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.

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.

Multiple Evanescent White Dot Syndrome Associated with Coronavirus Infection: A Case Report.

Coronavirus disease 2019 (COVID-19) causes ocular manifestations in approximately 11% of patients. Most patients typically develop ocular symptoms within 30 days of the onset of the first COVID-19 symptoms. The most common ocular manifestation is conjunctivitis, which affects nearly 89% of patients with eye problems. Other much less common anterior segment abnormalities caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are scleritis, episcleritis, and acute anterior uveitis. Posterior segment abnormalities caused by SARS-CoV-2 are mainly vascular, such as hemorrhages, cotton wool spots, dilated veins, and vasculitis. Herein, we report a rare manifestation of COVID-19 and multiple evanescent white dot syndrome (MEWDS) of the retina. In April 2021, a 40-year-old female patient was admitted to the Eye Clinic of Clinical Center of Montenegro (Podgorica, Montenegro). The patient's main complaint was sudden vision impairment, which occurred 14 days after a positive polymerase chain reaction (PCR) test result for SARS-CoV-2 infection. A complete eye examination was performed, followed by fundoscopy, optical coherence tomography (OCT), and fluorescein angiography (FA) tests. The results showed retinal changes associated with MEWDS. The patient underwent additional examinations to rule out common causes of multifocal retinitis, all of which were unremarkable. Therefore, it was concluded that retinitis was a complication of COVID-19. Given its non-invasive nature, fundus examination should be used as a standard screening method for retinal changes in patients with COVID-19.

Bilateral radiation retinopathy 17 years following radiotherapy for nasopharyngeal carcinoma: A diagnostic and therapeutic challenge during COVID-19 lockdown.

A 40-year-old male presented with reduced vision in the right eye for one week. He had a history of nasopharyngeal carcinoma for which 34-Gy radiation was administered. The best-corrected visual acuity (BCVA) was 20/40 in the right eye and 20/20 in the left eye. Anterior segment examination suggested a bilateral early posterior subcapsular cataract. Fundoscopy revealed bilateral localized telangiectasia and macular edema in the right eye. Diagnosis of bilateral extremely delayed onset radiation retinopathy with right eye macular edema was made. Three doses of intravitreal bevacizumab injection were administered in the right eye. The patient was lost to follow-up due to COVID-19 and presented with recurrence.

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.

Unilateral Purtscher-like retinopathy post-COVID-19.

A 32-year-old male with no known systemic illness presented with unilateral Purtscher-like retinopathy in his left eye 2 weeks after recovering from a severe COVID-19 infection. Fundus examination revealed areas of intraretinal whitening and few cotton wool spots. Multimodal imaging findings were consistent with embolic occlusion of capillaries seen in Purtscher-like retinopathy. The case highlights the effect of virus-directed coagulation cascade activation leading to unilateral microvasculopathy in our patient. The case adds to the spectrum of COVID-19 retinopathy and presses that retina screening strategies should be established for patients suffering from or recovering from severe COVID-19 infection.

Acute macular neuroretinopathy following COVID-19 infection.

COVID-19 is a global pandemic with over 600 million cases worldwide and over 1.7 million cases in New Zealand to date. The most recent spread of Omicron variant saw widespread infection across the country that was unable to be controlled like the initial Alpha or Delta variants. There is limited information on ocular complications of COVID 19. In our case, there was a close relationship between time of COVID-19 infection and acute visual changes including ongoing scotomas (blind spots). This report explores a case of a young female with positive visual phenomena following COVID-19 infection, with the diagnosis of acute macula neuroretinopathy.

Purtscher-like retinopathy in a patient with COVID-19-associated coagulopathy.

The most frequently reported ophthalmic manifestation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is conjunctivitis. We have described a case of Purtscher-like retinopathy in a patient with severe coronavirus disease 2019 (COVID-19)-associated coagulopathy. A young woman with multiple comorbidities was admitted for COVID-19-related acute respiratory distress syndrome. Her course was complicated by fungemia. Ophthalmic examination revealed bilateral posterior pole, intraretinal lesions and fluconazole was added for presumed fungal retinitis. At 1-week follow-up, widespread peripapillary cotton-wool spots and hemorrhages suggestive of Purtscher-like retinopathy were observed. The levels of D-dimers, fibrinogen, and C-reactive protein were markedly elevated prior to our consultation, indicating preceding prothrombotic and pro-inflammatory states. Subsequent venous duplex revealed deep venous thrombosis in the right subclavian and internal jugular veins. Von Willebrand factor indices were markedly elevated, suggesting severe COVID-19-associated coagulopathy. Purtscher-like retinopathy, a rare occlusive microangiopathy has been described in various pro-inflammatory and prothrombotic conditions. To the best of our knowledge, this is the first report of Purtscher-like retinopathy in COVID-19-associated coagulopathy.

Paracentral acute middle maculopathy in Susac syndrome after dual exposure to SARS-CoV-2 antigen.

