|Year : 2022 | Volume
| Issue : 2 | Page : 70-71
A rare case report of branch retinal vein occlusion in a COVID-19-positive patient
Pradeep Kumar Panigrahi
Department of Ophthalmology, Institute of Medical Sciences and SUM Hospital, SOA (Deemed to be) University, Bhubaneswar, Odisha, India
|Date of Submission||16-Jun-2021|
|Date of Decision||18-Aug-2021|
|Date of Acceptance||27-Aug-2021|
|Date of Web Publication||18-Jul-2022|
Pradeep Kumar Panigrahi
Department of Ophthalmology, Institute of Medical Sciences and SUM Hospital, SOA (Deemed to be) University, 8-Kalinga Nagar, Bhubaneswar - 751 003, Odisha
Source of Support: None, Conflict of Interest: None
This case report is about a rare case of branch retinal vein occlusion in a healthy 53-year-old male with active COVID-19 infection. All laboratory tests for hypercoagulable state were normal. The patient responded well to multiple injections of intravitreal ranibizumab with complete resolution of macular edema and improvement of vision.
Keywords: Branch retinal vein occlusion, COVID-19, intravitreal injection, retinal vein occlusion
|How to cite this article:|
Panigrahi PK. A rare case report of branch retinal vein occlusion in a COVID-19-positive patient. J Clin Ophthalmol Res 2022;10:70-1
|How to cite this URL:|
Panigrahi PK. A rare case report of branch retinal vein occlusion in a COVID-19-positive patient. J Clin Ophthalmol Res [serial online] 2022 [cited 2023 Mar 24];10:70-1. Available from: https://www.jcor.in/text.asp?2022/10/2/70/351303
Retinal vein occlusion is a common cause of ocular morbidity in the elderly population. It is commonly associated with increasing age, hyperlipidemia, hypertension, hypercoagulability, and vascular inflammation. There have been few reports of retinal vein occlusion following COVID-19 infection in the recent literature.,,,,, The purpose of this case study is to report a rare case of branch retinal vein occlusion in a COVID-19-positive patient.
| Case Report|| |
A 53-year-old healthy male presented with sudden onset painless loss of vision in the left eye (LE) of 3 weeks' duration. The patient gave a history of fever, fatigue, and sore throat 1 month before presentation. Reverse transcriptase polymerase chain reaction (RT-PCR) test of nasopharyngeal sample for COVID-19 was positive. The patient underwent home isolation and followed the treatment regimen prescribed by his physician. One week following the positive test, the patient developed painless loss of vision in LE. On examination, best-corrected visual acuity (BCVA) in the right eye (RE) and LE was 6/6, N6 and 6/24, N36, respectively. Slit-lamp examination of the anterior segment examination of both eyes was within normal limits. Pupillary reaction was normal in both eyes. Intraocular pressure measured using Goldmann's applanation tonometer was 16 and 15 mm of Hg in RE and LE, respectively. Fundoscopy of RE using indirect ophthalmoscope was within normal limits. Fundoscopic examination of LE revealed clear vitreous, normal disc, retinal hemorrhages with cotton wool spots superotemporal to fovea, and macular edema [Figure 1]a. Few hard drusens were noted temporally away from the foveal center. It was diagnosed as a case of superotemporal branch retinal vein occlusion in LE.
|Figure 1: (a) Color fundus photograph of the left eye showing retinal hemorrhages, cotton wool spots, and macular edema. (b) Optical coherence tomography scan of the left eye showing distorted foveal contour, intraretinal cysctic spaces, and neurosensory detachment|
Click here to view
Optical coherence tomography (OCT) of RE showed normal foveal contour. OCT scan of LE showed distorted foveal contour with intraretinal cystic spaces and neurosensory detachment [Figure 1]b. Central retinal thickness in RE and LE was 223 and 398 μ, respectively. Laboratory tests, including random blood sugar, C-reactive protein, erythrocyte sedimentation rate, total blood counts, and serum homocysteine, were normal. Tests for coagulation profile like prothrombin test, activated partial thromboplastin time, International normalized ratio, Protein–C, Protein-S, anti-cardiolipin antibodies, etc., were within the normal limits. D-dimer was found to be only mildly elevated. After obtaining cardiological clearance, the patient was treated with intravitreal injection of Ranibizumab (Accentrix, NovartisTM, 0.5 mg/0.05 ml) in LE. One month following injection, BCVA in LE had improved to 6/12, N8. The patient was treated with 2 more injections of Ranibizumab in LE at monthly intervals. Three months following presentation, BCVA in LE had improved to 6/9, N6. The retinal hemorrhages had got almost totally resolved and there was complete resolution of macular edema [Figure 2].
