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LETTER TO EDITOR
Year : 2022  |  Volume : 10  |  Issue : 3  |  Page : 135-136

Retinal artery occlusion and COVID-19


Department of Ophthalmology, Tung Wah Eastern Hospital, Hong Kong, China

Date of Submission06-Mar-2021
Date of Decision29-Apr-2022
Date of Acceptance03-May-2022
Date of Web Publication1-Dec-2022

Correspondence Address:
Sunny Chi Lik Au
Department of Ophthalmology, Tung Wah Eastern Hospital, 9/F, MO Office, Lo Ka Chow Memorial Ophthalmic Centre, 19 Eastern Hospital Road, Causeway Bay, HKSAR, Hong Kong
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcor.jcor_37_21

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How to cite this article:
Lik Au SC. Retinal artery occlusion and COVID-19. J Clin Ophthalmol Res 2022;10:135-6

How to cite this URL:
Lik Au SC. Retinal artery occlusion and COVID-19. J Clin Ophthalmol Res [serial online] 2022 [cited 2023 Jan 31];10:135-6. Available from: https://www.jcor.in/text.asp?2022/10/3/135/362504



Dear Editor,

COVID-19 has been associated with thromboembolic disease due to its effect of endothelial dysfunction, platelet activation, and excessive inflammation from the “cytokine storm.” More case reports are now published to describe the blinding ocular arterial occlusion diseases (both the more proximal ophthalmic artery and the distal retinal artery) among COVID-19 patients as a result of hypercoagulable state.[1],[2],[3] Besides, retinal vascular damage could be demonstrated by the altered ocular expression of the angiotensin-converting enzyme 2 (ACE2), particularly concentrated over the pigmented epithelial cells and photoreceptors.[4] ACE2 plays an essential role in vascular protection, and in contrast, COVID-19 patients show a depletion of ACE2 function, both as a result of direct binding of ACE2 with SARS-CoV-2 and indirectly via ACE2 shedding and proteolytic processing.

Researchers are hypothesizing that the prothrombotic vascular endothelial microenvironment induced by SARS-CoV-2 virus could be the precipitating factor causing the development of retinal artery occlusion, similar to observation over other organs such as the renal microvasculature.[5] This microvascular environment change was best demonstrated with the advancing optical coherence tomography angiography technology,[6] where vascular density could be precisely measured. Despite an evolving association, there are still unanswered questions regarding the genuine retinal pathophysiology, especially patients in these case reports all process multiple metabolic and lifestyle risk factors. It is impossible to certain the association between retinal vessel occlusion and COVID-19, particularly with the lack of autopsy evidence when full effects of COVID-19 inflammatory and pro-coagulant state over the retinal vascular system are currently unknown. Under the COVID-19 pandemic, routine ophthalmic monitoring has been suspended in most places; underreporting definitely exists.

Both mild and severe COVID-19 patients are at higher risk of ocular microvascular complications.[7] Patients with a severe illness such as COVID-19 may not be aware on their ocular symptoms. Physicians handling COVID-19 should also consider ocular symptoms and signs of possible ocular thromboembolic complication like painless acute visual loss. Trivial symptoms including painless acute vision loss, new onset scotomas, decreased vision and blurry vision. Ophthalmologists should stay alert and keep the suspicion on retinal vascular occlusions in patients with a history of COVID-19 infection, particularly those acute visual loss cases, as immediate interventions could prevent irreversible blindness.

During the pandemic, COVID-19 screening test is encouraged in patients diagnosed of retinal vascular occlusions, as SARS-CoV-2 carriers can be asymptomatic initially running the risk of SARS-CoV-2 transmission over the ophthalmology clinics. The increasing number of reported cases also highlighted the need to strictly follow the infection control protocols, particularly the personal protection equipment wear, when assessing patients with symptoms of blurry vision or signs of vessel occlusions. With the prevalence of SARS-CoV-2 infection, these patients could have an underlying undiagnosed active COVID-19.

In conclusion, the alteration of ocular microvasculature in COVID-19 patients may develop a new whole spectrum of posterior segment diseases as the retinal circulation is an end arterial system. The potentially vision-threatening nature of retinal vascular disease is of paramount clinical significance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dumitrascu OM, Volod O, Bose S, Wang Y, Biousse V, Lyden PD. Acute ophthalmic artery occlusion in a COVID-19 patient on apixaban. J Stroke Cerebrovasc Dis 2020;29:104982.  Back to cited text no. 1
    
2.
Karahan M, Erdem S, Hazar L, Dursun ME, Ava S, Emek H, et al. Bilateral central retinal artery occlusion secondary to SARS-CoV-2 infection in the early and late periods: A case report. Klin Monbl Augenheilkd 2021;238:1325-7.  Back to cited text no. 2
    
3.
Sweid A, Hammoud B, Weinberg JH, Oneissi M, Raz E, Shapiro M, et al. Letter: Thrombotic neurovascular disease in COVID-19 patients. Neurosurgery 2020;87:E400-6.  Back to cited text no. 3
    
4.
Gheblawi M, Wang K, Viveiros A, Nguyen Q, Zhong JC, Turner AJ, et al. Angiotensin-converting enzyme 2: SARS-CoV-2 receptor and regulator of the renin-angiotensin system: Celebrating the 20th anniversary of the discovery of ACE2. Circ Res 2020;126:1456-74.  Back to cited text no. 4
    
5.
El Shamy O, Munoz-Casablanca N, Coca S, Sharma S, Lookstein R, Uribarri J. Bilateral renal artery thrombosis in a patient with COVID-19. Kidney Med 2021;3:116-9.  Back to cited text no. 5
    
6.
Zapata MÁ, Banderas García S, Sánchez-Moltalvá A, Falcó A, Otero-Romero S, Arcos G, et al. Retinal microvascular abnormalities in patients after COVID-19 depending on disease severity. Br J Ophthalmol 2022;106:559-63.  Back to cited text no. 6
    
7.
Teo KY, Invernizzi A, Staurenghi G, Cheung CM. COVID-19-related retinal micro-vasculopathy – A review of current evidence. Am J Ophthalmol 2022;235:98-110.  Back to cited text no. 7
    




 

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