Bilateral macular hemorrhage in a patient with COVID-19
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A 46-year-old male was admitted to the Intensive Care Unit (ICU), for respiratory failure and unilateral visual loss after a 12-day history of fever, cough, and worsening dyspnea. Medical history included well-controlled hypertension and hereditary spherocytosis with stable mild chronic hemolytic anemia (Hb mean values: 10–11 g/dL). Chest-X-Ray showed bilateral peripheral airspace opacities. SARS-CoV-2 infection was documented by reverse transcriptase-polymerase chain reaction on a nasopharyngeal swab. Bacterial co-infection was excluded. Blood tests showed severe anemia (Hb: 6.2 g/dL), with normal platelet and leukocytes counts, while levels of hemolytic markers were consistent with a hemolytic exacerbation (total Bilirubin (mostly indirect) was 1.8 mg/dl; Serum Lactate Dehydrogenase was 690 U/L (normal range 230–460); haptoglobin was 244 (normal range 34–200)).

The peripheral blood smear demonstrated the presence of several erythrocytes agglutinates (confirmed with direct antiglobulin test), along with spherocytes, polychromasia, and circulating erythroblasts, so revealing mixed pathogenesis of the hemolytic process (cold-agglutinin-mediated and non-immune-mediated due to spherocytosis). G6PD levels were within normal limits. Concurrently, bilateral retinal hemorrhage with macular involvement was found. The patient was mechanically ventilated for 4 days, transfused with 3 units of packed red blood cells, and treated with Chloroquine. Progressive clinical improvement was observed, along with an increase of Hb up to 11.6 g/dL. The patient was discharged on the 6th of April and referred for ophthalmic assessment. The visual acuity was 20/20 in the right eye and 20/70 in the left eye. Fundus examination showed few hemorrhages bilaterally, with right parafoveal and left foveal involvement. The latter was responsible for the central scotoma.

The anterior segment, pupillary response, and intraocular pressure were normal bilaterally. Findings on high-resolution optical coherence tomography demonstrated hemorrhages beneath the internal limiting membrane in both eyes, obliterating the foveal dip in the left one. Fluorescein and indocyanine green angiography showed bilateral blockage corresponding to the areas of hemorrhage in the context of normal circulation, excluding other causes of hemorrhages such as vascular occlusion, hypertensive retinopathy, or vasculitis. No treatment was required and the hemorrhage spontaneously improved in 1 month, with consequent final visual acuity increase of 20/20 in both eyes.