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.