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Case Report: A bizarre contingency in the retinal artery and vein post COVID-19 recovery

Abstract:

A 40-year-old woman with no systemic diseases had undergone treatment for coronavirus-19 (COVID-19) and presented with symptoms of sudden painless loss of vision in the left eye (LE). In the LE she was only able to perceive light PL as best corrected visual acuity (BCVA). Ocular fundus examination of LE revealed old sheathing associated with sclerosed veins and arteries. In optical coherence tomography angiography (OCT-A), total loss of vasculature was observed in the LE which suggests combined retinal artery and vein occlusion. Reverse transcription-polymerase chain reaction (RT-PCR) revealed the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus infection. Hematological investigations revealed a normal range. The chest computed tomography (CT) score was 20 out of 25 because of that the patient was treated with oxygen, steroids, and blood thinners.

COVID-19 infection is basically asymptomatic but, in a few cases, it can cause some serious damage to the eyes. Therefore, it is recommended to undergo a proper eye examination for those who are affected by COVID-19.

Keywords:

COVID-19, OCT-A, RT-PCR, CT score.

Background:

COVID-19 is an infectious disease that was also declared a pandemic caused by SARS-CoV- 2 which typically affects the respiratory system.[1] COVID-19 leads to greater production of cytokines by white blood cells (WBCs) than any other virus.[2] This can lead to hypercytokinemia or cytokine release syndrome, which causes systemic inflammatory response syndrome (SIRS), acute respiratory distress syndrome (ARDS), multiorgan injury, shock, and death.[3] Ocular involvement is hardly seen in the form of retinal artery occlusion, retinal vein occlusion and loss of vision.[4] Retinal findings following infection with SARS- CoV-2 virus occur due to complement activated thrombotic microangiopathy and a hypercoagulable state, which can lead to retinal artery and venous occlusions.[5]

Case Presentation:

A female patient aged 40 years presented to us with sudden onset of painless vision loss 1 month back in the left eye (LE). The BCVA was 6/6, N06 in the right eye (RE) and perception of light positive, inaccurate projection of light (PL+PR inaccurate),

Systemic examinations were within normal limits. History of Covid-19 and CT score was 20 out of 25 for which the patient was treated with oxygen, steroids, blood thinners (low-molecular-weight heparins). Cardio-vascular system and carotid arterial examinations were normal.

Figure 1: Fundus photo of LE showing old sheathing and sclerosis of veins and arteries

Investigations:

Optical coherence tomography (OCT) showed loss of retinal layers, and optical coherence tomography angiography (OCT-A) showed total loss of vasculature in all slabs consistent with the diagnosis of combined artery and vein occlusion.

The chest computed tomography score was 20 out of 25. Hematological investigations were notable for the following characteristics: the D-dimer level was 0.3 g/L, and the prothrombin time was 13.7 with an international normalized ratio of 1.01. Serum cholesterol was 274 mg/dL, low-density lipoprotein was 214 mg/dL, and very low-density lipoprotein was 48.08 mg/dL which was mildly increased.

Hba1c 5.1% with fasting blood sugar 83 mg/dL and postprandial blood sugar 119 mg/dL.

Direct bilirubin was 0.29, and serum glutamic pyruvic transaminase was 54.7 units per liter of blood serum which was mildly elevated.

Based on the diagnostic workup, laboratory evaluation and consultation with physicians, the diagnosis of combined artery and vein occlusion due to COVID-19 was made.

Treatment:

Treatment with aspirin was advised to continue, and advised to have good systemic control.

The poor prognosis for visual recovery in the LE was explained to the patient. She was counselled regarding regular follow-up for RE and to wear protective polycarbonate eyewear.

Outcome and follow-up:

The patient did not come for regular follow-up. Therefore, we were unable to know whether the condition worsened or remained the same.

Discussion:

COVID-19, also known as coronavirus disease (recognized in late 2019), is a highly infectious viral disease caused by severe acute respiratory syndrome coronavirus 2 (SARS- CoV-2), and is characterized by acute respiratory failure, septic shock, and multiple organ failure [6]. The total numbers of reported cases of COVID-19 in India are 10,375,478 of which 9,997,272 recovered and 150,151 died by January 6, 2021 [7]. The predisposition to arterial thrombosis in COVID-19 patients can be a result of arterial occlusion, although it is thought that there is not much relation between arterial occlusion with COVID-19 infection [8]. Changes in the retina next to Covid-19 infection occur due to complement activated thrombotic microangiopathy and a hypercoagulable state. Classic findings in this scenario are an increased D-dimer concentration, a decrease in platelet count and a prolonged prothrombin time [9].

