Are Women with COVID-19 and Migraine Prone to AMN Type 2?

Purpose: To describe 3 cases of acute macular neuroretinopathy (AMN) type 2 associated with SARS-CoV-2 viral infection and migraine. Methods: Observational case series and literature review. Results: The three patients, which were all women in their reproductive years with a mean age of 31 (range, 22-43), were diagnosed with AMN type 2 after presenting with acute onset of uni- or bilateral persisting paracentral scotomata. On multi-modal imaging with near-infrared (NIR) reflectance imaging, wedge-shaped dark-gray lesions were discernable in a perifoveal petaloid configuration. SD-OCT through the lesions revealed initial hyperreflectivity at the level of the outer retina, beneath the OPL (outer plexiform layer) and comprising the ONL (outer nuclear layer), with disruption of the inner segment/outer segment (IS/OS) band, eventually evolving into thinning of the ONL with or without persisting disruption of the photoreceptor complex. Anterior segment, fundoscopic, angiographic and electrophysiologic examinations were unremarkable. Conclusion: All three cases were diagnosed with a concurrent viral upper respiratory tract infection caused by the SARS-CoV-2 virus. While AMN is considered to be a rare disease, a worldwide surge in the incidence of AMN has recently been reported and the largest case series to date have been described during the latest SARS-CoV-2 viral pandemic. Thus, COVID-19 could be considered a potential risk factor for the development of AMN type 2. Two of our cases were associated with migraine, one of which experienced the onset of AMN symptoms in the immediate setting of a migraine attack and the use of triptans. This association between migraine, triptans and AMN type 2 should be considered in the context of a seemingly persisting visual aura, particularly in the presence of additional risk factors, such as female gender and oral contraceptive use. Summary statement An increased incidence of acute macular neuroretinopathy (AMN) type 2 is observed in the context of SARS-CoV-2 viral infection. The presently described association between AMN, migraine, and triptans should be considered when examining a patient with seemingly persisting visual aura, in particular negative scotomata, in the context of migraine.