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      Central Retinal Vein Occlusion in a 46-Year-Old Man with COVID-19: Case Report and Review of the Literature

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          Abstract

          A 46-year-old man with a history of well-controlled hypertension presented with a central retinal vein occlusion (CRVO) in his right eye, which was complicated by cystoid macular edema. When the patient noted new visual symptoms, he was also experiencing muscle aches and easy fatiguability. A standard hypercoagulability panel failed to identify an etiology for his CRVO. However, the patient underwent COVID-19 antibody testing, which returned positive. The patient received a series of aflibercept injections for his macular edema, and his vision improved. Further study is warranted to determine if there is any association between mild infection with COVID-19 and the development of CRVO.

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          Most cited references18

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          Incidence of thrombotic complications in critically ill ICU patients with COVID-19

          Introduction COVID-19 may predispose to both venous and arterial thromboembolism due to excessive inflammation, hypoxia, immobilisation and diffuse intravascular coagulation. Reports on the incidence of thrombotic complications are however not available. Methods We evaluated the incidence of the composite outcome of symptomatic acute pulmonary embolism (PE), deep-vein thrombosis, ischemic stroke, myocardial infarction or systemic arterial embolism in all COVID-19 patients admitted to the ICU of 2 Dutch university hospitals and 1 Dutch teaching hospital. Results We studied 184 ICU patients with proven COVID-19 pneumonia of whom 23 died (13%), 22 were discharged alive (12%) and 139 (76%) were still on the ICU on April 5th 2020. All patients received at least standard doses thromboprophylaxis. The cumulative incidence of the composite outcome was 31% (95%CI 20-41), of which CTPA and/or ultrasonography confirmed VTE in 27% (95%CI 17-37%) and arterial thrombotic events in 3.7% (95%CI 0-8.2%). PE was the most frequent thrombotic complication (n = 25, 81%). Age (adjusted hazard ratio (aHR) 1.05/per year, 95%CI 1.004-1.01) and coagulopathy, defined as spontaneous prolongation of the prothrombin time > 3 s or activated partial thromboplastin time > 5 s (aHR 4.1, 95%CI 1.9-9.1), were independent predictors of thrombotic complications. Conclusion The 31% incidence of thrombotic complications in ICU patients with COVID-19 infections is remarkably high. Our findings reinforce the recommendation to strictly apply pharmacological thrombosis prophylaxis in all COVID-19 patients admitted to the ICU, and are strongly suggestive of increasing the prophylaxis towards high-prophylactic doses, even in the absence of randomized evidence.
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            Retinal findings in patients with COVID-19

            Coronavirus disease 2019 (COVID-19) has been shown to affect different parts of the body, and ophthalmological changes have been associated with ocular external diseases such as conjuntivitis 1 . Optical coherence tomography (OCT) is a non-invasive imaging technique that is useful for demonstrating subclinical retinal changes in systemic conditions such as diabetes, Parkinson's disease, and Alzheimer's disease, as well as many viral infections. 2 We used OCT to evaluate patients infected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The protocol was approved by INVIRARE Pesquisa Clínica Auditoria e Consultoria Institutional Review Board Ethics Committee. Here we report retinal and OCT changes in 12 adults (six men and six women, aged 25–69 years), examined 11–33 days after COVID-19 symptom onset. All patients had fever, asthenia, and dyspnoea, and 11 patients also presented with anosmia. Two patients were admitted to hospital but none required intensive care. Nine patients were physicians, and two were health-care workers. All patients had normal blood parameters at the time of ophthalmological evaluation. Nine patients tested positive for SARS-CoV-2 by PCR (using nasal and oral swabs), and two patients tested positive in antibody tests for COVID-19. Two different OCT devices were used: DRI-OCT Triton Swept Source (Topcon, Tokyo, Japan) and XR Avanti SD-OCT (Optovue, Fremont, CA, USA). All patients showed hyper-reflective lesions at the level of ganglion cell and inner plexiform layers more prominently at the papillomacular bundle in both eyes (figure ). Results of OCT-angiography and ganglionar cells complex analysis appeared normal. Furthermore, four patients presented subtle cotton wool spots and microhaemorrhages along the retinal arcade, observed on fundus examination, color fundus photography, and red-free imaging. Visual acuity and pupillary reflexes were normal in all eyes, and we detected no symptoms or signs of intraocular inflammation. Figure Retinal findings in four patients with COVID-19 Panels A-D represent four different patients. (A) Colour fundus photography and red-free imaging show a cotton wool spot at the superior retinal arcade with subtle microhaemorrhage. (B–D) Cross-sectional B-scan OCT in three patients shows hyper-reflective lesions at the level of the inner plexiform and ganglion cell layers, a feature observed in all patients. COVID-19=coronavirus disease 2019. OCT=optical coherence tomography. Although animal models suggest ocular lesions could include retinitis and optic neuritis,3, 4 this is, to the best of our knowledge, the first report of retinal findings possibly associated with COVID-19 infection in humans. Ganglion cell and plexiform layer findings could be associated with CNS manifestations that have been described in animal studies 4 and in COVID-19 neurological events. 5
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              Detection of SARS-CoV-2 in Human Retinal Biopsies of Deceased COVID-19 Patients

              To report the presence of viral ribonucleic acid (RNA) of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in human retina in deceased patients with confirmed novel coronavirus disease 2019 (COVID-19).
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                Author and article information

                Journal
                COP
                COP
                10.1159/issn.1663-2699
                Case Reports in Ophthalmology
                S. Karger AG
                1663-2699
                2021
                May - August 2021
                19 July 2021
                : 12
                : 2
                : 646-652
                Affiliations
                Department of Ophthalmology, Scheie Eye Institute, University of Pennsylvania, Philadelphia, Pennsylvania, USA
                Author notes
                *Benjamin J. Kim, benjamin.kim@pennmedicine.upenn.edu
                Article
                517417 Case Rep Ophthalmol 2021;12:646–652
                10.1159/000517417
                8339514
                34413756
                31106e12-15be-4f6e-bc7e-0fe99e30df95
                © 2021 The Author(s). Published by S. Karger AG, Basel

                This article is licensed under the Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC). Usage and distribution for commercial purposes requires written permission. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                History
                : 25 February 2021
                : 01 May 2021
                Page count
                Figures: 1, Tables: 2, Pages: 7
                Categories
                Case Report

                Vision sciences,Ophthalmology & Optometry,Pathology
                Central retinal vein occlusion,Hypercoagulability,COVID19,Coronavirus,Severe acute respiratory syndrome coronavirus 2

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