Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 
  • Users Online: 1958
  • Home
  • Print this page
  • Email this page

   Table of Contents      
LETTER TO THE EDITOR
Year : 2021  |  Volume : 69  |  Issue : 1  |  Page : 193-194

Response to comments on: Retinal vein occlusion in COVID 19: A novel entity


1 Department of Vitreoretinal Services, Surya Eye Institute and Research Center, Mumbai, Maharashtra; Clinical Research Lead, Chaitanya Eye Hospital and Research Center, Trivandrum, Kerala, India
2 General Secretary, Vitreoretinal Society of India; Suven Clinical Research Center, LV Prasad Eye Institute, Hyderabad, Telangana, India

Date of Web Publication15-Dec-2020

Correspondence Address:
Dr. Jay U Sheth
Surya Eye Institute and Research Center, Mumbai, Maharashtra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_3221_20

Rights and Permissions

How to cite this article:
Sheth JU, Narayanan R. Response to comments on: Retinal vein occlusion in COVID 19: A novel entity. Indian J Ophthalmol 2021;69:193-4

How to cite this URL:
Sheth JU, Narayanan R. Response to comments on: Retinal vein occlusion in COVID 19: A novel entity. Indian J Ophthalmol [serial online] 2021 [cited 2021 Jan 16];69:193-4. Available from: https://www.ijo.in/text.asp?2021/69/1/193/303332



Dear Editor,

We thank the authors[1] for taking interest in our case report[2] and giving us an opportunity to clarify the fundamentals of diagnosing Uveitis and its associated spectrum of presentations.

Characterizing retinal vasculitis is a challenging task. It needs meticulous clinical evaluation and interpreting multimodal imaging based on recommendations laid down by the “Standardization of Uveitis Nomenclature Working group”.[3] To quote from the 'Results of the First International Workshop of SUN', “Achieving consensus on which retinal vascular changes constituted retinal vasculitis was more problematic. Although the group provisionally agreed to consider perivascular sheathing and vascular leakage or occlusion on fluorescein angiogram as evidence of retinal vascular disease for the classification of retinal vasculitis, there was consensus that the definition of retinal vasculitis required more work”.[3] Although the authors state that “vascular staining and posterior pole leak” as seen in our case can occur in retinal vein occlusions,[1] one important pointer towards an inflammatory etiology is the additional presence of leakage of optic disc and vessel wall in our patient.[2] Moreover, perivascular sheathing or cuffing has been reported in only around 64% of cases with retinal vasculitis.[4] Hence the notion of the authors that absence of perivascular exudates, cuffing or sheathing rules out vasculitis is incorrect. Furthermore, in occlusive retinal vasculitis secondary to other viral infections such as dengue and chikungunya, it is uncommon to see these clinical findings of perivascular exudations or sheathing.[5],[6] Though retinal vasculitis in COVID-19 has not been described earlier, it may have similar pathogenesis as dengue and chikungunya viruses.

The authors correctly point out that COVID-19 related vasculopathy has been described in literature, including a solitary case of central retinal artery occlusion (CRAO).[7] We have reported a case of retinal vein occlusion (RVO) secondary to COVID-19 and its successful management, which has not been reported in literature.[2] Regarding the role of biomarker in COVID-19, a diverse range have been evaluated including C-reactive protein, D-Dimer, IL-6, platelet count, cardiac troponin, lactate dehydrogenase (LDH), white cell count (WCC) and so on.[8] Of these, the utility of CRP and D-Dimer levels is most useful for predicting clinical outcomes.[9] Additionally, CRP is the earliest biomarker to be elevated and studies have shown it to be more reliable than even computer tomography (CT) scan for earliest identification of disease severity.[10] Nonetheless, studies have shown these biomarkers to be normal in mild to moderate cases. In our case, D-dimer levels were not tested but the CRP levels were within normal limits, which has been mentioned in the case report.[2] This is suggestive of mild-moderate disease systemically, as evident by his discharge from the COVID hospital in stable condition three days prior to presenting for the retinal disease. With regards to the details of the patient's one-week course during hospital admission, we were unable to incorporate it in the original manuscript[2] due to paucity of word limit based on the journal guidelines. For the information of the readers, the patient was admitted for one week with symptoms of fever which was treated with oral paracetamol 500 mg QID. Additionally, he received supplementary medications in the form of vitamin C (2000 mg daily), vitamin D (5000 IU daily) and zinc (22 mg). His vitals, including heart rate, blood pressure and SPO2 levels remained stable throughout his hospital stay. There were no complications and he was discharge in stable condition at the end of one week.

The authors state that since there is absence of other features of systemic vasculitis, COVID-19 cannot be an etiology of RVO. In literature, cases of solitary involvement of a particular organ being affected by COVID-19 has been distinctly illustrated, including CRAO, Vestibular Neuritis and urticaria.[7],[11],[12] Hence it is not uncommon to have an isolated organ damage due to COVID-19 as seen in our case. Lastly, the authors claim that temporal association is unlikely a causative reason for vasculitic RVO. We have only claimed an association, which may or may not be causal. However, we cannot rule out causality and more cases need to be studied. Furthermore, we would like to inform the readers that ocular involvement such as retinitis/retinal pigment epithelitis/vasculitis/uveitis are common after viral fever.[13] Hence to question temporal association between COVID-19 and RVO within an interval of ten days, and in the absence of any other plausible etiology, is indeed surprising.

