Chorioretinopathy Post COVID-19: A Systematic Review and Prevalence Assessment, Unveiling Insights into an Emerging Ocular Entity

Figures & data

Figure 1. PRISMA flowchart of included studies.

Table 1. Baseline characteristics of the included studies.

Study ID	Study design	Location	Gender	Age	Onset and duration of symptoms	Any previous medication
Fuganti^Citation17	Case series	Brazil	Male	41	13 days after COVID-19 infection, improved after 3 months	8 mg of oral dexamethasone
		Brazil	Female	43	20 days after diagnosis of COVID-19 and 5 days after completion of treatment for pneumonia secondary to COVID-19. improved after 1 month	antibiotics and high doses of dexamethasone intravenously (10 mg/day) and orally (8 mg/day)
Goyal^Citation8	Case series	India	Female	27	2 weeks after recovery from COVID-19, had signs of visual deterioration for 10 days, improved after a few weeks	oral steroids for covid infection
Miyata^Citation18	Case report	Japan	Female	25	6 days after the symptoms of COVID-19 infection. duration of 12 days after the onset of symptoms	N/R
Mohd-Alif^Citation16	Case report	Malaysia	Male	38	3 weeks after COVID-19 infection. regained full visual recovery after three months	intravenous ceftriaxone 1 g daily and dexamethasone 4 mg three times daily over his nine-day stay at the hospital. The corticosteroid was changed to oral dexamethasone upon discharge, with a slow tapering dose for over two weeks.
Nicolai^Citation15	Case report	Italy	Female	29	3 weeks after COVID-19 infection and resolved after 2 days of treatment	Cyclosporine 3 mg/kg/day 6 months ago
Sanjay^Citation9	Case report	India	Female	42	12 Days after COVID-19 infection and improved after 1 month	I.V Cefoperazone+ Sulbactam, S.C Heparin, I.V Remdesivir, ORAL (Dexamethasone, Azithromycin, Doxycycline, Levocetirizine, Montelukast and Levocetirizine combination, Vitamin C, Pantoprazole, Ivermectin) Inhalation (OXYGEN, Formoterol fumarate dehydrate and budesonide 200 combination, Salbutamol rotacaps)
Sharifi^Citation14	Case report	Iran	Female	49	3 months after COVID-19 infection, symptoms improved after 2 months	During her five-day hospital admission, intravenous Remdesivir (200 mg as an initial dose, and then 100 mg daily) and Dexamethasone (4 mg daily) with subcutaneous low-molecular-weight heparin (50 mg twice daily) for prophylaxis of thrombosis had been administrated, and she had been discharged with prednisolone 10 mg twice daily for two weeks.
Amulya, and Thanuja^Citation19	Case report	India	Male	30	2 weeks after COVID-19 infection, duration 2 months	Vit C 500 mg BD, Vitamin supplements and he was on regular anti-hypertensive medication.
Sanjay^Citation12	Case report	India	Male	41	22 days after COVID-19 infection and a month later, he had improvement in his symptoms with no cells in both eyes with topical steroids with resolution of serous retinopathy.	intravenous dexamethasone, ceftriaxone, remdesivir 200 mg 1st day followed by 100 mg for next 4 days, and subcutaneous low-molecular-weight heparin 40 mg for prophylaxis and oral azithromycin 500 mg/oseltamivir 75 mg orally twice a day for 5 days and was discharged after a week with oral steroids 20 mg and apixaban 2.5 mg twice daily, intravenous dexamethasone, ceftriaxone, remdesivir 200 mg 1st day followed by 100 mg for next 4 days, and subcutaneous low-molecular-weight heparin 40 mg for prophylaxis and oral azithromycin 500 mg/oseltamivir 75 mg orally twice a day for 5 days and was discharged after a week with oral steroids 20 mg and apixaban 2.5 mg twice daily. Intravenous methylprednisolone was administered for a delayed cytokine storm in the second admission followed by oral tapering dose of 20 mg steroids and insulin for diabetes at discharge. Steroids gradually tapered over the next 4 weeks. He was a recently detected diabetic and was on 50 mg oral sitagliptin for the last 6 months and mild cutaneous psoriasis and not on any treatment for the past 5 years.

