Case description
A 57-year-old male with a past medical history of controlled diabetes
mellitus (DM) and no prior ophthalmic examination was referred due to
gradually bilateral vision loss six days before the presentation which
was accompanied by ocular pain in recent days. Eighteen days before the
onset of visual symptoms, the patient was diagnosed with SARS-CoV-2 by a
positive polymerase chain reaction (PCR) diagnostic test and symptoms of
high fever, persistent cough, and shortness of breath. The patient was
admitted for two weeks and received systemic Dexamethasone and
Remdesivir. At presentation, his viral and systemic symptoms were
resolved. There was no history of headache, scalp tenderness, fever,
weight loss, and muscle weakness.
On examination, the best-corrected visual acuity (BCVA) was light
perception for the right eye (RE) and no light perception for the left
eye (LE). Examination of the pupils revealed nonreactive pupils to light
therefore the relative afferent pupillary defect was not assessable.
Extraocular movements were normal. Intraocular pressure was measured 28
mmHg for the RE and 42 mmHg for the LE. Slit-lamp examination findings
indicated bilateral shallow anterior chambers (360˚ peripheral anterior
synechiae (PAS) was found on gonioscopic examination), corneal
microcystic edema, and nuclear sclerosis 1+ cataract in both eyes.
Dilated fundoscopic examination revealed bilateral optic disc swelling.
Optic discs were small-sized and the cup disc ratio was 0.5 in the RE
and 0.7 in the LE. Also, an intraretinal macular hemorrhage in the RE
was seen (figures 1-A, 2-A). Papillary edema was documented in retinal
nerve fiber layer optical coherence tomography (RNFL OCT) (figures 1-B,
2-B). Analysis of blood tests including complete blood test (CBC),
erythrocyte sedimentation rate (ESR), and C- reactive protein (CRP) was
not remarkable. Increased choroidal thickness was noted in enhanced
depth imaging OCT (EDI-OCT), especially in the LE (figures 1-C, 2-C). In
fluorescein angiography, no sign of ischemia or peripheral vasculitis
was detected (figures 1-D, 2-D). Indocyanine green angiography confirmed
severe choroidal ischemia (figures 1-E, 2-E). No pathologic finding was
reported in brain magnetic resonance imaging (MRI). The patient was
admitted and after medical IOP reduction, peripheral laser iridotomy was
done. Intravenous methylprednisolone (one gr daily) for three days was
prescribed. In follow-up examination there was no improvement in visual
acuity, IOP was controlled with topical medication and optic disc
swelling was diminished.