may be effective in these processes.

Central retinal artery occlusion with cilioretinal artery sparing secondary to COVID-19: Additional ocular complication.

We describe a 68-year-old female patient with unilateral central retinal artery occlusion (CRAO) with cilioretinal artery sparing post-coronavirus disease 2019 (COVID-19) infection. The patient presented with acute vision loss in the left eye 11 days after discharge from a severe COVID-19 infection, with altered D-dimer, C-reactive protein, and fibrinogen levels. The best-corrected visual acuity (BCVA) in the left eye was 20/400; fundoscopic examination revealed diffuse pallor retina with a patent arterial branch from the optic disk to the fovea, confirmed by fluorescein angiography. CRAO with a cilioretinal artery sparing post-COVID-19 may be considered an additional ocular manifestation of the post-acute COVID-19 syndrome spectrum.

Optical coherence tomography-based assessment of macular vessel density, retinal layer metrics and sub-foveal choroidal thickness in COVID-19 recovered patients.

Purpose: The primary objective of the study was to assess the macular retinal vessel density, subfoveal choroidal thickness, and retinal layer metrics by optical coherence tomography angiography (OCTA), enhanced-depth imaging optical coherence tomography (EDI-OCT), and spectral domain optical coherence tomography (SD-OCT), respectively, in recovered COVID-19 patients and its comparison with the same in control subjects. The secondary objective was to evaluate differences in OCTA parameters in relation with the severity of COVID-19 disease and administration of corticosteroids. Methods: A case-control study was performed that included patients who had recovered from COVID-19 and age-matched healthy controls. Complete ocular examination including OCTA, SD-OCT, and EDI-OCT were performed three months following the diagnosis. Results: Three hundred sixty eyes of 180 subjects were enrolled between the two groups. A decreased mean foveal avascular zone area in both superficial capillary plexuses (P = 0.03) and deep capillary plexuses (P < 0.01), reduced average ganglion cell layer-inner plexiform layer thickness (P = 0.04), and increased subfoveal choroidal thickness (P < 0.001) were observed among cases in comparison to the control group. A significant correlation was found between sectoral macular vessel density in relation to disease severity and a decrease in vessel density with greater severity of the disease. Conclusion: OCTA detected retinal microvascular alterations following SARS-CoV-2 infection in subjects with the absence of any clinical ocular manifestation or systemic thrombotic events. These parameters could be used to help identify patients with a higher incidence of systemic thromboembolism on longer follow-ups and identify the impact of corticosteroids on retinal architecture.

Paracentral acute middle maculopathy with occlusive retinal vasculitis in presumed intraocular tuberculosis and hyperhomocysteinemia.

A male patient presented with a sudden visual decline in the right eye (OD). Fundus revealed bilateral vasculitis; OD also showed an occluded inferior retinal vein and a wedge-shaped retinal opacification of the inferior macula and nasal retina. Fluorescein angiography revealed occlusive retinal vasculitis, while optical coherence tomography showed paracentral acute middle maculopathy (PAMM) in the OD. A thorough systemic evaluation revealed hyperhomocysteinemia and a positive Mantoux test. A diagnosis of PAMM with occlusive retinal vasculitis in presumed intraocular tuberculosis and hyperhomocysteinemia was made. Retinal vasculitis improved with oral corticosteroid, intravitreal anti-vascular endothelial growth factor and laser photocoagulation. However, the patient declined antitubercular therapy despite recommendations. This unique report indicates that PAMM may complicate tubercular retinal vasculitis, especially in the presence of systemic hypercoagulable states.