Table 2. Presentation and outcomes of chorioretinopathy following COVID-19.

Study ID	Laterality	Symptoms	Investigations	Treatment	Final outcome
Fuganti^Citation17	Left eye	unilateral acute visual loss	Biomicroscopy of the anterior segment, pupillary reaction, intraocular pressure, Fundus examination, Laboratory tests, complete blood count (CBC), chest and sinus X-rays, C-reactive protein.	corticosteroid discontinuation	By 3 months follow-up, the subretinal fluid spontaneously and completely resorbed, and the best-corrected visual acuity of the left eyes improved to 20/25.
	Right eye	visual loss	Biomicroscopy of the anterior segment, pupillary reactions, B-scan spectral-domain and intraocular pressure, fundus examination, Laboratory tests, CBC, and chest and sinus X-rays	corticosteroid discontinuation	At 1-month follow-up, the BCVA of the right eye improved to 20/20. best-corrected visual acuity of the right eye improved to 20/20
Goyal^Citation8	Left eye	central vision deterioration in the Left eye	Fundus examination, Optical coherence tomography	No treatment, corticosteroid was stopped before presentation at the hospital	symptoms resolved spontaneously a few weeks later
Miyata^Citation18	Right eye	blurred vision, fever	Color fundus photography, Fundus autofluorescence, fundus infrared image, Optical coherence tomography (OCT) angiography of the outer retina to the choriocapillaris layer, fluorescein fundus angiography, Indocyanine green fundus angiography	oral prednisolone 30 mg/day. corticosteroids was changed to oral dexamethasone upon discharge, with a slow tapering dose for over two weeksfor 14 days to manage Punctate inner choroidopathy. Fundus abnormality decreasedand ocular symptoms improved. Oral prednisolone reduced to 15 mg/day for thenext 14 days, to 10 mg/day for the next 14 days, and to5 mg/day for the next 28 days	visual improvement general side effects.
Mohd-Alif^Citation16	Both	central visual loss in both eyes, multiple blackish spots increasing in size over time, affecting his central vision	Visual acuity examination, anterior segment examinations, Fundus examination, and Spectral-domain optical coherence tomography (OCT) of the macula	The patient was treated with topical non-steroidal anti-inflammatory eye drops (nepafenac).	full recovery after 3 months
Nicolai^Citation15	Right eye	acute decrease of visual acuity in her right eye	Visual acuity (BCVA), intraocular pressure measured using Goldmann applanation tonometry, fundus examination, and enhanced depth imaging optical coherence tomography (EDI-OCT) were assessed.	High-dose corticosteroids: systemic methylprednisolone (1 mg/kg/day)	Two days later, after administration of systemic methylprednisolone (1 mg/kg/day), the visual acuity of the RE improved to 20/20.EDI-OCT of the RE showed complete regression of RPE elevation and a fainter hyperreflective signal under the RPE; the photoreceptor inner/outer segment junction discontinuities were less marked and the intraretinal fluid disappeared.
Sanjay^Citation9	Right eye	She experienced symptoms such as fever, chills, shortness of breath, and cough, accompanied by fatigue, and subsequently tested positive for COVID-19 through RT-PCR. Notably, unilateral blurring in the right eye developed 12 days after the onset of the COVID-19 infection.	Visual acuity, fundus examination, intraocular pressure measurement, SpectralisTM optical coherence tomography (SD-OCT) scan, complete blood count (CBC), erythrocyte sedimentation rate (ESR), random blood sugar (RBS), COVID-19 rapid antigen test, upper respiratory swab for COVID-19, WIDAL test, urine analysis, and chest X-ray	Inhalational and oral steroids were stopped.	One month later, there was an improvement in her vision to 20/25 in OD, OCT showed a reduction of the sub-retinal fluid and the hyper-reflective material and resolution of the pigment epithelial detachment.
Sharifi^Citation14	Both	gradual blurring of vision in both eyes	optical coherence tomography	propranolol 20 mg and eplerenone 25 mg daily for one month.	The symptoms were resolved about two months later, and the BCVA of both eyes improved to 20/25.
Amulya, and Thanuja^Citation19	right eye	sudden diminution of vision in his right eye for 3 days	A comprehensive ophthalmologic examination was performed, encompassing assessments such as visual acuity in the right eye (OD) and left eye (OS), color vision in both eyes, anterior segment examination of both eyes, fundus examination, and optical coherence tomography. Additionally, blood investigations included assessments of lactate dehydrogenase, C-reactive protein (CRP), D-dimer, and serum ferritin levels.	No treatment but rest and follow up after 2 months	the patient showed visual recovery within 2 months as his VA was 6/6 in both eyes.
Sanjay^Citation11	both	unilateral blurring, glare, and pain in the left eye	Ocular investigations: - Eye evaluation showed corrected distance visual acuity of 20/20 in both the eyes (BEs). - Anterior chamber showed inflammation in the LE, a day later in the right eye. − Fundus examination of the BE showed retinal pigment epithelial changes with serous elevation suggestive of multifocal serous chorioretinopathy. - A spectral-domain optical coherence tomography scan on the Spectralis™ (Heidelberg Engineering, Heidelberg, Germany) of the RE showed serous detachment temporal to the disc and in the LE showed posterior vitreous cells and serous detachment near the superior/inferior arcade. - An optical coherence tomography angiography done on the Optovue AngioVue ™(Optovue, Inc., Fremont, CA) did not show any pathological changes in retinal or choroid circulation. Non-ocular investigations: - The patient had a chest computed tomography (CT) scan which showed ground glass opacities in his lungs.	The patient was administered intravenous dexamethasone, ceftriaxone, remdesivir, subcutaneous low-molecular-weight heparin, oral azithromycin, and oseltamivir for COVID-19 treatment. He was discharged after a week with oral steroids and apixaban. Three days after discharge, he developed a fever and was readmitted. Intravenous methylprednisolone was administered for a delayed cytokine storm in the second admission followed by oral tapering dose of 20 mg steroids and insulin for diabetes at discharge. Steroids gradually tapered over the next 4 weeks. Topical steroids were also used for the patient’s ocular symptoms	a month later, he had improvement in his symptoms with no cells in both eyes with topical steroids with resolution of serous retinopathy. The patient was advised to continue follow-up with the ophthalmology department.

