Acute Macular Neuroretinopathy and COVID-19

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Acute macular neuroretinopathy (AMN) is a rare, poorly understood retinal disease that most commonly occurs in young, healthy women. Now, based on findings of the largest case series to date, researchers report a possible association between AMN and COVID-19.¹

Although the relationship between the two processes remains theoretical, both have been associated with micro­thrombi as well as being preceded by respiratory or influenza-like illness. Established associations with AMN include the use of oral contraceptives, antecedent trauma, injections of epi­nephrine and pseudoephedrine, and pregnancy-induced hypertension.

“AMN has not been confirmed to be a sequela of COVID infection, but we believe it may be in certain individuals, which is why we felt it important to publish these data,” said Brian K. Do, MD, who practices in Chevy Chase, Maryland.

SEQUELA OF COVID? Near-infrared imaging demonstrating a large perifoveal lesion in an individual with acute macular neuroretinopathy associated with COVID-19 infection.

Retrospective case series. The find­ings are based on data from 25 eyes of 15 patients seen at eight referral centers from November 2020 to June 2022. All had concomitant symptomatic COVID-19 infection and AMN, which was diagnosed by one or more imaging modalities.

The patients’ mean age was 24 years, and most (80%) were female. All had paracentral scotomas. Ten (67%) had bilateral disease, and four (27%) also present­ed with headache. All but one (93%) had symptoms of COVID-19 within two days of onset of symptoms of AMN. On average, their ocu­lar symptoms began one day after they began experienc­ing COVID-19 symptoms.

Only two patients pre­sented with decreased VA. One was a 19-year-old woman who was on oral contraceptives. Two weeks after she tested positive for SARS-CoV-2, she presented with central scotomas and VA of 20/125 in her right eye and 20/450 in her left. She stopped taking the oral contraceptives and was man­aged with prednisone; within a week, her vision was 20/25 in both eyes. The second case involved an 11-year-old girl with VA of 20/125 in both eyes. She was concurrently diagnosed with panuve­itis, which the researchers suspect was the main contributor to the visual loss.

Building on earlier data. The report includes data from earlier case series, thus creating the largest compilation of cases to date—43 eyes in 29 patients. Earlier reports had far fewer bilater­al events and fewer female patients; in addition, some cases were noted months after COVID-19 infection. Nevertheless, the rates from the differ­ent series were not markedly different, Dr. Do said. “The point is that there are relatively high rates of bilateral involve­ment, and that these problems can arise in anyone.”

More than coincidence? While the report involves only a small number of cases, the authors noted that the association is strengthened by the short time frame between the onset of ocular symptoms and COVID diagnosis.

They acknowledged that, because of AMN’s rarity, it is difficult to assess whether its incidence truly increased during the COVID pandemic. How­ever, they cited an earlier retrospective study that found AMN diagnoses rose from .66 per 100,000 visits in 2019 to 8.97 per 100,000 in 2020.²

Dr. Do stressed that the latest study does not suggest a causal relationship between COVID-19 and AMN. How­ever, he said, the temporal relationship between COVID-19 symptoms and the onset of visual symptoms and associ­ated retinal imaging findings suggests that AMN “may be more than just a coincidence.”

—Miriam Karmel

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1 Dinh RH et al. Ophthalmol Retina. Published online Oct. 7, 2022.

2 Azar G et al. J Clin Med. 2021;10(21):5038.

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Relevant financial disclosures: Dr. Do—None.

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