Multimodal imaging case series of acute macular neuroretinopathy secondary to COVID-19 infection

Abstract

Purpose : Understanding of the ocular manifestations of coronavirus disease 2019 (COVID-19) is continuing to develop. While ocular symptoms, chiefly conjunctivitis, have been reported, retinal pathologies have been suggested as a rarer complication and are hypothesized to derive from a combination of the inflammatory and vasculopathic effects of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Using a retrospective, observational case series design, we describe a series of four eyes in three patients with acute macular neuroretinopathy (AMN) and paracentral acute middle maculopathy (PAMM) associated with COVID-19 illness.

Methods : Our practice’s electronic medical record (EMR) was retrospectively queried for patients from April 2020 to December 2021 who had been diagnosed with AMN or PAMM and COVID-19 illness. Three patients were identified by this method. Patient demographic information, physical exam, optical coherence tomography (OCT), infrared reflectance (IR), and fluorescein angiography (FA) studies were all used for analysis.

Results : Imaging signs of AMN were revealed in four eyes in three female patients, aged 22, 32, and 64 years old, all with confirmed symptomatic COVID-19 corresponding to the start of visual symptoms. The average onset of visual symptoms from COVID-19 illness was 14 days (range 0–56). 4/4 eyes were symptomatic for scotomata. Average logMAR visual acuity was 0.024 (Snellen 20/21, range 0–0.097). 4/4 eyes demonstrated typical findings of AMN: IR imaging with prominent dark petaloid or ovoid parafoveal lesions and corresponding disruption of the ellipsoid zone on OCT (Fig. 1). FA imaging did not show any abnormal fluorescence pattern. Autofluorescence in 1/4 eyes demonstrated hyperautofluorescence corresponding to the abnormal area on IR imaging (Fig. 2). Two month follow-up showed persistent symptoms of scotomata with unchanged findings on follow-up imaging in 100% of cases.

Conclusions : This series demonstrates that, although rare, SARS-CoV-2 infection may result in microvasculopathic injuries to the retina, namely AMN and PAMM.

This abstract was presented at the 2022 ARVO Annual Meeting, held in Denver, CO, May 1-4, 2022, and virtually.

 

Figure 1. 22 year-old female with bilateral AMN at presentation (A and B) and at 2 month follow-up (C and D). Green arrows indicate ellpsoid zone disruption.

 

Figure 2. OCT-IR images in a 64-year-old female at presentiation (A) and at 2 month follow-up (B). A region of hyperautofluorescence (asterisk) is seen in panel C.