Atypical COVID-19-Related Acute Macular Neuroretinopathy with Progression Resulting in Severe Vision Loss

We review the clinical course of a patient with decreased vision in the setting of COVID-19 infection consistent with an atypical presentation of acute macular neuroretinopathy (AMN).

A 56-year-old Caucasian woman developed a scotoma in the right eye 3 days after COVID-19 diagnosis and in her left eye on day 5. Baseline exam showed significantly reduced visual acuity bilaterally best corrected visual acuity of 20/60 in the right eye and 20/40 in the left eye from a patient-reported baseline of 20/20 in each eye. Examination of the fundus was remarkable for small flame-shaped hemorrhages in the superior arcade of both eyes. Near-infrared reflectance imaging revealed a singular wedge-shaped lesion in each eye close to the fovea and spectral domain-optical coherence tomography confirmed disruption of the photoreceptor layer and ellipsoid zones. Our leading diagnosis given the presentation was COVID-19-associated AMN. Given no evidence of a clear treatment, observation was selected. Three weeks later, visual acuity deteriorated further to 20/100 OD and 20/80 OS, with persistence of the wedge-shaped lesions. At 3-month follow-up, fundus photographs remained unremarkable; however, visual acuity had dropped further to 20/300 bilaterally, with persistence of the scotomata and outer retinal layer disruptions. 6 months later, treatment with a dexamethasone implant improved vision to 20/125 OD and 20/150 OS.

Among COVID-19-induced AMN, our case is remarkable for the severe progression of visual impairment over 3 months of follow-up and improvement with a dexamethasone implant. Furthermore, absence of classical AMN lesions on fundus photography raises the question whether COVID-induced AMN may lead to a clinically distinct, potentially more severe picture than AMN arising from previously identified causes.