Seeking clarity on retinal findings in patients with COVID-19 – Authors' reply
Authors: Paula M Marinho, Heloisa Nascimento, Allexya A A Marcos, André C Romano, Rubens Belfort
Journal: The Lancet (2020)

We are thankful for the comments in response to our Correspondence about retinal findings in patients with COVID-19.1Marinho PM Marcos AAA Romano AC Nascimento H Belfort Jr, R Retinal findings in patients with COVID-19.Lancet. 2020; 3951610Summary Full Text Full Text PDF PubMed Scopus (370) Google Scholar COVID-19 is a challenging new disease that has raised many questions around unusual findings. Regarding the comorbidities of the 12 patients,1Marinho PM Marcos AAA Romano AC Nascimento H Belfort Jr, R Retinal findings in patients with COVID-19.Lancet. 2020; 3951610Summary Full Text Full Text PDF PubMed Scopus (370) Google Scholar seven patients had no comorbidities, one had controlled type 2 diabetes and high blood pressure, two had high blood pressure with good clinical control, one had a history of dyslipidaemia, and one had ankylosing spondylitis, controlled with adalimumab, and no previous history of ocular involvement. A major concern raised was that the reported hyper-reflective lesions at the level of the ganglion cell and inner plexiform layers were, in fact, cuts through normal retinal blood vessels. To ensure that this was not the case, we excluded vertical optical coherence tomography (OCT) scans from our analysis and used only horizontal scans to avoid vessel crossings. Since our original Correspondence,1Marinho PM Marcos AAA Romano AC Nascimento H Belfort Jr, R Retinal findings in patients with COVID-19.Lancet. 2020; 3951610Summary Full Text Full Text PDF PubMed Scopus (370) Google Scholar we have examined more than 150 patients who tested positive for COVID-19 and whose disease ranged in severity, from asymptomatic to requiring admission to intensive care. We have refined our examination protocols. Using the B-scan flow overlay feature of OCT angiography, we found an absence of blood flow within the retinal lesions of many patients, differentiating these lesions from blood vessels with active blood flow. We observed similar findings outside of the posterior pole. Additionally, we have noticed fewer cotton wool spots and microhaemorrhages with time in these patients. More than 6 months has passed since the outbreak of severe acute respiratory syndrome coronavirus 2, and lots of new information has emerged describing COVID-19 pathophysiology. These retinal lesions appear to be part of a widespread, ischaemic, microvascular process, the effects of which have been reported in other parts of the body,2Danzi GB Loffi M Galeazzi G Gherbesi E Acute pulmonary embolism and COVID-19 pneumonia: a random association?.Eur Heart J. 2020; 411858Crossref PubMed Scopus (470) Google Scholar, 3Iba T Levy JH Levi M Connors JM Thachil J Coagulopathy of coronavirus disease 2019.Crit Care Med. 2020; (published online May 27.)https://doi.org/10.1097/CCM.0000000000004458Crossref PubMed Scopus (374) Google Scholar, 4Varga Z Flammer AJ Steiger P et al.Endothelial cell infection and endotheliitis in COVID-19.Lancet. 2020; 395: 1417-1418Summary Full Text Full Text PDF PubMed Scopus (4499) Google Scholar, 5Yin S Huang M Li D Tang N Difference of coagulation features between severe pneumonia induced by SARS-CoV2 and non-SARS-CoV2.J Thromb Thrombolysis. 2020; (published online April 3.)https://doi.org/10.1007/s11239-020-02105-8Crossref PubMed Scopus (304) Google Scholar as Pradeep Venkatesh suggested. Following up these patients closely is essential, and we understand the urgency of finding answers but also agree with the necessity for caution when interpreting new information. We intended our Correspondence to call attention to the need for careful evaluation of the fundus because therein lies a unique opportunity to analyse the body's microvasculature in vivo. We are collecting more information and intend to describe these in the medical literature in due course. We declare no competing interests. Seeking clarity on retinal findings in patients with COVID-19Reading about Paula M Marinho and colleagues'1 retinal findings in patients with COVID-19 was very interesting. Their Correspondence was the first to report on ocular findings, other than conjunctivitis, in patients with COVID-19, and the authors suggest that these retinal findings are probably associated with COVID-19. Full-Text PDF Seeking clarity on retinal findings in patients with COVID-19We read with enthusiasm about retinal changes in patients with COVID-19 symptoms, reported by Paula M Marinho and colleagues.1 The COVID-19 pandemic is a global health emergency challenging citizens, health authorities, and scientists.2 The academic response to the pandemic has been amazing. However, many questions remain unanswered. Full-Text PDF Seeking clarity on retinal findings in patients with COVID-19Paula M Marinho and colleagues1 described hyper-reflective lesions in ganglion cell and inner plexiform layers on optical coherence tomography (OCT) images from 24 eyes of 12 adults who had symptoms of COVID-19. Marinho and colleagues argued that these lesions could be associated with COVID-19-related neurological events in humans.2 On the basis of the fundamental principles of OCT, we hold different views as to how the hyper-reflective foci were generated and their relevance to COVID-19. Full-Text PDF Seeking clarity on retinal findings in patients with COVID-19We read with interest the Correspondence by Paula M Marinho and colleagues,1 in which they describe retinal findings in patients with COVID-19. We agree that the small cotton wool spots and retinal microhaemorrhages in a subset of these patients represent important findings showing the non-respiratory aspects of COVID-19, which are probably relevant to the neurological findings seen in some patients. Full-Text PDF Retinal findings in patients with COVID-19Coronavirus disease 2019 (COVID-19) has been shown to affect different parts of the body, and ophthalmological changes have been associated with ocular external diseases such as conjuntivitis1. Full-Text PDF Seeking clarity on retinal findings in patients with COVID-19Paula M Marinho and colleagues1 described their retinal and optical coherence tomography findings from 12 adults with recent onset of COVID-19 symptoms. Infection with severe acute respiratory syndrome coronavirus 2 has been increasingly linked to systemic damage beyond that of the respiratory system.2 Therefore, identifying additional sites affected by COVID-19 is crucial. Ocular surface abnormalities, including conjunctivitis,3 are well established manifestations of COVID-19. Marinho and colleagues1 bring attention to the possibility of retinal involvement in COVID-19. Full-Text PDF