April 2021
Case Reports 987
Post COVID-19 opportunistic candida
retinitis: A case report
Ridhima Bhagali, Nitin P Prabhudesai1,
Medha N Prabhudesai1
A 42‑year‑old male patient presented with profound impairment
of vision in both eyes, just as he was recovering from COVID‑19.
A known diabetic and hypertensive, he suffered from COVID‑19
pneumonia further complicated by ARDS, septicaemia and acute
kidney injury. His vision on presentation was finger counting
close to face bilaterally with multiple, yellowish lesions at the
posterior pole. Based on the clinical findings and previous
Downloaded from http://journals.lww.com/ijo by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 07/21/2021
blood culture report, it was diagnosed as candida retinitis and
treated with oral and intravitreal anti‑fungals. The lesions were
regressing at follow‑up. This is a post COVID‑19 presumed
candida retinitis case report.
Key words: Candida retinitis, coronavirus, Covid and eye,
Covid‑19, intravitreal voriconazole
The coronavirus disease‑2019 (COVID‑19) caused by the severe
acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) has
resulted in a global pandemic.[1] Recent studies reporting
ocular involvement with SARS‑CoV‑2 infection have described
conjunctivitis as the commonest ocular manifestation, with
incidence ranging from 0.8%[2] to 31.6%.[3] Other manifestations
like uveitis, retinitis, retinal vasculitis and optic neuritis have
been described in animal models with few reports in humans.
Ocular involvement in COVID‑19 can also be secondary to
immunosuppressive modalities used in its management.
Case Report
A 42‑year‑old male patient, known diabetic and hypertensive
since 6 years, presented with diminution of vision in both eyes.
He had contracted COVID‑19 infection 2 months earlier and
was hospitalised for ARDS and kept on ventilatory support for
3 weeks. He had received Tocilizumab 162 mg subcutaneous
single dose and intravenous Dexamethasone 4 mg twice a
day for 10  days followed by oral dexamethasone tapered
over a month. After recovery from pneumonia and discharge
Access this article online
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DOI:
10.4103/ijo.IJO_3047_20
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Pioneer Medilaser Pvt. Ltd., 1Insight Vision Foundation, Pune,
Maharashtra, India
Correspondence to: Dr. Ridhima Bhagali, F1002 Treasure Park,
Santnagar, Off Pune Satara Road, Parvati, Pune ‑ 411 009, Maharashtra,
India. E‑mail: reema.bhagali@rediffmail.com
Received: 23-Sep-2020 Revision: 21-Jan-2021
Accepted: 07-Feb-2021 Published: 16-Mar-2021
from the hospital, he had developed acute kidney injury
and urosepsis necessitating readmission. During the 2‑week
hospital stay, investigations revealed pancytopenia, increased
serum creatinine, blood culture positive for Candida Albicans
and urine culture positive for Klebsiella Pneumoniae. He was
treated with IV fluids, antibiotics, antiemetics, antifungals
& supportive medication. When systemically stable, he was
discharged. He had noticed gradually progressive, painless
diminution of vision in both eyes during these 2  weeks of
hospitalization.
On visiting our eye clinic, his BCVA in both eyes was
counting fingers close to face. Anterior segment evaluation
was unremarkable. Fundus examination of both eyes revealed
clear vitreous, with multiple, yellowish‑white, fluffy lesions,
1/2 to 1‑disc diameter in size scattered, predominantly across
the posterior pole [Fig. 1]. The foveal centre was involved with
the retinitis lesion in the left eye and just spared in the right.
No retinal haemorrhages or pigmentary changes were seen.
Inferotemporal periphery from 3 to 6 o clock had evidence
of moderate choroidal detachment in both eyes. Retina was
attached throughout in both eyes. Based on the clinical features
and prior positive blood culture, a diagnosis of bilateral candida
retinitis was made.
Standard Fundus Photography  (Topcon Triton)  [Fig.  1],
Ultra‑Wide Field retinal imaging  (Optos Daytona)
[Figs. 2a, b and 3a, b] & Swept Source OCT  (Topcon
Triton) [Figs. 2c, d and 3c, d] were performed. OCT revealed
hyperreflective lesions mainly involving the inner layers of
the retina and obscuring the deeper retinal layers & RPE in
both eyes. Additionally, the right eye had a small pocket of
subretinal fibrinous fluid just under the foveal centre [Fig. 3c].
With bilateral macular involvement and profound
impairment of vision, intravitreal Voriconazole injection (100
micrograms in 0.1 ml) was planned in both eyes sequentially.
Simultaneously, systemic Fluconazole therapy was restarted
in co‑ordination with his physician. A month later, vision had
improved to 3/60 in both eyes; retinitis lesions and choroidals
had regressed significantly  [Figs.  2b and 3b]. OCT showed
regression of lesions in both eyes  [Figs.  2d and 3d] with
clearance of right eye subfoveal fluid [Fig. 2d]. This was his last
follow‑up visit and though his eye condition was improving,
the patient died 6 weeks later of other systemic complications.
