Posterior segment manifestations and imaging features post-COVID-19

Abstract

Background: To report the posterior segment (uvea and retinal) manifestations and imaging characteristics of eyes of patients with and after coronavirus disease 2019 (COVID-19).

Methods: We searched the PubMed/MEDLINE database to identify relevant articles using the following search terms: COVID-19, SARS-CoV-2, retina, uvea, optic nerve, retinal findings, posterior segment manifestations, and endophthalmitis. Articles published from December 1, 2019, to May 30, 2021, and indexed in PubMed/ MEDLINE were screened.

Results: For the purpose of this review, we included clinical features of 26 case reports and 8 case series. The posterior segment manifestations reported included cotton wool spots, retinal hemorrhages, central serous retinopathy, papillophlebitis, optic neuritis, panuveitis, multifocal retinitis, necrotizing retinitis, central retinal artery/vein occlusion, and Purtschner like retinopathy. In this review, we have also included optical coherence tomography angiography (OCTA) features that have been described in COVID-19 patients with pneumonia.

Conclusions: COVID-19 patients can experience uveo-retinal manifestations even after recovery. These patients, even if asymptomatic for eye symptoms, should undergo an eye evaluation to rule out posterior segment involvement. OCTA performed in these patients revealed microvascular changes in the superficial and deep retinal plexuses. Some of these patients may require anticoagulant or antiplatelet therapy.

Keywords: COVID-19; OCTA; SARS-CoV-2; ocular manifestations; optical coherence tomography angiography; posterior segment; retina; uvea.

Figure 1

A 48-year-old Asian Indian female presented with right upper lid ptosis. Her best corrected visual acuity in both eyes were 20/20. Her diabetes was under control, and she had no previous diabetic retinopathy. She had been diagnosed with COVID-19 infection a month earlier and had received supportive treatment at the local hospital. Wide-field fundus imaging of the right eye with Optos™ (Optos P200DTx icg, Optos, Marlborough, MA, USA) showed an isolated cotton wool spot in the right eye (red arrow) with no other evidence of diabetic retinopathy in either eye.

Figure 2

A 51-year-old Asian Indian female presented with blurring of central vision of 2 weeks’ duration. She had been tested for COVID-19 on two previous occasions in the last 6 months and was SARS-CoV-2-negative by reverse-transcription polymerase chain reaction. She was known to have diabetes, with mild diabetic retinopathy in both eyes, and her condition was stable. (A) At this episode she had a retinitis patch temporal to the optic disc of the left eye (blue arrow) and a cotton wool spot (CWS) at the inferior macula (red arrow). (B) Corresponding spectral-domain optical coherence tomography (SD-OCT) over the retinitis patch showed disorganization and swelling of the inner and middle retinal layers (blue arrow). (C) Over the CWS, SD-OCT showed focal swelling of the nerve fiber layer (red arrow). The red circle indicates a blood vessel. The only positive result was an increased high SARS-CoV-2 IgM/IgG total antibody titer. The infiammatory markers, the erythrocyte sedimentation rate and C-reactive protein levels, were within normal limits.

Figure 3

A 56-year-old Asian Indian male, who had no known systemic disease history, presented with blurring of vision in his left eye. On evaluation, he was diagnosed to have central retinal vein occlusion with macular edema, with poor vision (20/200) in the left eye. On investigation, his erythrocyte sedimentation rate was elevated, he had hyperhomocysteinemia (detected during the investigations). His carotid Doppler and lipid profile were normal. He had a high SARS-CoV-2 IgM/IgG total antibody titer.

Figure 4

Spectral-domain optical coherence tomography images showing the presence of right eye subretinal fiuid with pigment epithelial detachment after being treated for COVID-19 infection (upper left). Once steroids were stopped, the serous fiuid reduced 1 month later (upper right). (A‒E) Fundus fiuorescein angiography of the right eye from the early phases (A, B) to later phases (C‒E). The yellow arrows point to an initial pinpoint leak that increased in size in later phases, resembling an ink-blot pattern. The black arrow with yellow arrow-head adjacent to the optic disc shows a mixed ink-blot and fine smoke-stack pattern. (F) The normal left eye. This figure has been reused from J Ophthal Infiamm Infect, a journal from Springer Nature, with permission under Creative Commons Attribution v4.0 International license (CC BY) [41].

Figure 5

A 47-year-old Indian male, who was COVID-19-positive with no other systemic illness, developed right eye visual blurring 3 weeks after COVID-19 diagnosis and was diagnosed as having endogenous endophthalmitis. The diffuse slit lamp image of the right eye (figure on the left) shows ciliary congestion, hazy cornea, anterior chamber exudates, and fibrinous reaction, and posterior synechiae of the iris with a pupillary membrane. The ultrasound B scan image of his right eye (top, right) shows hyperrefiective membranes in the entire vitreous cavity. The right, bottom image shows pre- and subretinal exudates. He underwent anterior chamber tap polymerase chain reaction, which was positive for Eubacteria, and he had a raised SARS-CoV-2 IgM/IgG total antibody titer.