Retinal Manifestations of Covid 19

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1. Introduction

2. Retinal Manifestations of COVID-19

a. Microvascular Changes

b. Retinal Vascular Occlusion

c. Retinal Artery Occlusion

3. Conclusion

4. References


The coronavirus disease 2019 (COVID-19) pandemic is an ongoing global health crisis that is caused by the acute respiratory syndrome coronavirus 2 (SARS-CoV-2)1. As of March 12, 2022, there have been over 450 million confirmed cases of COVID-19 and over 6 million deaths around the world2. Although most research and therapeutic efforts are directed towards the respiratory complications of the disease, COVID-19 can also lead to significant ophthalmic manifestations. The most commonly reported of these is conjunctivitis3, which in some patients may be the only manifestation of SARS-CoV-2 infection4. While eyelid, ocular surface, and anterior segment manifestations of COVID-19 are well documented, posterior segment involvement is less common and has mainly been described in the form of case reports5. In this article, we will provide an overview of the most commonly reported retinal manifestations of COVID-19.

Retinal Manifestations of COVID-19

Microvascular Changes

The most common retinal manifestations of COVID-19 are microvascular changes like cotton wool spots and retinal microhemorrhages5. Many of these patients had preserved visual acuity and pupillary reflexes6, but there have also been instances where patients developed visual field defects7. SARS-CoV-2 infection has also been associated with new onset paracentral acute middle maculopathy (PAMM) and acute macular neuroretinopathy (AMN), although a true relationship between these conditions and COVID-19 has yet to be established8. Increased tortuosity of retinal vessels is another finding that has been documented in patients with COVID-199. However, many of these retinal findings can also be seen in septic patients and patients with conditions like diabetic retinopathy, making it difficult to establish a true causal relationship between SARS-CoV-2 infection and microvascular retinal changes10.

Retinal Vein Occlusion

Central retinal vein occlusion (CRVO) has been identified as an important complication of COVID-19, as early detection and treatment is necessary for improved prognosis. SARS-CoV-2 infection is known to cause endothelial disruption, complement activation, and inflammation, leading to a hypercoagulable state that increases the risk of thrombus formation11. Decreased vision and blurred vision are the most common presenting symptoms or CRVO, and can start anytime from 5 days to 6 weeks after initial onset of fever12. Although CRVO is classically associated with risk factors like age, hypertension, glaucoma, and diabetes, COVID-19 has been shown to have a causal relationship with CRVO irrespective of patient age or comorbidities12. Because timely diagnosis and management is crucial for vision preservation, clinicians should be vigilant about monitoring for signs of CRVO in patients with a history of COVID-19.

Retinal Artery Occlusion

Central retinal artery occlusion (CRAO) is a medical emergency that can lead to complete vision loss if not treated promptly , and has also been documented in the context of SARS-CoV-2 infection. In case reports, patients developed sudden, unilateral and painless vision loss two to six weeks after the initial onset of COVID-19 symptoms, and were found to have mild-to-significant retinal whitening on fundus exam13. However, it is important to note that most of these patients had additional underlying conditions like hypertension, obesity, and coronary artery disease, which may have placed them at a higher risk of developing CRAO. Regardless, because rapid identification and treatment is necessary to restore visual acuity, clinicians should consider CRAO in patients with a history of COVID-19 who present with sudden and painless vision loss.


While there are many case reports documenting retinal changes in the setting of COVID-19, the presence of additional comorbidities and their effects on the retina cannot be excluded. Despite this, clinicians should still be aware of and assess for the retinal manifestations SARS-CoV-2 infection to prevent any vision-threatening complications. Future studies to investigate whether these documented retinal changes are truly attributable to COVID-19 or are incidental findings in the setting of clinical intercurrences are warranted.


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2. WHO Coronavirus (COVID-19) Dashboard. Accessed March 12, 2022.

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4. Bertoli F, Veritti D, Danese C, et al. Ocular Findings in COVID-19 Patients: A Review of Direct Manifestations and Indirect Effects on the Eye. J Ophthalmol. 2020;2020:4827304. doi:10.1155/2020/4827304

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6. Invernizzi A, Torre A, Parrulli S, et al. Retinal findings in patients with COVID-19: Results from the SERPICO-19 study. EClinicalMedicine. 2020;27:100550. doi:10.1016/j.eclinm.2020.100550

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8. Virgo J, Mohamed M. Paracentral acute middle maculopathy and acute macular neuroretinopathy following SARS-CoV-2 infection. Eye. 2020;34(12):2352-2353. doi:10.1038/s41433-020-1069-8

9. Hernandez M, González-Zamora J, Recalde S, et al. Evaluation of Macular Retinal Vessels and Histological Changes in Two Cases of COVID-19. Biomedicines. 2021;9(11):1546. doi:10.3390/biomedicines9111546

10. Lani-Louzada R, Ramos C do VF, Cordeiro RM, Sadun AA. Retinal changes in COVID-19 hospitalized cases. PLoS One. 2020;15(12):e0243346. doi:10.1371/journal.pone.0243346

11. Abou-Ismail MY, Diamond A, Kapoor S, Arafah Y, Nayak L. The hypercoagulable state in COVID-19: Incidence, pathophysiology, and management. Thromb Res. 2020;194:101-115. doi:10.1016/j.thromres.2020.06.029

12. Ullah I, Sohail A, Shah MUFA, et al. Central Retinal Vein Occlusion in patients with COVID-19 infection: A systematic review. Ann Med Surg (Lond). 2021;71:102898. doi:10.1016/j.amsu.2021.102898

13. Ucar F, Cetinkaya S. Central retinal artery occlusion in a patient who contracted COVID-19 and review of similar cases. BMJ Case Reports CP. 2021;14(7):e244181. doi:10.1136/bcr-2021-244181

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