Retinal Imaging Study Diagnoses in COVID-19

A Case Report

José M. Ortiz-Egea; Jorge Ruiz-Medrano; José M. Ruiz-Moreno


J Med Case Reports. 2021;15(15) 

In This Article

Case Presentation

We present the case of a 42-year-old, healthy Caucasian male anesthetist who had been working with COVID-19 patients during the 5 weeks prior to onset, who presented with a sudden temporal relative scotoma in the left eye. The patient had no previous retinal disease or systemic disease with retinal compromise. Best-corrected visual acuity was 20/20 for the left eye, and no discromatopsy or afferent pupillary defect was present. A visual field test (SITA Fast 30–2) was performed, with no significant findings associated with a focal loss of sensitivity described by the patient. The anterior segment and fundus examination were unremarkable in both eyes.

Swept-source optical coherence tomography (SS-OCT, Topcon Co., Tokyo, Japan) showed a hyperreflective band at the level of ganglion cell and inner plexiform layers, which spared the outer retina (Figure 1a, b). Multimodal imaging showed neither hypo- nor hyper-autofluorescence in the area. Fluorescein angiography showed no areas of leakage or vascular exudation in early or late phases.

Figure 1.

a and b Swept-source optical coherence tomography (SS-OCT, Topcon Co., Tokyo, Japan) showed a hyperreflective band (yellow arrows) at the level of the ganglion cell and inner plexiform retinal layers, which spared the outer retina. Green line where the B-scan of the OCT was acquired superposed automatically by the acquisition instrument on an en face infrared fundus image, where there are signs of arterial and venous vessel reflexes (red asterisks) and nerve fiber layer hyperreflectivity (green star)

The patient did not report respiratory symptoms, fever or any other clinical symptoms typically described in COVID-19 cases. Thoracic computed tomography imaging did not show lesions compatible with those described in COVID-19 cases with respiratory involvement. Blood tests performed were normal, with no signs of coagulopathy alterations. The patient had normal blood pressure values.

After identifying the aforementioned retinal lesions and considering the patient's high-risk profession with regard to COVID-19 exposure, a pharyngeal swab test for SARS-CoV-2 ribonucleic acid (RNA) and enzyme-linked immunosorbent assay (ELISA) determination of immunoglobulin G (IgG) and immunoglobulin M (IgM) were requested. At that time, the patient remembers that he had limited ageusia for several days 3 weeks before the onset of the scotoma. Real-time reverse-transcriptase polymerase chain reaction (RT-PCR) was negative. ELISA testing and a third rapid antibody detection test performed 7 days after the onset of symptoms were positive.

In the subsequent follow-up of the patient 30 days after the start of the scotoma perception, he continued to describe it. Retinal imaging study showed the same hyperreflective lesions observed in SS-OCT, with even greater intensity (Figure 2a, b), and there were no arteries or veins in the inner layers of the retina on this B-scan that could cause a hyperreflective shadow.

Figure 2.

a and b One month later, SS-OCT follow-up shows a more prominent hyperreflective band at the level of ganglion cell and inner plexiform retinal layers (yellow arrows). An en face infrared fundus image with a green line where the OCT B-scan was acquired automatically overlaid by the acquisition instrument. On the left, the hyperreflective signal corresponds to the layer of nerve fibers (green star) and reflex vessels (red asterisks)