Ocular side effects of vaccination: neuroretinitis, MEWDS and more

A 78-year-old healthy woman was presented with blurry vision in her left eye 1 day after receiving the third dose of the Pfizer-BioNTech COVID-19 vaccine. The ocular examination revealed an optic disc swelling and retinal thickening of the macula with subretinal fluid in the left eye. The fluorescein angiography revealed hyperfluorescence of the left optic disc. The neuroretinitis resolved gradually after taking azithromycin and prednisolone orally. unilateral neuroretinitis

A 30-year-old female was diagnosed with bilateral acute anterior uveitis about a month after Pfizer COVID-19 booster vaccine and was started on prednisolone and cyclopentolate in both eyes. The symptoms had initially improved after a week of therapy, but a couple of weeks later she noticed that the visual acuity in the right eye precipitously dropped, which she described as “smoke” in her vision. She progressed to a serous retinal detachment involving the fovea in the left eye. Unilateral neuroretinitis is often caused by infection by Bartonella species (eg, transmitted from cats), but the patient stated that she did not have any exposures to animals, water or exotic food. 

17-year-old Hispanic female was diagnosed with multiple evanescent white dot syndrome (MEWDS) 16 days after the simultaneous administration of the human papillomavirus and meningococcal (conjugate) vaccine. One month following her initial diagnosis, the patient's symptoms had resolved without any therapy. Subsequently, she received the second dose of the HPV vaccine and then developed a mild COVID-19 infection. Four months after the initial presentation, she received the first dose of the BNT162b2 COVID-19 vaccine, followed by the second dose a month later. Eight months following her initial presentation, she presented with photopsia in the right eye. The contralateral MEWDS diagnosis was confirmed by tests. At her one-month follow-up, she presented new onset photopsia of the right eye. Her visual acuity remained 20/20 in both eyes, and a fundus examination revealed white lesions suggestive of active MEWDS.

38-year-old Caucasian, otherwise healthy female patient, presented with a complaint of vision loss in the outer quadrant in her left eye after the second dose of Pfizer®-BioNTech™ COVID-19 vaccine. The Snellen visual acuity was 20/20 in both eyes. She did not have relative afferent pupillary defect nor disturbance of color vision. Her intraocular pressures, slit lamp and fundus examinations were normal. In the VF test, a temporal hemifield defect in the left eye and a nasal peripheral VF defect in the right eye were detected. Other imaging characteristics and neurological examination were normal. She was followed without any treatment. One week later, the patient was re-evaluated, and complete resolution of the VF defect was observed.

Cases of sixty-three patients (37 males, 26 females) with a mean age of 61.6 ± 13.3 years (range, 22–81 years) were included in another study. Among 61 applicable patients with sufficient information regarding medical histories, 38 (62.3%) had one or more significant underlying past medical histories including vasculopathic risk factors. The interval between initial symptoms and vaccination was 8.6 ± 8.2 (range, 0–28) days. Forty-two (66.7%), 14 (22.2%), and 7 (11.1%) patients developed symptoms after the first, second, and third vaccinations, respectively. One case of internuclear ophthalmoplegia, 52 cases of cranial nerve palsy, two cases of myasthenia gravis, six cases of orbital diseases (such as myositis, thyroid eye disease, and IgG-related orbital myopathy), and two cases of comitant vertical strabismus with acute onset diplopia were found. 

