Case Study Shows Simultaneous Bilateral NAION in COVID-19 Patient

Modern laboratory interior. Neurological Research Laboratory. Asian ethnicity woman using microscope. Wearing protectie mask
Researchers sought to determine how a COVID-19 patient underwent a severe loss of vision following COVID-19.

The following article is a part of conference coverage from the 2021 meeting of the North American Neuro-Ophthalmology Society, being held virtually from February 20 to 23, 2021. The team at Ophthalmology Advisor will be reporting on the latest news and research conducted by these leading experts in neuro-ophthalmology. Check back for more from the NANOS 2021 Meeting.


While COVID-19 has been shown to impact eyes, simultaneous bilateral optic anterior ischemic neuropathy does not commonly present, according to researchers who presented a case study at the 2021 North American Neuro-Ophthalmology Society’s annual meeting.1,2 Seeking to understand why the patient they encountered developed bilateral simultaneous nonarteritic anterior ischemic optic neuropathy (NAION) and underwent severe, irreversible loss of vision in both eyes, they concluded his COVID-19 infection caused additional inflammation and occlusion of his already short posterior ciliary arteries that led to endothelial damage.2

The patient was a 55-year-old male with a history of high blood pressure, coronary stenting, and smoking. He presented with vision loss after having transient bilateral loss of vision 1 week prior. The researchers discovered prominent optic disc edema in both eyes. His visual acuity was hand movement for his right eye and no light perception for his left eye.

Through magnetic resonance imaging (MRI) of the brain, the researchers discovered the patient had pansinusitis that, in 3D time-of-flight angiography, showed a hyperintense signal on the left transverse sinus compared with the other side.

For 5 days, he received treatment with hydroxyheparin, hydroxychloroquine, remdesivir, azithromycin, paracetamol, and IV boluses of methylprednisolone. His final vision was 20/600 in both eyes and severe bilateral optic nerve atrophy. Fifteen days following hospital discharge, the researchers found that the papilledema had partially solved but the pale aspect of the optic head nerves remained consistent.

They determined that the patient’s optic nerve arterial occlusion and slight cerebral vein thrombus in the left transverse sinus was the result of COVID-19’s hypercoagulation augmenting the patient’s previously existing risk factors as seen on lab test results: high Hematocrit 54.3% (42-54), low D-dimer (32.7 ng/ml), high C-reactive protein (3.18 mg/L), and high Ferritin (826.14 mg/ml).

“We propose that damage from the SARS-CoV-2 virus was not a cytopathic effect in the retinal ganglion cells, but endothelial damage in arteries and veins that caused in situ inflammation of occlusion of the short posterior ciliary arteries, ending in a bilateral simultaneous NAAON, aside of a generalized procoagulant status manifested also in mild cerebral transverse sinus thrombosis,” the presentation concluded. 

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1.  Tisdale A, Chwalisz B. Neuro-ophthalmic manifestations of coronavirus disease 19Curr Opin Ophthalmol. 2020;31(10):489-494. doi: 10.1097/ICU.0000000000000707.

2. Garcia Briones G, Ramirez-Gutierrez de Valasco A, Regalado Chico JA, et al. Simultaneous bilateral nonarteritic anterior ischemic optic neuropathy (NAION) and cerebral venous thromboses due to COVID-19. Presented at: North American Neuro-Ophthalmology Society Annual Meeting; February 20-23, 2021; Poster 20.