Two Cases of Acute Macular Neuroretinopathy Associated with the Adenovirus-based COVID-19 Vaccine Vaxzevria (Astrazeneca)

The characteristics of white dot syndromes following COVID-19 Vaccines: a systematic review

PURPOSE

To review all studies reporting the onset of white dot syndromes following COVID-19 vaccines.

METHODS

Our protocol was registered prospectively on PROSPERO [registration number: CRD42023426012]. We searched five different databases including PubMed, Scopus, Web of Science, Google Scholar, and Science Direct up to May 2023. All the studies that reported the occurrence of white dot syndrome following COVID-19 vaccines were included. All statistical tests were conducted with a 95% confidence interval and a 5% error margin. A p value of less than 0.05 was considered statistically significant. The methodological quality of included studies was performed using the IHE Quality Appraisal Checklist for Case Series studies and JBI Critical Appraisal Checklist for Case Reports.

RESULTS

Fifty studies involving seventy-one subjects were included. Multiple evanescent white dot syndrome (MEWDS) was the most common disease (n = 25, 35.2% %), followed by acute macular neuroretinopathy (AMN) (n = 22, 31.0%) and acute posterior multifocal placoid pigment epitheliopathy (APMPPE) (n = 4, 5.6%). They were mostly unilateral (n = 50, 70.4%). The presenting symptoms were blurred vision (n = 26, 36.6%), paracentral scotoma (n = 19, 26.8%), visual field disturbance, and photopsia (n = 7, 9.9%). The mean duration for follow-up was 10.15 ± 14.04 weeks. Nineteen subjects (29.69%) received steroids with improvement reported in 68.4%. Eleven subjects (17.19%) were managed by observation only with reported full recovery and improvement.

CONCLUSION

White dot syndromes are very rare entities. Our findings highlight a possible association between COVID-19 vaccines and the occurrence of white dot syndromes. However, larger studies with good quality should be implemented to confirm these findings.

Transient Increase in Patient Numbers with "Acute Macular Neuroretinopathy" Post SARS-CoV-2 Infection-Case Series During the First Surge of Infection in December 2022

Objective

Acute macular neuroretinopathy (AMN) has been associated with several conditions. The aim of this study is to report a surge of AMN cases diagnosed since the easing of epidemic control for COVID-19 in China, in early December 2022.

Case Report

Four cases presented with paracentral or central scotomas, or blurred vision soon after SARS-CoV-2 coronavirus infection. Fundus manifestations were recorded, including typical hyper-reflective segments of the outer plexiform layer (OPL) and outer nuclear layer (ONL), and associated disruption of ellipsoid, interdigitation zones, and retinal pigment epithelium (RPE) layers on optical coherence tomography (OCT). Oral prednisone was administered and gradually tapered. Slight scotoma persisted with hyper-reflective segments fading and irregularity of outer retina on OCT during the follow-up. Case 4 was lost to follow-up.

Conclusion

With the ongoing pandemic and extensive vaccination programs, it is expected that cases of AMN will surge. It is important for ophthalmologists to be aware of the possibility of COVID-19-induced AMN.

Early Effects of Inactivated (CoronaVac) SARS-CoV-2 Vaccine on Retrobulbar Vascular Blood Flow and Retinal Vascular Density

AIMS

We aimed to investigate the early effects of inactivated SARS-CoV-2 vaccine on retrobulbar vascular blood flow and retinal vascular density in healthy subjects.

METHODS

Thirty-four eyes of 34 healthy volunteers who received the CoronaVac (Sinovac Life Sciences, China) were included in this prospective study. Resistive index (RI), pulsatility index (PI) and peak systolic velocity (PSV) of the ophthalmic artery (OA), central retinal artery (CRA), and the temporal and nasal posterior ciliary arteries (PCA) were evaluated with color Doppler ultrasonography (CDUS) before vaccination, at the 2^nd and 4^th weeks after vaccination. Superficial capillary plexus (SCP) and deep capillary plexus (DCP) vessel density (VD), foveal avascular zone (FAZ), and choriocapillaris blood flow (CCF) measurements were made using optical coherence tomography angiography (OCTA).

