Retinal changes in COVID-19 hospitalized cases

Abstract

The main objective of this study was to evaluate the retinas of severely or critically ill COVID-19 patients during their hospital stay, at varying time points after symptoms onset. This was a case series observed during May 2020 in two referral centers for COVID-19 treatment in Rio de Janeiro, Brazil. 47 eyes from 25 hospitalized patients with severe or critical confirmed illness were evaluated. A handheld retinal camera was used to acquire bilateral fundus images at several time points after symptoms onset. Electronic health records were retrospectively analyzed and clinical data collected. Severe and critical diseases were noticed in 52% (13/25) and 48% (12/25) of enrolled patients, respectively. Retinal changes were present in 12% (3/25) of patients: a 35 year-old male demonstrated bilateral nerve fiber layer infarcts and microhemorrhages in the papillomacular bundle, but required mechanical ventilation and developed severe anemia and systemic hypotension, acute kidney injury and neurologic symptoms during the course of the disease (critical illness); a 56 year-old male, who required full enoxaparin anticoagulation due to particularly elevated D-dimer (>5.0 mcg/mL), demonstrated unilateral and isolated flame-shaped hemorrhages; and a 49 year-old hypertensive male showed bilateral and discrete retinal dot and blot microhemorrhages. The other 22 patients evaluated did not demonstrate convincing retinal changes upon examination. There was no correlation between disease severity and admission serum levels of CRP, D-dimer and ferritin. This was the first study to show that vascular retinal changes may be present in not insignificant numbers of severe or critical COVID-19 inpatients. These retinal changes, only seen after morbid developments, were likely secondary to clinical intercurrences or comorbidities instead of a direct damage by SARS-CoV-2, and may be important and easily accessible outcome measures of therapeutic interventions and sentinels of neurologic and systemic diseases during COVID-19 pandemic.

Ophthalmic Screening in Patients with Coronavirus Disease 2019: A Prospective Cohort Study

“…Some reports suggest high incidences of retinal lesions, while other studies did not find any signs of intraocular manifestations [ 22 , 23 ]. Various mechanisms of nervous system and ocular involvement in COVID-19 are under debate including cytokine dysregulation (referred to as “cytokine storm”), vascular endothelial injury and ischemic processes triggered by hypercoagulability, direct viral cytotoxicity as well as secondary damages mediated by aggravation of pre-existing hypoxia and HT [ 9 , 11 , 18 , 20 , 24 , 25 , 26 , 27 ].…”

“…Lani-Louzada et al stated that COVID-19-related deterioration of pre-existing systemic conditions most likely caused the retinal lesions found in their patients [ 18 ]. We came to the same conclusion regarding our patients.…”

How to Manage COVID-19 Vaccination in Immune-Mediated Inflammatory Diseases: An Expert Opinion by IMIDs Study Group

“…Apparently, SARS-CoV-2 can be found at several levels in the ocular tissues, from the conjunctiva (80) to the retina (81) even though no specific uveitis have been associated to COVID-19. By contrast, several authors have highlighted the presence of non-specific signs of retinal perfusion impairment (82,83) as well as the occurrence of sight threatening thrombotic events affecting the retinal vasculature in COVID-19 patients (84,85).…”

Potency of SARS-CoV-2 on Ocular Tissues

“…Retinal examinations were performed at 12-59 days after the onset of symptoms and only one patient had a medical history of hypertension. Another patient had hypotension, severe anemia, kidney and peripheral nervous system damage, which may explain microhemorrhages and nerve fiber layer infarcts [89]. These findings suggest that retinal alterations may occur depending on the patients' medical histories, yet it may also be due to the cytokine storm, which is developed as a result of immune response induced by COVID-19 and reaches to the retina by passing through the blood retina barrier.…”