Ocular manifestations of COVID
February 6, 2021
San Diego County Optometric Society Newsletter: Retina Corner
By Nikolas J.S. London, MD FACS
President and Director of Clinical Research, Retina Consultants San Diego
Chief of Ophthalmology, Scripps Memorial Hospital La Jolla
Dear SDCOS membership,
Happy February everyone! I hope that you all have gotten vaccinated by now. This may be a bit ridiculous, but for me the psychological relief of feeling immune to a deadly virus has been priceless. What a milestone. Speaking of COVID, Dr. Orlando Guiang of Mira Mesa Optometry sent me a fascinating patient the other day – a healthy young man with cotton wool spots and small retinal hemorrhages reminiscent of hypertensive retinopathy (figure). He had a recent history of uneventful SARS-Cov-2, and had fully recovered from his symptoms. These findings are interesting and have been seen by others, and I thought this would be a great opportunity to review the retinal and ocular manifestations of this disease which has overshadowed our lives for the past year.
As we all know, SARS-CoV-2 has led to a global pandemic with millions of affected patients and hundreds of thousands of deaths. While primarily a respiratory disease, SARS-Cov-2 has effects throughout the body including the cardiovascular system, the GI tract, kidneys, liver, blood, musculoskeletal system, and central nervous system. As a part of the CNS, it is not surprising that SARS-Cov-2 has ocular and retinal manifestations.
One of the first reported findings was conjunctivitis. This presents similar to other forms of viral conjunctivitis with bilateral conjunctival erythema, epiphora, chemosis, and a follicular reaction. Enlarged pre-auricular and submaxillary lymph notes are also present. The incidence is unclear, but has been reported to affect as many as 32% of patients, and it may be a presenting symptom of infection. Again similar to other viral conjunctivitis, the cases are self-limiting, and supportive care is indicated. On the other hand, conjunctival injection can also be seen in Kawasaki Disease (KD), which is another reported association of SARS-Cov-2. KD is a rare condition that affects young children and is characterized by fever, rash, lymphadenopathy, and oropharyngeal changes (strawberry tongue). In the eye KD may cause iridocyclitis, keratitis, conjunctivitis and/or subconjunctival hemorrhage, and optic nerve edema.
Retinal findings are, of course, more interesting than any of the above (I’m not biased). Reports of affected patients are very similar to what we saw in Dr. Guiang’s patient, and include cotton wool spots and macular microhemorrhages along the vascular arcades. These are often seen in the absence of intraocular inflammation, and likely represent a transient microvasculopathy. Only rare cases of large-vessel occlusion have been reported. The microvasculopathy appears to be due to complement system activation with endothelial cell damage, thrombus formation, and microvascular damage. Retinal findings are expected to fully resolve, and observation with careful attention to other possible vascular events is warranted.
As this pandemic continues and evolves, I am certain that we will learn of additional ocular manifestations. As always, the retina is a window to the health of the rest of the body, and it is interesting to consider how retinal findings might be followed to determine the effect of both acute and chronic infection.
Best wishes, and until next time,