In the letter, the authors demonstrate ambiguity by initially pointing to a COVID-19 related vasculopathy rather than vasculitis as an etiology, and later refuting association with COVID-19 altogether.[1] It would be interesting to know the etiology which the authors propose for a case of retinal vasculitis developing within 10 days of a viral infection (COVID-19) with the best part of potential causative factors being ruled out.

We would like to conclude by highlighting key points:

  1. Presence of vessel wall staining, with leakage at posterior pole, from the vessel walls and optic disc are important attributes of vasculitis.
  2. Clinical findings such as perivascular sheathing, cuffing and exudates may not always be present in vasculitis; rather FFA is crucial to confirm retinal vasculitis.
  3. It is not uncommon to observe posterior segment involvement post-viral fever; a temporal association is frequently noted after ruling out other common etiologies.
  4. Whether the COVID-19 related vasculitic RVO is due to direct involvement of viral particles or secondary to an immune mediated thromboembolic event remains a conjecture, unless we perform a thorough histopathological evaluation.


We would like to reiterate to our colleagues and readers to view this case report from a broader perspective of the COVID-19 pandemic. Subsequent to this case, we have come across an expanding array of posterior segment involvement due to COVID-19 such as isolated retinal hemorrhages, optic neuritis, and third nerve palsy (Unpublished data). We have now included RT-PCR analysis for COVID-19 in workup protocol for all cases of young vasculitis, or other posterior uveitic/occlusive pathologies. Although much remains to be known about the COVID-19 virus and its ocular involvement, we are optimistic that our initial work in this area would encourage other researchers to undertake comprehensive studies in this field.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Reddy PR, Singh DV, Baharani A. Comments on: Retinal vein occlusion in COVID-19: A novel entity. Indian J Ophthalmol 2021;69:192.  Back to cited text no. 1
    
2.
Sheth JU, Narayanan R, Goyal J, Goyal V. Retinal vein occlusion in COVID-19: A novel entity. Indian J Ophthalmol 2020;68:2291-3.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Jabs DA, Nussenblatt RB, Rosenbaum JT; Standardization of Uveitis Nomenclature (SUN) Working Group. Standardization of uveitis nomenclature for reporting clinical data. Results of the First International Workshop. Am J Ophthalmol 2005;140:509-16.  Back to cited text no. 3
    
4.
Graham EM, Stanford MR, Sanders MD, Kasp E, Dumonde DC. A point prevalence study of 150 patients with idiopathic retinal vasculitis: 1. Diagnostic value of ophthalmological features. Br J Ophthalmol 1989;73:714-21.  Back to cited text no. 4
    
5.
Velaitham P, Vijayasingham N. Central retinal vein occlusion concomitant with dengue fever. Int J Retina Vitreous 2016;2:1.  Back to cited text no. 5
    
6.
Lalitha P, Rathinam S, Banushree K, Maheshkumar S, Vijayakumar R, Sathe P. Ocular involvement associated with an epidemic outbreak of chikungunya virus infection. Am J Ophthalmol 2007;144:552-6.  Back to cited text no. 6
    
7.
Acharya S, Diamond M, Anwar S, Glaser A, Tyagi P. Unique case of central retinal artery occlusion secondary to COVID-19 disease. IDCases 2020;21:e00867.  Back to cited text no. 7
    
8.
Kermali M, Khalsa RK, Pillai K, Ismail Z, Harky A. The role of biomarkers in diagnosis of COVID-19-A systematic review. Life Sci 2020;254:117788.  Back to cited text no. 8
    
9.
Pan F, Yang L, Li Y, Liang B, Li L, Ye T, et al. Factors associated with death outcome in patients with severe coronavirus disease-19 (COVID-19): A case-control study. Int J Med Sci 2020;17:1281-92.  Back to cited text no. 9
    
10.
Tan C, Huang Y, Shi F, Tan K, Ma Q, Chen Y, et al. C-reactive protein correlates with computed tomographic findings and predicts severe COVID-19 early. J Med Virol 2020;92:856-62.  Back to cited text no. 10
    
11.
Malayala SV, Raza A. A case of COVID-19-induced vestibular neuritis. Cureus 2020;12:e8918.  Back to cited text no. 11
    
12.
Henry D, Ackerman M, Sancelme E, Finon A, Esteve E. Urticarial eruption in COVID-19 infection. J Eur Acad Dermatol Venereol 2020;34:e244-5.AS  Back to cited text no. 12
    
13.
Mahendradas P, Kawali A, Luthra S, Srinivasan S, Curi AL, Maheswari S, et al. Post-fever retinitis-Newer concepts. Indian J Ophthalmol 2020;68:1775-86.  Back to cited text no. 13
[PUBMED]  [Full text]  




 

Top
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
References

 Article Access Statistics
    Viewed306    
    Printed0    
    Emailed0    
    PDF Downloaded28    
    Comments [Add]    

Recommend this journal