Ocular symptoms of COVID-19 are due to severe endothelial disruption, complement activation and generalized inflammation which leads to an overall procoagulant state [10]. Additionally deteriorated endothelial cells could also cause malfunction of the inner blood retinal barrier, resulting in increased capillary permeability and the subsequent occurrence of macular edema [11].

Patients with COVID-19 infection can be asymptomatic or can show critical illness with the development of acute respiratory distress syndrome (ARDs), which is mainly characterized by respiratory failure, and covid-19 can cause multiple organ dysfunction [12].

In summary, patients presenting with features of combined retinal vein and artery occlusion require a thorough systemic evaluation and detailed medical history. This case highlights the importance of thorough systemic and hematological workup in patients with combined vein and artery occlusion.

Acknowledgements:

The author thanks Mr. Brajesh, Senior Faculty Optometrist, Ophthalmic Photographer.

Competing interests: None declared

Patient consent: Obtained

References:

1. Cucinotta, D., & Vanelli, M. (2020). WHO Declares COVID-19 a Pandemic. Acta bio- medica : Atenei Parmensis, 91(1), 157–160. https://doi.org/10.23750/abm.v91i1.9397

2. Merad, M., & Martin, J. C. (2020). Pathological inflammation in patients with COVID-19: a key role for monocytes and macrophages. Nature reviews. Immunology, 20(6), 355–362. https://doi.org/10.1038/s41577-020-0331-4

3. Jain U. (2020). Effect of COVID-19 on the Organs. Cureus, 12(8), e9540. https://doi.org/10.7759/cureus.9540

4. Rao, K., Shenoy, S. B., Kamath, Y., & Kapoor, S. (2016). Central retinal artery occlusion as a presenting manifestation of polycythaemia vera. BMJ case reports, 2016, bcr2016216417. https://doi.org/10.1136/bcr-2016-216417

5. Kulkarni, M. S., Rajesh, R., & Shanmugam, M. P. (2022). Ocular occlusions in two cases of COVID-19. Indian journal of ophthalmology, 70(5), 1825–1827. https://doi.org/10.4103/ijo.IJO_3139_21

6. Cascella M, Rajnik M, Aleem A, et al. Features, Evaluation, and Treatment of Coronavirus (COVID-19) [Updated 2022 Oct 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554776/

7. Shivangi, & Meena, L. S. (2021). A comprehensive review of COVID-19 in India: A frequent catch of the information. Biotechnology and applied biochemistry, 68(4), 700–711. https://doi.org/10.1002/bab.2101

8. Nguyen, A., Al Hage, A., Yu, H., & Gunaga, S. (2022). Arterial Occlusion and Acute Deep Vein Thrombosis-Induced Acute Limb Ischemia in a COVID-19 Patient. Cureus, 14(7), e26689. https://doi.org/10.7759/cureus.26689

9. Song, W. C., & FitzGerald, G. A. (2020). COVID-19, microangiopathy, hemostatic activation, and complement. The Journal of clinical investigation, 130(8), 3950–3953. https://doi.org/10.1172/JCI140183

10. Pelle, M. C., Zaffina, I., Lucà, S., Forte, V., Trapanese, V., Melina, M., Giofrè, F., & Arturi, F. (2022). Endothelial Dysfunction in COVID-19: Potential Mechanisms and Possible Therapeutic Options. Life (Basel, Switzerland), 12(10), 1605. https://doi.org/10.3390/life12101605

11. Adamis, A. P., Miller, J. W., Bernal, M. T., D'Amico, D. J., Folkman, J., Yeo, T. K., & Yeo, K. T. (1994). Increased vascular endothelial growth factor levels in the vitreous of eyes with proliferative diabetic retinopathy. American journal of ophthalmology, 118(4), 445–450. https://doi.org/10.1016/s0002-9394(14)75794-0

12. Aslan, A., Aslan, C., Zolbanin, N.M. et al. Acute respiratory distress syndrome in COVID- 19: possible mechanisms and therapeutic management. Pneumonia 13, 14 (2021). https://doi.org/10.1186/s41479-021-00092-9

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