Background: Acute macular neuroretinopathy (AMN) is an increasingly diagnosed disorder associated with several diseases. The aim of this study was to report the incidence of AMN cases diagnosed during the 2020 coronavirus disease 2019 (COVID-19) pandemic year in a French hospital, and to describe their different forms. Methods: All patients diagnosed between 2019 and 2020, in Paris Rothschild Foundation Hospital, with AMN, paracentral acute middle maculopathy (PAMM) and multiple evanescent white dot syndrome (MEWDS) were retrospectively collected using the software Ophtalmoquery® (Corilus, V1.86.0018, 9050 Gand, Belgium). Systemic and ophthalmological data from AMN patients were analyzed. Results: Eleven patients were diagnosed with AMN in 2020 vs. only one patient reported in 2019. The incidence of AMN significantly increased from 0.66/100,000 visits in 2019 to 8.97/100,000 visits in 2020 (p = 0.001), whereas the incidence of PAMM and MEWDS remained unchanged. Four (36%) of these AMN patients were tested for COVID-19 and received positive polymerase chain reaction (PCR) tests. Conclusions: The incidence of AMN cases increased significantly in our institution in 2020, which was the year of the COVID-19 pandemic. All AMN-tested patients received a positive COVID PCR test, suggesting a possible causative link. According to the different clinical presentations, AMN may reflect different severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pathogenic mechanisms.

Did the COVID-19 Pandemic Increase the Incidence of Acute Macular Neuroretinopathy?

A single-center retrospective observational case series was conducted. This case series enrolled patients who showed ophthalmic manifestations within one week after COVID-19 vaccination at Korea University Guro Hospital in Seoul, Korea, from May 2021 to January 2022. The medical records of patients who complained of ocular symptoms and showed ophthalmic adverse events within one week after COVID-19 vaccination were reviewed. Seventeen eyes from 16 patients with a mean age of 63.8 (range 33–83) years were included in the case series, and all symptoms developed within 1–7 days following inoculation. Retinal vein occlusion in nine eyes (52.9%), retinal artery occlusion in one eye (5.9%), newly developed anterior uveitis in one eye (5.9%), exacerbation of previously diagnosed panuveitis in two eyes (11.8%), and angle-closure attack with high intraocular pressure in four eyes (23.5%) were included. Twelve patients (75%) had been vaccinated with the AstraZeneca (AZD1222) and four (25%) with the Pfizer (BNT162b2) vaccines. Of these, 10 patients (62.5%) experienced ocular disease exacerbation after the first dose, 4 (25%) after the second dose, and 2 (12.5%) after the third dose (booster shot). Eleven patients (64.7%) underwent tests for hematological abnormalities, and three of them tested positive for anti-PF4 antibodies, but no abnormal findings were noted. A causal relationship between vaccination and the ocular manifestations could not be determined, which is a limitation of this study. However, clinicians should consider the effect of COVID-19 vaccination on ophthalmic disease. Further studies are required to elucidate the possible effects of COVID-19 vaccination on the eye.

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Vision-Threatening Ocular Adverse Events after Vaccination against Coronavirus Disease 2019

Abnormal hypercoagulability and increased thromboembolic risk are common in patients with coronavirus disease (COVID-19). COVID-19 has been suggested to cause retinal vascular damage, with several studies on COVID-19 patients with retinal vascular occlusions. We reviewed and investigated studies on retinal vascular occlusions in patients diagnosed with COVID-19 and in those vaccinated for COVID-19. Studies that reported retinal vascular occlusion in COVID-19 patients or in vaccinated people were identified using the terms “retinal occlusion,” together with “severe acute respiratory syndrome coronavirus 2”, “SARS-CoV-2,” “COVID-19,” “coronavirus,” and “vaccine,” through systematic searches of PubMed and Google Scholar databases until January 7, 2022. Thirteen cases of retinal artery occlusion (RAO) and 14 cases of retinal vein occlusion (RVO) were identified among patients diagnosed with COVID-19. Half of the patients with RAO or RVO revealed no systemic disorders except current or past COVID-19, and ocular symptoms were the initial presentation in five cases. Among patients with RAO, most presented with central RAO at 1–14 days of COVID-19 diagnosis, with abnormal coagulation and inflammatory markers. Among those with RVO, two-thirds presented with central RVO and one-third with RVO. Eleven cases with acute macular neuroretinopathy (AMN) and/or paracentral acute middle maculopathy (PAMM) were reported among patients with COVID-19, presenting scotoma resolved spontaneously in most cases. Among the 26 cases vaccinated with either mRNA or adenoviral vector vaccines for COVID-19 and presenting retinal vascular occlusions, there were more RVO cases than RAO cases, and ocular symptoms mostly occurred within 3 weeks after vaccination. One case presented bilateral AMN and PAMM after COVID-19 vaccination. Retinal vascular occlusions might be a manifestation of COVID-19, although rare, especially in patients at risk of systemic hypercoagulability and thromboembolism. For COVID-19 vaccines, the causal relationship is controversial because there are few case reports of retinal vascular occlusions after COVID-19 vaccination. 

