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Central retinal vein occlusion in the setting of COVID-19 infection
Journal of Ophthalmic Inflammation and Infection ( IF 2.9 ) Pub Date : 2021-04-02 , DOI: 10.1186/s12348-021-00241-7
Nilesh Raval 1 , Anna Djougarian 2 , James Lin 1
Affiliation  

To the Editor:

We report a case of central retinal vein occlusion (CRVO) in the setting of symptomatic coronavirus disease 2019 (COVID-19) infection in an otherwise healthy adult male.

A 39-year-old male with no past medical or ocular history developed a fever in the Dominican Republic. The following day, the patient traveled back to the United States and tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by reverse transcriptase polymerase chain reaction (RT-PCR) assay. A week after the positive test, the patient developed decreased vision and floaters in the right eye and was referred for retinal exam 1 month later.

On initial presentation, visual acuity was 20/150 in the right eye (OD) and 20/30 in the left eye (OS). Pupils were equal, round, and reactive to light, and intraocular pressures were 16 mmHg OD and 17 mmHg OS. Slit lamp biomicroscopy of the anterior segment was normal except for nasal pterygia in both eyes. Dilated fundus examination OD revealed a hyperemic optic nerve head, macular thickening, tortuous vasculature, and diffusely scattered intraretinal hemorrhages (Fig. 1a). Fluorescein angiography OD showed tortuous vasculature and vessel wall staining without neovascularization, leakage, or areas of non-perfusion (Fig. 1b). Optical coherence tomography OD demonstrated cystoid macular edema (CME) (Fig. 2a). Fundus exam and ancillary testing OS were unremarkable.

Fig. 1
figure1

a Color fundus photograph OD showing a hyperemic optic nerve head, macular thickening, vascular tortuosity, and diffuse intraretinal hemorrhages. b Late-phase fluorescein angiogram OD demonstrating vascular tortuosity and vessel wall staining without capillary non-perfusion

Full size image
Fig. 2
figure2

a Optical coherence tomography (OCT) OD showing CME on initial presentation. b OCT OD showing improvement of CME after intravitreal injection of bevacizumab

Full size image

Diagnostic workup, including blood pressure, complete blood count, glucose level, QuantiFERON Gold, anti-Treponemal IgG and IgM antibodies, antinuclear antibodies, anti-double stranded DNA antibodies, angiotensin converting enzyme, rheumatoid factor, homocysteine, C-reactive protein, erythrocyte sedimentation rate, and thrombophilia panel, were unremarkable. The patient was treated with intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections of bevacizumab. After a series of injections, the macular edema decreased significantly and the patient’s visual acuity improved to 20/30 OD (Fig. 2b).

COVID-19-associated coagulopathy has been documented and studied since the onset of the pandemic [1]. Autopsy findings of patients with severe COVID-19 infection have demonstrated a hallmark diffuse small vessel thrombosis thought to be caused by complement-mediated microvascular injury, with platelet-fibrin microthrombi regularly found in venules, arterioles, and capillaries [2]. In addition, affinity of SARS-CoV-2 for vascular endothelial cell angiotensin-converting enzyme-2 (ACE2) receptors has been shown to activate apoptotic pathway signaling and prothrombotic cascades [3].

Hypercoagulability is a major risk factor for CRVO, and it is imperative to rule out other causes of CRVO in an otherwise healthy patient. Our patient did not have any significant medical history and infectious, inflammatory, and hypercoagulable studies were negative. There have only been a small number of cases of COVID-19-associated CRVO in recent literature [4,5,6]. Our patient’s positive RT-PCR SARS-CoV-2 assay and subsequent visual symptoms support the possibility that the pro-thrombotic state created by COVID-19 contributed to the development of CRVO.

This case builds upon the existing literature that demonstrates the occurrence of CRVO in the setting of COVID-19. Patients with COVID-19 are at risk for vascular occlusive events, and early detection and treatment are paramount in restoring visual function.

Not applicable.

CRVO:

Central retinal vein occlusion

COVID-19:

Coronavirus disease 2019

SARS-CoV-2:

Severe acute respiratory syndrome coronavirus 2

RT-PCR:

Reverse transcriptase polymerase chain reaction

OD:

Right eye

OS:

Left eye

Anti-VEGF:

Anti-vascular endothelial growth factor

ACE2:

Angiotensin-converting enzyme-2

  1. 1.

    Connors JM, Levy JH (2020) COVID-19 and its implications for thrombosis and anticoagulation. Blood 135(23):2033–2040

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  2. 2.

    Magro C, Mulvey JJ, Berlin D et al (2020) Complement associated microvascular injury and thrombosis in the pathogenesis of severe COVID-19 infection: a report of five cases. Transl Res 220:1–13

    CAS Article Google Scholar

  3. 3.

