COVID‐19 retinal microangiopathy as an in vivo biomarker of systemic vascular disease?

Abstract

Importance. COVID-19 is caused by SARS-CoV-2, a betacoronavirus that uses the angiotensin-converting enzyme-related carboxypeptidase (ACE2) receptor to gain entry into cells. ACE2 receptor is widely expressed in multiple organs, including the retina, an extension of the central nervous system. The ACE2 receptor is involved in the diabetic and hypertensive retinopathy. Additionally, coronaviruses cause ocular infections in animals, including retinitis, and optic neuritis. Objective. To assess whether there is any retinal disease associated with COVID-19. Design. We have evaluated 27 asymptomatic subjects, with retinal fundoscopic, optical coherence tomography (OCT) and OCT angiography fourteen days after hospital discharge due to COVID-19 bilateral pneumonia. Results. Cotton wool exudates were evident in six out of 27 patients evaluated, a 22%. Cotton wool exudates are a marker vascular disease severity in other medical context, that is diabetes and hypertension, and are associated with increased risk for acute vascular events. Whether antiaggregation therapy may play a role on fundoscopicselected patients with COVID-19 requires prospective trials.

Reply to Editorial: Interpretation of OCT and fundus findings in COVID-19 patients in recent Lancet publication

“…On Fig. 3 we can see a follow-up composite of the same patient, where although the lesion is no longer visible on the fundus exam we can still spot it on b-scan OCT. Our findings are consistent with other reports that are now been presented [3][4][5]. We do appreciate all the input received.…”

Update and Recommendations for Ocular Manifestations of COVID-19 in Adults and Children: A Narrative Review

“…Optical coherence tomography (OCT) is a noninvasive imaging modality used to detect retinal changes that manifest during systemic disease [36]. COVID-positive individuals typically manifest conjunctivitis and ocular surface pathology; however, OCT and retinal fundus imaging have demonstrated the presence of cotton wool spots (CWS) [37]. CWS are retinal nerve fiber layer infarcts that can be visualized as lesions on imaging [38].…”

“…It is unclear if the vascular pathology of COVID-19 is due to hypercoagulation, ischemia (in individuals with diabetes), or a direct virus-induced vasculitis. Landecho et al suggest that a fundoscopic exam on admission may help identify individuals who may be more prone to acute vascular disease, because despite all patients being on heparin, 22% of individuals still developed CWS [37]. Similarly, Marinho et al presented a study which included 12 COVID-positive individuals examined by OCT and fundus images at least 10 days after symptom onset.…”

Does COVID-19 Involve the Retina?

“…It was also pointed out that the absence of near-infrared reflectance imaging, OCT angiography abnormalities as well as follow-up scans should be taken into account while interpreting these findings. Furthermore, Virgo and Mohamed presented two patients with paracentral acute middle maculopathy and acute macular neuroretinopathy following SARS-CoV-2 infection [3] and Landecho et al evaluated 27 asymptomatic subjects with previous COVID-19 respiratory tract infection and found that six of them had cotton wool spots [4]. In addition, Insausti-García et al reported a case of papillophlebitis associated with SARS-CoV-2 [5].…”