Table 3. The quality assessment of the included case reports.

Study ID	1. Were patient’s demographic characteristics clearlydescribed?	2. Was the patient’s history clearly described and presented as a timeline?	3. Was the current clinical condition of the patient on presentation clearly described?	4.Were diagnostic tests or assessment methods and the results clearly described?	5. Was the intervention(s) or treatment procedure(s) clearlydescribed?	6. Was the post-intervention clinical condition clearly described?	7. Were adverse events (harms) or unanticipated events identified and described?	8. Does the case report provide takeaway lessons?	Quality
Sharifi^Citation14	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	7/8, high
Sanjay^Citation9	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	7/8, high
Nicolai^Citation15	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	7/8, high
Mohd-Alif^Citation16	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	7/8, high
Miyata^Citation18	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	7/8, high
Sanjay^Citation11	Yes	No	Yes	Yes	Yes	Yes	No	Yes	6/8, moderate
Amulya, and Thanuja^Citation19	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8/8, high

Table 4. The quality assessment of the included case series.

Study ID	1. Were there clear criteria for inclusion in the case series?	2. Was the condition measured in a standard, reliable way for all participants included in the case series?	3. Were valid methods used for identification of the condition for all participants included in the case series?	4.Did the case series have consecutive inclusion of participants?	5. Did the case series have complete inclusion of participants?	6. Was there clear reporting of the demographics of the participants in the study?	7. Was there clear reporting of clinical information of the participants?	8. Were the outcomes or follow up results of cases clearly reported?	9. Was there clear reporting of the presenting site(s)/clinic(s) demographic information?	10. Was statistical analysis appropriate?	Quality
Goyal^Citation8	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Unclear	9/10, high
Fuganti^Citation17	Yes	Yes	Yes	No	Unclear	Yes	Yes	Yes	Unclear	Unclear	6/10, moderate

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