Purtscher-like retinopathy in patients with COVID-19

Several ophthalmological complications of coronavirus disease 2019 (COVID-19) involving the anterior and posterior segment have been reported in the literature. We present two patients with Purtscher-like retinopathy presenting with bilateral central vision loss and diffuse peripapillary cotton wool spots extending into the macula bilaterally.

In both cases, the patients were diagnosed with COVID-19 within a week of their presentations and had relatively mild courses of COVID-19. In the first case, the patient's vision was hand motion in the right eye and count fingers in the left eye. A broad workup was negative, revealing no concerns for underlying conditions traditionally associated with Purtscher-like retinopathy. Head and neck imaging was also negative for vascular abnormalities. The patient was given a diagnosis of Purtscher-like retinopathy due to COVID-19 infection and was started on 60 mg of oral prednisone. At 4-week follow up, patient's vision had improved to 20/100 in the right eye and 20/80 in the left eye, although she continued to have minimal central vision. The patient continued to have Purtscher flecken in the posterior pole, but the density of the opacities and retinal hemorrhages had significantly improved. In the second case, the patient's past medical history was significant for Huntington's disease and kidney transplant on dialysis but she had not had any ocular issues prior. One week within diagnosis of COVID-19, she presented with a vision of count fingers in the right eye and 20/400 in the left eye. The patient's baseline dose of 5 mg prednisone was increased to 60 mg for 1 week. She received an Ozurdex implant in both eyes. The patient's vision at 9 week follow up improved to 20/40 pinholing to 20/25 in the right eye and 20/200 pinholing to 20/70 in the left eye and dilated exam showed improving edema and improving density of Purtscher-flecken from initial presentation.

Very few cases of COVID-19 associated Purtscher-like retinopathy have been reported in the literature and all have been reported with serious clinical courses of COVID-19. To the best of our knowledge, these are the first cases to be reported after relatively mild courses of COVID-19 and highlight the importance of including COVID-19 in the differential for Purtscher-like retinopathy.