Papillophlebitis in a COVID-19 patient: Inflammation and hypercoagulable state

Abstract

Introduction: Papillophlebitis is a rare condition characterized by venous congestion and optic disc edema, which has been suggested to occur as a consequence of inflammation of the retinal veins or, possibly, the capillaries of the optic disc, leading to venous insufficiency and compression of the central retina vein. The disease affects healthy young adults and commonly has a benign course, however, if complications such as macular edema or ischemia appears, treatment should be instituted immediately to avoid poor prognosis.

Case report: A 40-year old white male patient consulted for a slight decrease in the sensitivity of the visual field in his left eye (OS). Visual acuities (VA) were 20/20 in both eyes. OS fundus examination showed dilated and tortuous retinal vessels, disc edema, and retinal hemorrhages. The patient was diagnosed with papillophlebitis. OS VA decreased to 20/200 due to macular edema, and he was treated with a intravitreal dexamethasone implant. An exhaustive and interdisciplinary exploration process was performed, identifying a recent disease and recovery of Covid-19 as the only factor of inflammation and coagulation alteration. Other systemic diseases were excluded. We also describe a rapid decrease in disc and macular edema after intravitreal dexametasone injection, which could support the inflammatory hypothesis.

Conclusion: The importance of this case lies in the possible association of papillophlebitis with the new Covid-19 disease. We believe that the inflammatory reaction and the coagulation alteration present in our patient due to Sars-Cov2 coronavirus may have acted as risk factors for the development of papillophlebitis.

Keywords: Venous occlusive disease; infections disease/AIDS; neuro ophthalmology; optic neuropathy; retina; retinal degenerations associated with systemic disease; retinal pathology/research.

Figure 1.

(a) Retinography and (b) red free retinography: inflammation of the optic disc, retinal venous vasodilatation and tortuosity, and superficial hemorrhages in all four quadrants. (c) Early arteriovenous phase FA and (d) arteriovenous phase FA: discrete venous staining and leakage, in addition to leakage and late staining from the optic disc. No evidence of areas of ischemia or peripheral vasculitis. (e) OCT: optic disc edema without macular edema. (f) VF: slight central scotoma and a slight to moderate increase in the blind spot.

Figure 2.

(a and b) Macular optical coherence tomography (OCT) demonstrating cystoid macular edema (CMO). (c) Retinography and (d) macular OCT: 2 weeks after intravitreal dexamethasone sustained-release implant treatment. Marked improvement of vascular tortuosity, optic disc, and macular edema.