Monocular visual loss as the presenting symptom of COVID-19 infection

Abstract

Background and importance: Additional time is needed to determine the exact impact of COVID-19 on acute cerebrovascular disease incidence, but recently published data has correlated COVID-19 to large vessel occlusion strokes.

Clinical presentation: We report the first case of central retinal artery occlusion (CRAO) as the initial manifestation of COVID-19 infection. Subsequent neuroimaging revealed a large thrombus extending into the internal carotid artery.

Conclusion: This case illustrates the need to suspect COVID-19 infection in patients presenting with retinal arterial occlusion, including individuals who are asymptomatic or minimally symptomatic for COVID-19 infection.

Keywords: COVID-19; Central nervous system; Central retinal artery occlusion; Cerebrovascular disease; SARS-CoV-2.

Fig. 1

Handheld digital fundus photos performed at bedside two days after admission. Left: The right fundus with nonperfused retinal arteries (red arrows) and “boxcar” defects in the retinal veins (blue arrows). Cilioretinal artery sparing (green asterisk) is present but does not extend into the fovea. Note the diffuse nerve fiber later edema manifesting as retinal whitening along with a foveal “cherry red spot”. Right: The left fundus shows arteriovenous nicking consistent with hypertension. A flame hemorrhage is presnt along the superior arcade and questionable cotton-wool spot may be present inferior to the optic disc, consistent with hypertensive retinopathy. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article).

Fig. 2

A. Coronal CTA of normal left internal carotid artery (arrow). B. Axial CTA at the level of the right ophthalmic artery showing diminished flow compared to the left (arrows). C. Coronal and D. Sagittal CTA images of right internal carotid artery demonstrating extensive thrombus and cervical occlusion (arrows). E. Normal left arterial flow traced in white.The tracing in white illustrates normal left arterial flow.

Fig. 3

A. Axial MRA image depicting supraclinoid carotid artery reconstitution through the posterior communicating artery (arrow). B. Axial MRA showing lack of flow in the right ophthalmic artery (arrows), compared to left normal side. C. 3D MRA reconstruction depicting attenuated flow in the right hemisphere.