Discussion
The grave morbidity and mortality associated with the
COVID‑19 pandemic is due to the collateral damage caused by
an exaggerated host immune response.[4] Corticosteroids and
monoclonal antibody against IL6 receptor (tocilizumab) are used
in the mainstream treatment protocols of COVID‑19 for their
This is an open access journal, and articles are distributed under the terms of
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which allows others to remix, tweak, and build upon the work non‑commercially,
as long as appropriate credit is given and the new creations are licensed under
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For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
Cite this article as: Bhagali R, Prabhudesai NP, Prabhudesai MN. Post
COVID-19 opportunistic candida retinitis: A case report. Indian J Ophthalmol
2021;69:987-9.
988 Indian Journal of Ophthalmology Volume 69 Issue 4
Figure 1: Standard 45‑degree posterior pole photo of both eyes
showing yellowish‑white, fluffy lesions involving fovea
a parafoveal lesion (d) One month post Intravitreal Voriconazole there
b
c
d with or without intravitreal antifungal agents like amphotericin
Figure 3: (a) Left eye retinitis lesions and inferotemporal choroidal
detachment (b) One month post intravitreal Voriconazole, both appear
to have regressed. (c) Left eye OCT image of foveal and parafoveal
retinitis (d) One month post Intravitreal Voriconazole resolution of
lesions
effectiveness in controlling the cytokine storm.[5] This particular
diabetic patient received both, corticosteroids and tocilizumab,
making him susceptible for opportunistic infections.
Differential diagnoses for retinal infiltrates without
significant vitritis or anterior segment inflammation are
cytomegalovirus  (CMV) retinitis and progressive outer
retinal necrosis  (PORN). Causes for retinal infiltrates with
vitritis and anterior segment inflammation include acute
retinal necrosis  (ARN), bacterial or fungal endophthalmitis,
toxoplasmosis and Behcet’s disease. In this case, blood culture
was positive for fungal  (Candida) infection and corelating
it with the clinical picture, it was presumed that the retinal
infiltrates were also likely to be due to Candida. OCT image
clearly showed retinal infiltrates sparing the choroid, hence
conditions causing predominant choroidal infiltrates like
tuberculosis, toxoplasmosis, sarcoidosis, VKH, sympathetic
ophthalmia, white dot syndromes were excluded.
Candida albicans is a common culprit causing opportunistic
infections in the immunocompromised. Candida retinitis
a b
c
d
Figure 2: (a) Ultra‑wide field retinal imaging showing right eye candida
retinitis lesions (b) Regressed lesions one month post intravitreal
Voriconazole. (c) OCT of right eye shows sub foveal fibrinous fluid and
is resolution of fluid and lesion
has been reported after influenza virus type A infection.[6] Its
diagnoses can be challenging in the initial stage with only
chorioretinal involvement.[7] Candida endophthalmitis has been
reported in the immunocompromised, however, its treatment
options have not been evaluated through well‑designed
trials. Traditional systemic therapy for chorioretinitis
has been amphotericin B with or without flucytosine or
fluconazole.[8] More aggressive treatment involving vitrectomy
B, caspofungin[9] or voriconazole would be necessary for
endophthalmitis.[8] Though the clinical picture in this case was
not in favour of endophthalmitis, we decided to treat with
additional intravitreal antifungal Voriconazole as the patient
had bilateral foveal involvement and was not on any systemic
anti‑fungal medication for more than one week.
Conclusion
Even though the recommendation of routine ophthalmic
evaluation of patients with systemic infections and
immunosuppressive therapies is not very strong, those with
candidemia should have a dilated retinal examination.[10]
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and other
clinical information to be reported in the journal. The patients
understand that their names and initials will not be published
and due efforts will be made to conceal their identity, but
anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
April 2021 Case Reports 989
References
1. Cascella M, Rajnik M, Cuomo A, Dulebohn SC, Di Napoli R. StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; May 18, 2020.
Features, Evaluation and Treatment Coronavirus (COVID‑19).
2. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical
characteristics of coronavirus disease 2019 in China. N Engl J Med
2020;382:1708‑20.
3. Wu P, Duan F, Luo C, Liu Q, Qu X, Liang L, et al. Characteristics of
ocular findings of patients with coronavirus disease 2019 (COVID‑19)
in Hubei Province, China. JAMA Ophthalmol 2020;138:575‑8.
4. Mehta  P, McAuley  DF, Brown  M, Sanchez  E, Tattersall  RS,
Manson JJ; on behalf of the HLH Across Speciality Collaboration,
UK. COVID‑19: Consider cytokine storm syndromes and
immunosuppression. Lancet 2020;395:P1033‑4.  10. Pappas  PG, Kauffman  CA, Andes  D, Benjamin DK Jr,
5. Riegler LL, Jones GP, Lee DW. Current approaches in the grading and
management of cytokine release syndrome after chimeric antigen
receptor T‑cell therapy. Ther Clin Risk Manag 2019;15:323‑35.
