key: cord-0856079-nlkhm4le authors: De Salvo, Gabriella; Meduri, Alessandro; Vaz-Pereira, Sara; Spencer, Doran title: An uncommon cold of the retina date: 2021-08-22 journal: Surv Ophthalmol DOI: 10.1016/j.survophthal.2021.08.006 sha: 820c28c8892fc869100d5bd64b66b4e9cdf51441 doc_id: 856079 cord_uid: nlkhm4le A 39-year-old woman with progressive loss of vision left eye was referred for evaluation. Notably, she had been diagnosed with COVID-19 two weeks beforehand. Examination and ancillary testing confirmed atypical multifocal evanescent white dot syndrome. Possible other masquerades were excluded. A few weeks later, visual acuity improved in the left eye, and symptoms resolved together with normalization of ancillary testing including visual fields. There was no relative afferent pupillary defect(RAPD). Intraocular pressures and extraocular motility were normal. Her Ishihara color test was full in OD, while she recognized only the test plate on OS. Ocular adnexa and anterior segments were unremarkable. Dilated fundus examination OD was unremarkable ( Fig 1A) ; OS presented tortuous dilated veins and multiple yellowish lesions spread across the retina (Fig 1B) . In the current scenario what should one consider as differential diagnoses? What initial systemic and ophthalmic workup should be done? In this case, the most salient features guiding a differential are the degree of vision loss, She was referred to neurology for further evaluation, and perimetry was repeated ( Figure 3D ). Neurologic examination was normal. Further blood tests (anti-MOG, anti-Aquaporin 4 antibodies, immunoglobulins and electrophoresis, connective tissue ANA screening, ANCA) and a brain and orbit MRI with gadolinium excluded possible central nervous system (CNS) involvement. The patient did not receive any medication and was followed up 8 weeks later by when OS FAF and SD-OCT had improved in appearance ( Figures 4G and 4H) ,along with the VA (20/50) and VF ( Figure 3E ). MEWDS ,was first described in 1984 by Jampol and coworkers, 1 is an inflammatory disease of the photoreceptors that recovers in nearly all cases without leaving any visible abnormality of the outer retinal structure and/or the retinal pigment epithelium. 4 A multimodal imaging approach may be necessary to confirm the diagnosis. 3 In typical cases of MEWDS, the ICGA shows in the mid to late phases multiple hypocyanescent areas spread across the retina. 5 During the recovery phase, those hypocyanescent spots disappear even though they may last longer on ICGA. 7 It is possible that the coronavirus infection in this case may be causing the peculiar MEWDS-like appearance to the retina-choroid complex with lack of hypocyanescent lesions in the choroid. Another possibility to explain this unusual behavior of the choroid may be related to the descending slope in the curve of the natural history of the disease. The choroidal hypocyanescent spots seen on the ICGA usually last longer than those visible via funduscopy or FFA. 7 In any case, the lack of typical hypocyanescence on ICGA in this case may confirm both sparing of the choriocapillaris and the theory that MEWDS is mainly a condition affecting the retinal photoreceptors recently described as a "photoreceptoritis". 4 Furthermore, MEWDS has also been recently described as 'the common cold of the retina' due to its nature: acute, benign, and self-limited. 6 In our case, we refer to the condition as 'the uncommon cold of the retina' because of its atypical ICGA appearance which we believe may be linked to the recent COVID-19 viral infection in our patient. This particular inflammatory process may be included among other ophthalmic manifestations of emerging viral diseases. 8 Multiple evanescent white dot syndrome. I. Clinical findings Retinal findings in patients with COVID-19 Expanded clinical spectrum of multiple evanescent white dot syndrome with multimodal imaging En face optical coherence tomography and optical coherence tomography angiography of multiple evanescent white dot syndrome: New Insights Into Pathogenesis Indocyanine green angiography of multifocal choroiditis Common Cold of the Retina Hypofluorescent spots on indocyanine green angiography at the recovery stage in multiple evanescent white dot syndrome Ocular manifestations of emerging viral diseases GDS collected the data and contributed to the conception and design of the work. GDS, AM and SVP contributed to data analysis and interpretation and drafted the manuscript. SVP and GDS elaborated the figures. All authors read and approved the final manuscript. The data is available from the corresponding author upon reasonable request. Informed consent was obtained from the patient. GDS reports consultant fees from Allergan, Bayer, Heidelberg Engineering and Novartis, outside the submitted work.AM declares no competing interests. SVP reports consultant fees from Alimera Sciences, Allergan, Bayer, Novartis and Roche, outside the submitted work.