A unique case of central retinal artery occlusion and total ophthalmoplegia in a patient with COVID-19

Author: Hillary Osorio Landa (Mexico)

Co-authors: Hillary Kimberly Osorio Landa, Pablo Baquero, Jorge Cárdenas Belaunzarán, Carlos Vázquez Vela, Juan Manuel Jiménez Sierra

Purpose

To present a clinical case that highlights an unusual presentation of central retinal artery occlusion (CRAO) and total ophthalmoplegia due to an infiltrative orbital tumor occurring in the context of Coronavirus disease 2019 (COVID‑19) infection, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

Setting/Venue

Retina and Vitreous Department at the Asociación para Evitar la Ceguera en México, I.A.P., Mexico City

Methods

Clinical Case Report

Results

A 56-year-old male with previous total blindness in his left eye (OS) due to ocular trauma and past medical history of diabetes mellitus presented to the hospital with sudden unilateral painless total vision loss occurring 18 days previously, followed the next day by sudden total ophthalmoplegia and ptosis in his right eye (OD), accompanied by right hemifacial hypoesthesia and paresthesia. His symptomatology started 2 weeks after testing positive for SARS-CoV-2 and 1 week after being discharged for COVID‑19 pneumonia, not requiring intubation or prone positioning. His bilateral best corrected visual acuity was of no light perception. Fundus examination of OD showed a pallid optic disc edema, vascular thinning and sheathing, retinal whitening with cherry red spot. Optical Coherence Tomography showed thickening and hyperreflectivity of the inner layers suggestive of retinal edema. Fundus fluorescein angiography revealed no choroidal filling and complete lack of filling of the retinal vessels. A magnetic resonance imaging was ordered to assess a right cavernous sinus syndrome, and showed an extraconal mass in the superior medial right orbit which extended to the superior orbital fissure with enlargement of the right cavernous sinus lateral wall, and pansinusitis. He was referred for biopsy of orbital lymphoma as presumptive diagnosis.

Conlusions

Retinal findings reported in patients infected with SARS-CoV-2 include cotton-wool spots and microhemorrhages as well as retinal vascular occlusions. Although he had a normal fundoscopic examination 1 year prior to COVID-19 infection and the absence of prone positioning, it is not possible to determine whether the CRAO in our patient was directly caused by SARS-CoV-2, as he had past medical history of diabetes mellitus with unknown glycemic control. Therefore, it remains unclear if COVID-19 was a contributing or a coincidental factor to the pathogenesis in this case. We hypothesize that the acute clinical presentation of the orbital tumor with sudden total ophthalmoplegia, ptosis and pansinusitis was probably exacerbated by the SARS-CoV-2-related inflammatory state. To our knowledge, this is the first case to report a CRAO and sudden total ophthalmoplegia and ptosis secondary to an infiltrative tumor in the context of COVID-19 infection. This case report adds to the diversity of ophthalmological manifestations following COVID-19, and will allow us to increase our awareness regarding sight-threatening complications such as CRAO. We suggest physicians treating COVID-19 patients to perform ophthalmologic evaluations in order to discard retinal and neuro-ophthalmological complications, and to be careful in attributing previous undiagnosed ophthalmological impairments to SARS-CoV-2 infection.

Financial Disclosure

None