The ocular surface was postulated to be a portal of entry and potential route of transmission of SARS-CoV-2 early in the course of the pandemic. Various adverse ocular effects have been reported after immunization by all COVID-19 vaccines. After the AstraZeneca adenovirus vector vaccine, acute macular neuroretinopathy, bilateral immune-mediated keratolysis, and VKH disease were all reported as potential adverse ocular events following vaccination.108–110 Meanwhile, we did not identify reports of ocular adverse events following immunization by the Johnson & Johnson vaccine vaccine in the current literature. A few adverse ocular effects were noted in the whole inactivated coronavirus vaccines. Following immunization, acute uveitis has been reported by the SinoPharm vaccine, which resolved with topical steroid treatment without recurrence. In a recent study, episcleritis, anterior scleritis, acute macular neuroretinopathy, paracentral acute middle maculopathy, and subretinal fluid were reported from studying 7 patients who presented with ocular complaints following SinoPharm vaccination. There was a report of bilateral transient visual field defect with spontaneous resolution in an ophthalmologist following Sinovac vaccination. The Pfizer-BioNTech vaccine was reported to be associated with a case of acute abducens nerve palsy following a febrile illness 2 days after vaccination in a patient without significant comorbidities. Various authors also reported cases of uveitis and Vogt-Koyanagi-Harada (VKH) disease following vaccination; most cases resolve or significantly improve following both steroidal and nonsteroidal immunosuppression. Retinal occlusion was observed after a protein subunit vaccine. A case of arteritic anterior ischemic optic neuropathy (AAION) manifesting as acute loss of vision following vaccination was also reported in the literature. There were also recent reports of corneal graft rejection following vaccination in patients who received endothelial keratoplasty or penetrating keratoplasty. As another mRNA vaccine, there is currently 1 report of bilateral acute zonal occult outer retinopathy (AZOOR) manifesting as progressive nasal field defect following Moderna vaccination.


REFERENCES


Yoshida N, Tsukada A. A Case of Neuroretinitis Following COVID-19 Vaccination. Ocul Immunol Inflamm. 2022 Oct 28:1-4. doi: 10.1080/09273948.2022.2137047. Epub ahead of print. PMID: 36306430.

Lin TP, Ko CN, Zheng K, Lai KH, Wong RL, Lee A, Zhang S, Huang SS, Wan KH, Lam DS. COVID-19: update on its ocular involvements, and complications from its treatments and vaccinations. Asia-Pacific Journal of Ophthalmology (Philadelphia, Pa.). 2021 Nov;10(6):521. 

Ramirez Marquez E, Ayala Rodríguez SC, Rivera L, Pappaterra-Rodriguez MC, Requejo-Figueroa GA, Rios R, Rivera-Grana E, Rodríguez-García EJ, Oliver AL. Contralateral Recurrences of Post-vaccination Multiple Evanescent White Dot Syndrome. Cureus. 2022 Dec 7;14(12):e32300. doi: 10.7759/cureus.32300. PMID: 36628035; PMCID: PMC9822784.

Fondriest J. Case Study: An Atypical Presentation of Neuroretinitis.

Park, KA., Jeon, H., Choi, D.G. et al. Ocular motility disorders following coronavirus disease-19 vaccination. Graefes Arch Clin Exp Ophthalmol (2022). https://doi.org/10.1007/s00417-022-05888-z

Sarıgül Sezenöz A, Güngör SG, Kibaroğlu S. A Case of Transient Visual Field Defect following Administration of Pfizer-BioNTech COVID-19 Vaccine. Ocul Immunol Inflamm. 2022 Jul;30(5):1255-1259. doi: 10.1080/09273948.2022.2055578. Epub 2022 Apr 11. PMID: 35404749.

Cunningham ET, Moorthy RS, Agarwal M, Smit DP, Zierhut M. Ocular Complications Following COVID-19 Vaccination–Coincidence, Correlation, or Causation?. Ocular Immunology and Inflammation. 2022 Jul 4;30(5):1031-4.

Lin TPH, Ko CN, Zheng K, Lai KHW, Wong RLM, Lee A, Zhang S, Huang SS, Wan KH, Lam DSC. COVID-19: Update on Its Ocular Involvements, and Complications From Its Treatments and Vaccinations. Asia Pac J Ophthalmol (Phila). 2021 Nov 24;10(6):521-529. doi: 10.1097/APO.0000000000000453. PMID: 34839344; PMCID: PMC8673850.


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