    Varga Z, Flammer AJ, Steiger P et al (2020) Endothelial cell infection and endotheliitis in COVID-19. Lancet 395(10234):1417–1418

    CAS Article Google Scholar

  4. 4.

    Sheth JU, Narayanan R, Goyal J, Goyal V (2020) Retinal vein occlusion in COVID-19: a novel entity. Indian J Ophthalmol 68:2291–2293

    Article Google Scholar

  5. 5.

    Invernizzi A, Pellegrini M, Messenio D et al (2019) Impending central retinal vein occlusion in a patient with coronavirus disease 2019 (COVID-19). Ocul Immunol Inflamm 28(8):1290–1292

    Article Google Scholar

  6. 6.

    Yahalomi T, Pikkel J, Arnon R, Pessach Y (2020) Central retinal vein occlusion in a young healthy COVID-19 patient: a case report. Am J Ophthalmol Case Rep 20:100992

    Article Google Scholar

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Not applicable.

This research is supported by gifts from Lewis Henkind, as well as the Irving and Branna Sisenwein Endowment Fund to the Department of Ophthalmology, Montefiore Medical Center.

Affiliations

  1. Department of Ophthalmology, Montefiore Medical Center, Albert Einstein College of Medicine, 3332 Rochambeau Ave, 3rd Floor, Bronx, NY, 10467, USA

    Nilesh Raval & James Lin

  2. Department of Ophthalmology, Northwell Health, Great Neck, NY, USA

    Anna Djougarian

Authors
  1. Nilesh RavalView author publications

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  2. Anna DjougarianView author publications

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  3. James LinView author publications

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Contributions

AD and JL worked together to diagnose the patient, and JL provided treatment for the patient with regular follow-up. NR compiled the images and was primary author of the case report. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Nilesh Raval.

Ethics approval and consent to participate

Not applicable.

Consent for publication

Written informed consent for publication of their clinical details and/or clinical images was obtained from the patient. A copy of the consent form is available for review by the Editor of this journal.

Competing interests

The authors declare that they have no competing interests.

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Cite this article

Raval, N., Djougarian, A. & Lin, J. Central retinal vein occlusion in the setting of COVID-19 infection. J Ophthal Inflamm Infect 11, 10 (2021). https://doi.org/10.1186/s12348-021-00241-7

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  • DOI: https://doi.org/10.1186/s12348-021-00241-7

中文翻译：
COVID-19感染情况下的视网膜中央静脉阻塞

致编辑：

我们报告了一例在其他方面健康的成年男性感染症状性冠状病毒病 2019 (COVID-19) 的情况下视网膜中央静脉阻塞 (CRVO) 的病例。

一名 39 岁男性在多米尼加共和国发烧，既往无病史或眼病史。次日，患者返回美国并通过逆转录酶聚合酶链反应 (RT-PCR) 检测检测出严重急性呼吸系统综合症冠状病毒 2 (SARS-CoV-2) 呈阳性。阳性测试一周后，患者出现视力下降和右眼飞蚊症，1 个月后转诊进行视网膜检查。

初次就诊时，右眼 (OD) 的视力为 20/150，左眼 (OS) 的视力为 20/30。瞳孔相等、圆润且对光有反应，眼压分别为 16 mmHg OD 和 17 mmHg OS。除双眼鼻翼痛外，眼前节裂隙灯活组织显微镜检查均正常。散瞳眼底检查 OD 显示视神经乳头充血、黄斑增厚、血管弯曲和弥漫性散在的视网膜内出血（图 1a）。荧光素血管造影 OD 显示曲折的脉管系统和血管壁染色，没有新血管形成、渗漏或非灌注区域（图 1b）。光学相干断层扫描 OD 显示黄斑囊样水肿（CME）（图 2a）。眼底检查和辅助检查 OS 无异常。

图。1
图1

a彩色眼底照片 OD 显示视神经乳头充血、黄斑增厚、血管迂曲和弥漫性视网膜内出血。b晚期荧光素血管造影 OD 显示血管迂曲和血管壁染色，无毛细血管无灌注

全尺寸图片
图2
图2

a光学相干断层扫描 (OCT) OD 显示初始演示时的 CME。b OCT OD 显示玻璃体内注射贝伐单抗后 CME 的改善

全尺寸图片

诊断检查，包括血压、全血细胞计数、血糖水平、QuantiFERON Gold、抗密螺旋体 IgG 和 IgM 抗体、抗核抗体、抗双链 DNA 抗体、血管紧张素转换酶、类风湿因子、同型半胱氨酸、C 反应蛋白、红细胞沉降率和血栓形成倾向均不显着。患者接受玻璃体内抗血管内皮生长因子（抗 VEGF）注射贝伐单抗治疗。一系列注射后，黄斑水肿明显减轻，患者视力提高至20/30 OD（图2b）。