|Figure 2: (a) Color fundus photograph of the left eye showing near complete resolution of retinal hemorrhages. (b) Optical coherence tomography scan of the left eye showing resolved macular edema|
Click here to view
| Discussion|| |
Coagulopathy associated with COVID-19 infections has been well described in the literature since the start of the pandemic. Magro et al. have described the autopsy findings of patients with severe COVID-19 infection. The characteristic finding of the study was small vessel thrombosis caused by complement mediated microvascular injury. Platelet fibrin microthrombi were regularly found in the lumen of venules, arterioles, and capillaries. Tests for compliment system were not done in our case due to nonavailability of the tests in our setting. In addition, it has also been reported that affinity of the SARS COV-2 for vascular endothelial angiotensin-converting enzyme-2 receptors lead to activation of apoptotic pathway signaling and prothrombotic cascades. The prothrombotic state produced by COVID-19 infection can lead to thrombus formation within the retinal microcirculation resulting in vascular occlusion.
Retinal vein occlusion can be associated with systemic disorders such as hypertension, hypercoagulability, and ocular inflammation. Our patient was a healthy male with no systemic disorders. Tests were performed for other diseases producing a hypercoagulable state in the body. All the tests came out to be normal other than D-dimer which was slightly elevated. There were no signs of ocular inflammation or retinal vasculitis in our case. Our patient had a positive RT-PCR assay for SARS-COV-2 before the visual symptoms started. The prothrombotic state associated with COVID-19 infection could have most probably produced a thrombosis within the retinal venous circulation resulting in venous occlusion. Other possibilities include direct involvement of viral particles and delayed immune response to the viral antigens. Our patient presented with ocular involvement 7 days after acute infection. There is a possibility that immune complex deposition mediated damage to the retinal vessels could have led to the vascular occlusion.
There are reports of dehydration being a potential cause of retinal vein occlusion. Dehydration can result from severe intensive exercise, bouts of gastroenteritis, and vomiting. During dehydration, the blood hematocrit rises leading to a state of hyperviscosity. This then can lead to thrombus formation within the retinal veins. Our patient did not have any history of severe exercise or gastroenteritis. He was well hydrated during his course of illness. Thus, dehydration as a potential cause of venous occlusion was ruled out in our case.
| Conclusion|| |
This report adds to the body of literature available on retinal venous occlusion following COVID-19 infection. Ophthalmologists need to remain aware of this possible complication following active COVID-19 infection. Prompt initiation of therapy is associated with good prognosis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Raval N, Djougarian A, Lin J. Central retinal vein occlusion in the setting of COVID-19 infection. J Ophthalmic Inflamm Infect 2021;11:10.
Duff SM, Wilde M, Khurshid G. Branch retinal vein occlusion in a COVID-19 positive patient. Cureus 2021;13:e13586.
Sheth JU, Narayanan R, Goyal J, Goyal V. Retinal vein occlusion in COVID-19: A novel entity. Indian J Ophthalmol 2020;68:2291-3.
] [Full text]
Walinjkar JA, Makhija SC, Sharma HR, Morekar SR, Natarajan S. Central retinal vein occlusion with COVID-19 infection as the presumptive etiology. Indian J Ophthalmol 2020;68:2572-4.
] [Full text]
Venkatesh R, Reddy NG, Agrawal S, Pereira A. COVID-19-associated central retinal vein occlusion treated with oral aspirin. BMJ Case Rep 2021;14:e242987.
Finn AP, Khurana RN, Chang LK. Hemi-retinal vein occlusion in a young patient with COVID-19. Am J Ophthalmol Case Rep 2021;22:101046.
Connors JM, Levy JH. COVID-19 and its implications for thrombosis and anticoagulation. Blood 2020;135:2033-40.
Magro C, Mulvey JJ, Berlin D, Nuovo G, Salvatore S, Harp J, et al.
Complement associated microvascular injury and thrombosis in the pathogenesis of severe COVID-19 infection: A report of five cases. Transl Res 2020;220:1-13.
Varga Z, Flammer AJ, Steiger P, Haberecker M, Andermatt R, Zinkernagel AS, et al.
Endothelial cell infection and endotheliitis in COVID-19. Lancet 2020;395:1417-8.
Moisseiev E, Sagiv O, Lazar M. Intense exercise causing central retinal vein occlusion in a young patient: Case report and review of the literature. Case Rep Ophthalmol 2014;5:116-20.
[Figure 1], [Figure 2]