Dr Jay Umed Sheth from Surya Eye Institute and Research Centre, Mumbai and his associates have reported a novel case of vasculitic retinal vein occlusion due to COVID-19.
The case report has been published in the Indian Journal of Ophthalmology.
A 52-year-old male patient, diagnosed around 10 days back by PCR as positive for COVID-19, presented with complaints of decreased vision in the left eye for the past 1 day. The clinical and ocular investigation findings in the left eye were as follows:
Best Corrected Visual acuity was 6/60
Fundus examination showed inferior hemiretinal vein occlusion with superonasal branch retinal vein occlusion and macular oedema
Fundus fluorescein angiography (FFA) revealed dilated and tortuous retinal veins in inferior and superonasal quadrants. There was significant vessel wall staining and leakage in late phases suggestive of extensive phlebitis. There was no evidence of arteritis or perivascular sparing.
Spectral-domain optical coherence tomography (SD-OCT) showed presence of serous macular detachment and significant cystoid macular edema (CME).
Systemic workup for vasculitic and non-vasculitic causes of retinal vein occlusion was done. Evaluation of blood pressure, complete blood count, erythrocyte sedimentation rate, serum lipid profile, sugar levels, plasma protein electrophoresis, C-reactive protein, serum homocysteine level, serum angiotensin-converting enzyme (ACE), tuberculin skin testing, QuantiFERON-TB Gold and thrombophilia-screening showed no significant abnormality.
A presumptive diagnosis of vasculitic retinal vein occlusion secondary to COVID-19 was made due to PCR positivity to the same and absence of any other associated cause. Systemic vasculitis due to COVID-19 secondary to Type 3 hypersensitivity reaction and triggering of cytokine storm by the deposition of immune complexes has been extensively reported. According to the authors, the retinal vasculitis in this patient could be a part of this spectrum of systemic immune mediated vasculitis. Similar occlusive retinal vasculitis has been reported with other viral infections like dengue and chikungunya
Based on this presumptive diagnosis, the patient was treated with oral methylprednisolone and intravitreal anti-vascular endothelial growth factor (anti-VEGF) injection. Recent studies recommend treatment with steroids and anti-coagulants like heparin to prevent thromboembolic complications associated with systemic vasculitis in COVID-19. Oral steroids were started in accordance to the same. At the end of a month, the best corrected visual acuity in the left eye improved to 6/9 with complete resolution of the serous detachment and edema at the macula.
Ocular manifestations in COVID-19 are uncommon with conjunctivitis being reported as the most common presentation. A few reports of intraretinal haemorrhages and cotton wool spots are also present in literature.
"Knowledge of this new entity will help us remain vigilant about similar vision-threatening complications while dealing with patients of COVID-19", conclude the authors.
For reading full case report with clinical photographs, click on the link
http://www.ijo.in/text.asp?2020/68/10/2291/295726