/pdf/retinal-vascular-occlusions-in-covid-19-infection-and-2gj3xwly.pdf

Retinal vascular occlusions in COVID-19 infection and vaccination: a literature review

The novel severe acute respiratory syndrome coronavins 2 (SARS-CoV-2) led to the severe Corona Virus Disease 2019 (COVID-19) outbreak that started in December 2019 in China and caused enormous health and economic problems worldwide. Over time, SARS-CoV-2 has demonstrated the capacity for mutation. As the most prevalent new coronavirus variety worldwide, the Omicron variant has supplanted the Delta variant. The COVID-19 primarily damages the immune system and the lungs, but it can also harm other organs secondarily, depending on the patients' co-existing conditions.COVID-19 is associated with ophthalmic manifestations such as conjunctival congestion, tear overflow, and conjunctival edema, with the majority of eye complications occurring in patients with severe infection. The virus may make a patient more susceptible to thrombotic conditions that affect venous and arterial circulation. Meanwhile, it can lead to efferent complications and mucormycosis which is more common in patients with diabetes or who have critical or severe SARS-CoV-2 infection. Significantly, there are a number of ocular side effects following the COVID-19 vaccination, such as herpetic keratitis and facial nerve palsy, which have been reported. These side effects may be caused by the vaccinations' propensity to trigger autoimmune symptoms or thromboembolic events. At present, large-scale nucleic acid testing mainly relies on nasopharyngeal swabs and throat swabs. Tear samples and conjunctival swabs may be helpful samples for the diagnosis of ocular SARS-CoV-2 infection. The eye could be a new route of infection, and finding ways such as effective environmental disinfection, scientific administrative control management, qualified personal protection and other measures to protect the eyes could further reduce the risk of infection.This review aims to sum up the ocular complications of COVID-19, the possible pathogenesis, and preventive strategies to protect ophthalmology practitioners and patients by reviewing the currently available literature on the topic. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9714126

COVID-19 and ocular complications: A review of ocular manifestations, diagnostic tools, and prevention strategies

Introduction The SARS-CoV-2 pandemic had a tremendous impact both on infected people as a disease and on noninfected subjects due to the social restrictions and healthcare facilities reorganization imposed by authorities to contain the contagion and treat patients. The scientific world was also shocked, with journals being overwhelmed with manuscripts describing COVID-19, the systemic condition caused by the virus.Areas covered This review will discuss the evidence of SARS-CoV-2 direct infection of the retina and the retinal alterations secondary to COVID-19. In addition, the impact of the pandemic on the management of retinal diseases and the possible retinal side-effects of the vaccination will be considered. Literature reviewed: PubMed, inclusive dates: 15 October 2019–15 October 2021.Expert opinion The retina is not the primary target of SARS-CoV-2, but the retinal vasculature often shows alterations in COVID-19, some of which can be sight threatening. The pandemic forced a redirection of most healthcare system resources to allow for COVID-19 patients management with an inevitable negative effect on the follow-up and treatment of chronic retinal diseases. New strategies are emerging to manage patients with retinal diseases in the “COVID-19 era,” while future studies will allow understanding the long-term impact of COVID-19 on the retina. 

The impact of COVID-19 on the retina: clinical features and management considerations

Purpose of review The novel coronavirus disease in 2019 (COVID-19) has a wide range of systemic manifestations. Ocular manifestations are now well recognized, with conjunctivitis being the most common. Posterior segment involvement is uncommon and has mainly been described in case reports. This review provides an overview of the posterior segment involvement of COVID-19. Recent findings Severe acute respiratory syndrome coronavirus 2 affects the retina and the choroid through either direct entry or triggering an indirect inflammatory response. Majority of the retinal findings is a result of microvascular derangement leading to cotton wool spots, intraretinal hemorrhages, paracentral acute middle maculopathy, acute macular neuroretinopathy, or retinal vein occlusions. Rarely, inflammation involving the retina or the choroid, or reactivation of previously quiescent uveitis, can be seen. Summary It is important to recognize the possible correlation between ophthalmic conditions and COVID-19 as it can aid in diagnosis, management, and mitigation of the disease.

Youning Zhang

Papers

Retinal and choroidal manifestations of COVID-19.