Retinal, choroidal microvascular lesions may be linked to severe COVID-19 infections

French investigators reported that all patients hospitalized with severe COVID-19 cases in their study had retinal and choroidal anomalies on indocyanine green angiography (ICGA) and optical coherence tomography (OCT) images that were possibly related to the virus.

The investigators, led by first author Youssef Abdelmassih, MD, from the Pediatric Ophthalmology and Retina Department, Rothschild Foundation Hospital, Paris, conducted an observational prospective monocentric cohort study.1

The rationale for the study was that the SARS-CoV-2 virus has bene found to affect the microvasculature in many organs, and the retinal and choroidal microvessels can be easily visualized and “could be an open window on the general microvascular state of COVID-19 patients,” they commented.

Fourteen patients, 9 of whom were male, were included in the study (28 eyes; mean age, 58.2 ± 11.4 years). The primary study outcome was the findings on ICGA and OCT images.

Imaging findings

ICGA showed mainly hypofluorescent spots in 19 eyes (68%), intervortex shunts in 10 eyes (36%), and characteristic “hemangioma-like” lesions in five eyes (18%), the investigators reported. The last of these findings were unique and unilateral and showed no washout on the late phase of the angiogram.

The described that the hemangioma-like lesions are a specific sign that have not previously been reported and speculated that this lesions may result from venous overload and leakage downstream of the microthrombosis.

“Interestingly, eyes presenting with hemangioma-like lesions had a higher choroidal vascularity index, defined as the ratio of the luminal to choroidal area, compared to contralateral eye of the same patient and to eyes without this lesion, which suggests the role of vessel dilation in this particular finding,” they said.

Another potential mechanism may be deregulation in the choroidal blood flow due to changes in the autonomous nervous system secondary to the COVID-19 infection, possibly resulting in vascular remodeling. The investigators also pointed out that unlike real hemangioma lesions that usually present with retinal pigment epithelial bulging and late washout on ICG image, the hemangioma-like lesions did not have those two characteristics.

OCT showed focal choroidal thickening in seven eyes (25%), caverns in six eyes (21%), and paracentral acute middle maculopathy lesions in one eye (4%).

“The images showed lesions in both the retinal and choroidal vasculature,” the investigators concluded. “These anomalies could be secondary to vascular involvement related directly or indirectly to the SARS-CoV2 virus. Although frequent in patients with COVID-19, we cannot assume with certainty that these anomalies were caused by COVID-19. Future studies including a control group would be necessary to attribute these abnormalities to COVID-19 infection.”

Reference

Abdelmassih Y, Azar G, Bonnin S, et al. COVID-19 associated choroidopathy. J Clin Med 2021;10:4686; https://doi.org/10.3390/jcm10204686