Central Retinal Artery Occlusion in COVID-Associated Mucormycosis

Abstract

Introduction: Significant surge of mucormycosis was reported in the Indian Subcontinent during the second wave of the COVID-19 pandemic. COVID-associated mucormycosis (CAM) was defined as the development of features of mucormycosis with prior or current history of COVID-19 infection. Rapid angioinvasion is an important characteristic of mucormycosis. Authors intended to find out the prevalence of retinal arterial occlusion and its association with vascular embolic occlusion elsewhere in the body among CAM patients in this study.

Methods: This was an observational study. All consecutive-confirmed cases of mucormycosis (n = 89) and age-/gender-/risk factor-matched controls (n = 324) admitted in the designated COVID center were included in the study. All cases and controls underwent comprehensive ophthalmological, otorhinological, and neurological examinations. All necessary investigations to support the clinical diagnosis were done. Qualitative data were analyzed using the Chi-square test. Quantitative data for comparison of means between the cases and controls were done using unpaired t-test.

Results: Twenty-one (23.59%) patients manifested the defined outcome of central retinal artery occlusion (CRAO). Among age-matched control, with similar diabetic status, none had developed the final outcome as defined (P < 0.05). About 90.47% of subjects with CRAO presented with no perception of light vision. Thirteen subjects (61.9%) with the final outcome developed clinical manifestations of stroke during the course of their illness with radiological evidence of watershed infarction (P = 0.001). Orbital debridement was performed in 9 (42.85%) subjects while orbital exenteration was done in 8 (38.09%) subjects.

Conclusions: CRAO in CAM patients was found to have aggressive nature turning the eye blind in a very short period of time. CRAO can serve as a harbinger for subsequent development of more debilitating and life-threatening conditions such as stroke among CAM patients.

Keywords: COVID-associated mucormycosis; Central retinal artery occlusion; stroke; watershed infarction.

Figure 1

Features associated in subjects with outcome of CRAO. CRAO: Central retinal artery occlusion, RAPD: Relative afferent pupillary defect, VA: Visual acuity, PL: Perception of light

Figure 2

Color fundus image of right eye showing retinal edema, pale macula with cherry red spot, and attenuation of retinal arterioles (acute stage, on presentation), suggestive of central retinal artery occlusion

Figure 3

T1 weighted gadolinium contrast axial image of brain/orbit showing soft-tissue enhancement with optic nerve sheath enhancement, infiltration into the orbital apex (left) with involvement of cavernous sinus, destruction of medial orbital wall, and involvement of ethmoidal sinus. The Bblue arrow is pointing the thrombosed cavernous sinus

Figure 4

Digital fluorescence angiography showing delayed filling up of retinal vessel in left eye with cattle trucking appearance

Figure 5

Diffusion-weighted magnetic resonance imaging image of coronal cut section of brain showing restriction in watershed zone of superficial and deep territories of left middle cerebral artery

Figure 6

Magnetic resonance angiography of cerebral vessels showing filling defect (time of flight image) in cavernous part of right internal carotid artery

Figure 7

×400 Gomori’s methenamine silver stain highlights the mucorales (mucormycosis: Broad aseptate wide-angled branching hyphae) within the lumen of the central retinal artery