Unilateral inferior altitudinal visual
field defect related to COVID‑19
Akanksha Sharma, Urvashi Sinai Kudchadkar,
Rohit Shirodkar, Ugam P S Usgaonkar, Aparna Naik
Ocular manifestations of COVID‑19 are still being studied.
Posterior segment involvement in viral entities is either direct
viral involvement or a delayed immune response to the antigen.
A  22‑year‑old woman presented with history of perceiving
absolute inferior scotoma in the right eye for 4 days and history
of fever and sore throat 10  days ago. Fundus examination
revealed disc edema and vessel tortuosity. Humphreys
Field Analyzer confirmed inferior field defect and Optical
Coherence Tomography showed superior, nasal and inferior
retinal nerve fiber layer thickening in the right eye. Patient was
positive for severe acute respiratory syndrome coronavirus
2  (SARS‑CoV‑2) by reverse transcription polymerase chain
reaction  (RT‑PCR) testing. Patient received three doses of
injection methylprednisolone over 3 days. There was subjective
resolution of scotoma reported 3 weeks posttreatment. We bring
Access this article online
Quick Response Code: Website:
www.ijo.in
DOI:
10.4103/ijo.IJO_3666_20
PMID:
***
Department of Ophthalmology, Goa Medical College, Bambolim,
Goa, India
Correspondence to: Dr. Akanksha Sharma, C‑103, The Bay Village,
Near Mes College, Zuarinagar, Vasco‑Da‑Gama 403 726, Goa, India.
E‑mail‑ akanksharma1318@gmail.com
Received: 11-Dec-2020 Revision: 21-Feb-2021
Accepted: 21-Feb-2021 Published: 16-Mar-2021
6. Menia  NK, Sharma  SP, Bansal  R. Fungal retinitis following
influenza virus type A  (H1N1) infection. Indian J Ophthalmol
2019;67:1483‑4.
7. Invernizzi A, Symes R, Miserocchi E, Cozzi M, Cereda M, Fogliato G,
et al. Spectral domain optical coherence tomography findings in
endogenous Candida endophthalmitis and their clinical relevance.
Retina. 2018;38:1011–8.
8. Khan FA, Slain D, Khakoo RA. Candida endophthalmitis: Focus on
current and future antifungal treatment options. Pharmacotherapy
2007;27:1711‑21.
9. Yadav  HM, Thomas  B, Thampy  C, Panaknti  TK. Management
of a case of Candida albicans endogenous endophthalmitis with
intravitreal caspofungin. Indian J Ophthalmol 2017;65:529‑31.
Calandra TF, Edwards JE Jr, et al. Clinical practice guidelines for
the management of candidiasis: 2009 update by the Infectious
Diseases Society of America. Clin Infect Dis 2009;48:503‑35.
forward the first reported case of parainfectious optic neuritis
associated with COVID‑19.
Key words: Disc edema, field defects, neuro‑ophthalmology,
pandemic, SARS‑CoV‑2
An outbreak of a novel coronavirus disease emerged in
Wuhan, China in December 2019 progressively causing a
pandemic, the infectious agent of it being the severe acute
respiratory syndrome coronavirus 2  (SARS‑CoV‑2). Though
the pathogenesis of COVID‑19 remains poorly understood
and under evaluation, it has been attributed to inflammatory
cytokine storm and viral evasion of cellular immune responses,
causing immunothrombosis. To add to the myriad of ocular
manifestations of SARS‑CoV‑2, which is still poorly understood
and is under evaluation, we report a case of unilateral inferior
altitudinal visual field defect in a COVID‑19 positive patient.
Case Report
A healthy 22‑year‑old woman presented to our outpatient
department with history of acute‑onset blurring of vision and
perceiving an absolute scotoma in the inferior field of vision
in the right eye since the last 4 days, not accompanied by any
neurological symptoms. The patient was not a known case of
any systemic disease and was not on any prior medications
like oral contraceptive pills. Patient gave history of fever, sore
throat, and fatigue around 10 days back. She was not tested
for COVID‑19 at the onset of symptoms. There was history of
exposure to a laboratory confirmed case of COVID‑19 15 days
prior. On examination, uncorrected visual acuity was 20/25
This is an open access journal, and articles are distributed under the terms of
the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License,
which allows others to remix, tweak, and build upon the work non‑commercially,
as long as appropriate credit is given and the new creations are licensed under
the identical terms.
For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
Cite this article as: Sharma A, Kudchadkar US, Shirodkar R, Usgaonkar UP,
Naik A. Unilateral inferior altitudinal visual field defect related to COVID‑19.
Indian J Ophthalmol 2021;69:989-91.