Author: Maria De Los Angeles Gonzalez Garrido (Spain)
Co-authors: Maria Del Monte Carmelo Rojo Arnao, Ricardo Menoyo Calatayud, Miguel Angel Gallego Domingo, Giovanni Yañez Castro
We present a healthy 65-year-old COVID-19 male patient who developed unilateral Central Retinal Vein Occlusion (CRVO) and severe macular edema (ME) in the left eye (OS), as a complication of asymtomatic COVID-19 on May 2020, and the successful intensive combined intravitreal treatment with dexametasone implant (Ozurdex) and antivegf (Ranibizumab and Aflibercept).
Patient was refered to the emergency department due to blurred vision in OS for the past two weeks. The patient reported a previous three-week period of fatigue during initial COVID-19 pandemic. Best-corrected visual acuity (VA) in OS was count fingers, with a relative afferent pupillary defect. Funduscopy showed tortuosity and dilatation of all branches of central retinal vein, dot, blot and flame-shaped hemorrhages throughout all four quadrants, optic disc edema and macular edema. Optical Coherence Tomography (OCT) showed neurosensory detachment and cystoid ME. OCT Angiography (OCT-A) showed isquemic superior peripheral areas with no neovascularization, confirmed by fluorescein angiography. Laboratory evaluation showed mild leukopenia with no evidence of thrombocytopenia or other hypercoagulability markers such as Anti-Thrombin-III, Protein C activity, Protein-S antigen, Fibrinogen and D-dimer. Polymerase chain reaction (PCR) for SARS-CoV-2 was found to be negative, however, an IgG/IgM Rapid Test was performed and was found to be both IgM and IgG Positive for SARS-CoV-2, confirming early recovery from COVID-19. RX torax scan was normal. The patient was given initially intravitreal injection of OZURDEX due to inflammatory ME on June.
After Ozurdex injection, VA improved to 0,7 Snellen decimal scale, with also improvement of ME and hemorrhages. Due to isquemic areas we decided to combine with Ranibizumab since first month, followed by two more monthly injections, disappearing ME. Intraocular pressure increased but it was controlled with topical medication. VA remained stable until fourth month, when despite of antivegf treatment, OCT showed inflammatory ME again and VA decreased to 0,1. Pacient received another Ozurdex injection, followed by three Aflibercept monthly injections. VA gain was lower, reaching 0,5. ME was resolved completely and retinal vascularization improved, disappearing partially isquemic areas in OCT-A. No neovascularization was found. At six month from second Ozurdex implant, central macular thickness increased slightly again, but no inflammatory signs were noticed on OCT, so the patient received another Aflibercept injection. Patient developed mild cataract during last months. However, VA still remained in 0.5.
Venous thromboembolic complications and coagulation abnormalities have been reported in association with SARS-CoV-2 infection. Two major possible mechanisms have been offered to explain vascular damage in COVID-19 disease, first a pseudo-vasculitis state as a result of a viral infiltration of the endothelial cells, and second, a hypercoagulable condition, characterized by a disseminated intravascular coagulation-like. Retinal vasculitis could be either because of the thromboinflammatory cascade secondary to the “cytokine-storm” immune response or because of direct involvement of viral particles. Similar occlusive retinal vasculitis has also been described in other viral infections such as dengue and chikungunya. In our patient, presence of a positive SARS-CoV-2-IgM-IgG COVID-19 can be a clue in a healthy patient with only age as risk factor. Thromboinflammatory state could explain the initial severity of CRVO, with isquemic areas and inflammatory ME signs, and also the premature failure of combined therapy. However, VA recovery has been possible with a strict follow up and repeated intensive combined therapy. We highlight this case to raise awareness that a retinal vein occlusion in an otherwise healthy patient may be a potential manifestation of the thromboinflammatory state associated with SARS-CoV-2 infection. Further studies should be performed to better understand the phenomenon.