自大流行开始以来，已记录和研究了 COVID-19 相关的凝血病 [1]。严重 COVID-19 感染患者的尸检结果表明，标志性的弥漫性小血管血栓形成被认为是由补体介导的微血管损伤引起的，在小静脉、小动脉和毛细血管中经常发现血小板-纤维蛋白微血栓 [2]。此外，SARS-CoV-2 对血管内皮细胞血管紧张素转换酶 2 (ACE2) 受体的亲和力已被证明可激活凋亡通路信号传导和促血栓形成级联反应 [3]。

高凝状态是 CRVO 的主要危险因素，在其他方面健康的患者中必须排除 CRVO 的其他原因。我们的患者没有任何重要的病史，感染性、炎症性和高凝状态研究均为阴性。在最近的文献中只有少数 COVID-19 相关的 CRVO 病例 [4,5,6]。我们患者的 RT-PCR SARS-CoV-2 检测阳性和随后的视觉症状支持 COVID-19 产生的促血栓形成状态有助于 CRVO 发展的可能性。

这个案例建立在现有文献的基础上，这些文献证明了在 COVID-19 环境中 CRVO 的发生。COVID-19 患者有发生血管闭塞事件的风险，早期发现和治疗对于恢复视觉功能至关重要。

不适用。

CRVO：

视网膜中央静脉阻塞

新冠肺炎：

2019冠状病毒病

SARS-CoV-2：

严重急性呼吸系统综合症冠状病毒 2

逆转录聚合酶链反应：

逆转录聚合酶链反应

外径：

右眼

操作系统：

左眼

抗VEGF：

抗血管内皮生长因子

ACE2：

血管紧张素转化酶-2

  1. 1.

    Connors JM、Levy JH (2020) COVID-19 及其对血栓形成和抗凝的影响。血 135(23):2033–2040

    CAS 文章 Google Scholar

  2. 2.

    Magro C、Mulvey JJ、Berlin D 等人（2020 年）在严重 COVID-19 感染的发病机制中补充相关微血管损伤和血栓形成：五例报告。翻译资源 220:1–13

    CAS 文章 Google Scholar

  3. 3.

    Varga Z、Flammer AJ、Steiger P 等人 (2020) COVID-19 中的内皮细胞感染和内皮炎。柳叶刀 395(10234):1417–1418

    CAS 文章 Google Scholar

  4. 4.

    Sheth JU、Narayanan R、Goyal J、Goyal V（2020）COVID-19 中的视网膜静脉阻塞：一个新实体。印度眼科杂志 68:2291–2293

    文章 谷歌学术

  5. 5.

    Invernizzi A、Pellegrini M、Messenio D 等人 (2019) 2019 年冠状病毒病 (COVID-19) 患者即将发生视网膜中央静脉阻塞。眼免疫炎症 28(8):1290–1292

    文章 谷歌学术

  6. 6.

    Yahalomi T、Pikkel J、Arnon R、Pessach Y（2020）一名年轻健康的 COVID-19 患者的视网膜中央静脉阻塞：病例报告。Am J Ophthalmol 案例代表 20:100992

    文章 谷歌学术

下载参考

不适用。

这项研究得到了 Lewis Henkind 以及 Irving 和 Branna Sisenwein Endowment Fund 捐赠给 Montefiore 医学中心眼科的礼物的支持。

隶属关系

  1. 眼科，Montefiore 医学中心，阿尔伯特爱因斯坦医学院，3332 Rochambeau Ave, 3rd Floor, Bronx, NY, 10467, USA

    Nilesh Raval & James Lin

  2. 眼科，Northwell Health，Great Neck，纽约，美国

    安娜·朱加里安

作者
  1. Nilesh Raval查看作者出版物

    您也可以在PubMed Google Scholar中搜索此作者 

  2. Anna Djougarian查看作者出版物

    您也可以在PubMed Google Scholar中搜索此作者 

  3. James Lin查看作者出版物

    您也可以在PubMed Google Scholar中搜索此作者 

贡献

AD和JL共同为患者诊断，JL为患者提供治疗并定期随访。NR 编译了图像并且是病例报告的主要作者。所有作者阅读并认可的终稿。

通讯作者

与 Nilesh Raval 的通信。

伦理批准和同意参与

不适用。

同意发表

从患者那里获得了公开其临床细节和/或临床图像的书面知情同意书。同意书的副本可供本期刊的编辑审查。

利益争夺

作者声明他们没有竞争利益。

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引用这篇文章

Raval, N., Djougarian, A. & Lin, J. COVID-19 感染情况下的视网膜中央静脉阻塞。J Ophthal Inflamm Infect 11, 10 (2021)。https://doi.org/10.1186/s12348-021-00241-7

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  • DOI : https://doi.org/10.1186/s12348-021-00241-7
更新日期：2021-04-02
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