Author: Daniela Rego-Lorca (Spain)
Co-authors: Andrea Rouco-Fernández, María Jiménez-Santos, Federico Sáenz-Francés, Bárbara Burgos-Blasco, Juan Donate-López
Purpose
To describe a case of bilateral central retinal vein occlusion (CRVO) and rapidly worsening diabetic retinopathy in the convalescent phase of SARS-CoV-2 infection.
Setting/Venue
Hospital Clínico San Carlos, Madrid, Spain. SARS-CoV-2 infection, responsible for the coronavirus disease of 2019 (COVID-19), has been linked to coagulation abnormalities and a prothrombotic state. Characteristic findings in COVID-19 patients include an increased D-dimer concentration and prolongation of the prothrombin time, which are more common in severe forms of the disease and have been associated with an increased risk of death. Diabetes Mellitus (DM) has also been associated with worse outcomes due to a pre-existing pro-inflammatory state and the downregulation of the angiotensin-converting enzyme 2 (ACE2), the SARS-CoV-2 internalization receptor.
Methods
We present a 30-year-old female with maturity-onset diabetes of the young who complained of bilateral blurred vision and myodesopsias since she had been discharged after COVID-19 pneumoonia. The patient was undergoing regular endocrinology check-ups and ocular fundus evaluation without any sign of diabetic retinopathy. During hospitalization she had significantly increased values of C-reactive protein, fibrinogen, ferritin, platelets and D-dimer. Her glycated haemoglobin reached 13%, while in her last chack-up it was 7.8%. Best corrected visual acuity (BCVA) was 0.7% in both eyes. Fundus examination showed bilateral dilatation of retinal veins, exudates and extensive deep blot and flame-shaped hemorrhages throughout the retinal parenchyma and some vitreous bleeding. Fluorescein angiography showed microaneurysms, dilated veins, ischemic areas and distal vasculitis. There was no evidence of retinal neovascularization.
Results
All these findings supported the diagnosis of bilateral central retinal vein occlusion and a rapidly worsening diabetic retinopathy.
Conlusions
The symptoms onset, retinal vein occlusion and worsening of the diabetic retinopathy diagnosed after COVID-19 infection, led us to hypothesize that the downregulation of ACE2 associated with her diabetes, the SARS-CoV-2 infection and the worsening of her metabolic control, caused a fast deterioration of her diabetic retinopathy. This situation, added to the vast inflammatory response with significantly increased inflammatory markers, such as CRP, fibrinogen, ferritin, or D-dimer, resulted in a prothrombotic state that triggered the bilateral CRVO. This is the first documented case of bilateral central RVO within SARS-CoV-2 infection. Physicians should be aware of how patients with cardiovascular risk factors and severe SARS-CoV-2 infection are at a higher risk of RVO and worsening of pre-existent retinopathies.
Financial Disclosure
None.
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