We report a case of Susac syndrome after SARS-CoV-2 infection and subsequent vaccination that presented with meningitis and retinal microembolisation in the form of paracentral acute middle maculopathy (PAMM). After presenting with headache, fever and myalgia followed by scotomata, a woman in her 50s was hospitalised for meningitis; she had had mild COVID-19 infection 2 months prior to admission, having received the first vaccine dose 1 month prior to the neurological manifestation. Eye fundus examination and optical coherence tomography were suggestive of PAMM. D-dimer levels and erythrocyte sedimentation rate were elevated. Before infectious investigation results were available, she was started on empirical antibiotic and antiviral treatment. Having ruled out infectious causes, she was started on high-dose prednisolone. After 1 month, there was partial resolution of retinal lesions. This case highlights that exposure to SARS-CoV-2 antigen may be related to this rare syndrome; treatment with steroids may improve central and retinal impairment.

Nonmydriatic Ultra-Widefield Fundus Photography in a Hematology Clinic Shows Utility for Screening of Sickle Cell Retinopathy.

PURPOSE: To determine the feasibility and accuracy of nonmydriatic ultra-widefield (UWF) fundus photographs taken in a hematology clinic setting for screening of sickle cell retinopathy (SCR) DESIGN: Prospective cohort study. METHODS: This single-site study took place at the Johns Hopkins Sickle Cell Center for Adults and the Wilmer Eye Institute. The study population was 90 eyes of 46 consecutive adults with sickle cell disease (SCD). Bilateral nonmydriatic fundus photos taken by clinic personnel during the participants' routine hematology appointment were graded by 2 masked retina specialists at the Wilmer Eye Institute for the presence of nonproliferative SCR (NPSR) and proliferative sickle retinopathy (PSR). A third retina specialist adjudicated in cases of grader disagreement. All participants underwent the standard dilated fundus examination (DFE) within 2 years of acquisition of UWF photographs. The main outcome measure was the sensitivity and specificity of nonmydriatic UWF images for the detection of NPSR and PSR RESULTS: PSR was noted in 19 of 90 eyes that underwent DFE and in 9 of 67 gradable UWF images. Interrater agreement between the 2 graders was moderate, with κ = 0.65 (range 0.43-0.87) for PSR. For gradable UWF photos, the sensitivity and specificity of detecting SCR using the nonmydriatic photos compared with the DFE were 85.2% and 62.5% for NPSR, respectively, and 69.2% and 100% for detection of PSR, respectively. One participant required ophthalmic therapy in both eyes for active sea-fan neovascularization. CONCLUSIONS: UWF imaging shows utility in screening for SCR and may help identify patients with PSR who require a DFE and who may benefit from treatment.

Multiple Evanescent White Dot Syndrome following COVID-19 mRNA Vaccination in Two Patients.

PURPOSE: To describe two cases of multiple evanescent white dot syndrome (MEWDS) occurring after administration of COVID-19 vaccine. STUDY DESIGN: Case Report. RESULTS: Two patients presented soon after receiving their second-dose of the BNT162b2 Pfizer-BioNTech COVID-19 vaccine with findings consistent with MEWDS. Due to the significant reduction in vision, patients were treated with a short dose of oral corticosteroids. Both had complete resolution of their symptoms, visual acuity and retinal findings. CONCLUSIONS: The onset of inflammatory ocular adverse events following COVID-19 vaccinations suggest a maladaptive inflammatory response triggered by the vaccine. Onset of symptoms after COVID-19 vaccinations should prompt the ophthalmologist to assess for these rare adverse events. Despite the extremely rare occurrences of ocular adverse events, we unequivocally recommend that patients receive the full vaccine due to the vast benefit for both individuals and society that far outweighs the inconsiderable risk of harm.

Retinal and choroidal manifestations of COVID-19.

PURPOSE OF REVIEW: The novel coronavirus disease in 2019 (COVID-19) has a wide range of systemic manifestations. Ocular manifestations are now well recognized, with conjunctivitis being the most common. Posterior segment involvement is uncommon and has mainly been described in case reports. This review provides an overview of the posterior segment involvement of COVID-19. RECENT FINDINGS: Severe acute respiratory syndrome coronavirus 2 affects the retina and the choroid through either direct entry or triggering an indirect inflammatory response. Majority of the retinal findings is a result of microvascular derangement leading to cotton wool spots, intraretinal hemorrhages, paracentral acute middle maculopathy, acute macular neuroretinopathy, or retinal vein occlusions. Rarely, inflammation involving the retina or the choroid, or reactivation of previously quiescent uveitis, can be seen. SUMMARY: It is important to recognize the possible correlation between ophthalmic conditions and COVID-19 as it can aid in diagnosis, management, and mitigation of the disease.

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.

Symptomatic Retinal Microangiopathy in a Patient with Coronavirus Disease 2019 (COVID-19): Single Case Report.

Purpose: Coronavirus Disease 2019 (COVID-19) can cause conjunctivitis in up to 31.6% of patients. Additionally, retinal findings compatible with retinal microvascular ischemia have also been associated with coronavirus disease in asymptomatic patients. We describe a case of bilateral retinal changes compatible with microangiopathy occurring during the late phase of COVID-19.Case report: A 50-year-old man with bilateral pneumonia and positive polymerase chain reaction for SARS-CoV-2 developed an arcuate visual field defect in his left eye. Funduscopy revealed multiple, bilateral cotton-wool spots without haemorraghes. OCT-angiography revealed multifocal areas of retinal microvascular ischemia in the superficial plexus, the largest of which corresponded to the arcuate scotoma observed in the automated perimetry.Conclusion: Visual field defects due to retinal microangiopathy can occur during the late phase of COVID-19. Vascular changes observed in the retina may mimic what may be happening in other, less-accessible organs.