RESULTS

When compared to the pre-vaccination values, there was no significant change in OA-PSV, temporal-nasal PCA-PSV, CRA-EDV, temporal-nasal PCA-EDV at 2^nd and 4^th weeks after vaccination. However statistically significant reductions were found in the OA-RI, OA-PI, CRA-RI, CRA-PI, temporal-nasal PCA-RI, temporal-nasal PCA-PI values, CRA-PSV at post-vaccination 2^nd week (p<0.05 for all). While there was sustained reduction in OA-RI, OA-PI, CRA-PSV, and nasal PCA-RI values at 4^th week after vaccination, the change in CRA-RI, CRA-PI, temporal PCA-RI, temporal-nasal PCA-PI values were not significant compared to pre-vaccination values. There was no statistically significant difference in the SCP-VD, DCP-VD, FAZ and CCF measurements.

CONCLUSIONS

Our findings demonstrating that CoronaVac vaccine did not affect retinal vascular density in the early period, but it caused alterations in the retrobulbar blood flow.

Acute Macular Neuroretinopathy and Paracentral Acute Middle Maculopathy during SARS-CoV-2 Infection and Vaccination

Purpose: To review the demographic and clinical profile of patients developing acute macular neuroretinopathy (AMN) or paracentral acute middle maculopathy (PAMM) after receiving coronavirus disease-2019 (COVID-19) vaccination or infection. Methods: In this review article, the published literature was searched to determine cases developing either AMN or PAMM after COVID-19 vaccinations or infections. Data, including demographic profile, presenting features, symptoms, diagnosis, and clinical outcomes, were extracted from the selected publications. These parameters were compared between the two groups, i.e., patients developing AMN/PAMM either after vaccination or infection. Results: After the literature review, 57 patients developing either AMN (n = 40), PAMM (n = 14), or both (n = 3) after COVID-19 infection (n = 29) or vaccination (n = 28) were included (mean age: 34.9 ± 14.4 years; n = 38; 66.7% females). In 24.6% patients, the diagnosis of COVID-19 infection was preceded by the development of ocular disease. There were no significant differences in the age or gender between the patients developing AMN or PAMM after vaccination or infection (p > 0.13). Among the vaccination group, the highest number of patients developing AMN/PAMM were after the Oxford-AstraZeneca (n = 12; 42.9%). Patients with vaccination had a significantly early onset of AMN/PAMM compared to those with infection (11.5 ± 17.6 days versus 37.8 ± 43.6 days; p = 0.001). Conclusions: Both AMN and PAMM are reported to be associated with COVID-19 infections and in persons receiving vaccination against COVID-19. While COVID-19 infections and vaccinations may have a contributory role, other risk factors such as oral contraceptive pills may also play a role in the development of the disease.

Uveitis and Posterior Ophthalmic Manifestations Following the SARS-CoV-2 (COVID-19) Vaccine

PURPOSE

To present four cases of posterior ophthalmic manifestations associated with a temporal relationship to SARS-CoV-2 vaccination.

METHODS

Retrospective case series with a review of clinical findings.

RESULTS

Four patients presented with various posterior ophthalmic findings including uveitis, maculopathy, and optic neuropathy. Each of their clinical courses varied in terms of ophthalmic imaging and exam findings.

CONCLUSION

The coronavirus disease 2019 (COVID-19) pandemic has ushered in a new wave of challenges to healthcare, epidemiological endeavors, and widespread vaccination efforts. Novel vaccines have been developed for the SARS-CoV-2 virus, including both mRNA and viral vector-based platforms. The ocular manifestations and side effects related to the SARS-CoV-2 vaccine is not well established or understood. There may be an association between vaccination and posterior ophthalmic manifestations.

Ischemic retinal events after COVID-19 vaccination

Purpose

We report 2 cases of ischemic retinal events occurring soon after administration of the Moderna and Johnson & Johnson/Janssen COVID-19 vaccines. To our knowledge, these are the first reports of isolated ischemic retinal events occurring after COVID-19 vaccination.

Observations

A 57-year-old female had new onset floaters of the left eye within days of her second Moderna COVID-19 vaccination, which progressively worsened prompting her to present for evaluation. She was diagnosed with a branch retinal vein occlusion in the left eye. A 20-year-old female presented with persistent central scotomata in both eyes, which she first noticed two days after her Johnson & Johnson/Jannsen COVID-19 vaccination. She was diagnosed with acute macular neuroretinopathy of both eyes.

Conclusions and Importance

The potential side effects of COVID-19 vaccines are still being established; however, there has been concern over pro-thrombotic events with these vaccines, with most concerns directed toward the Johnson & Johnson vaccine. We observed likely transient pro-thrombotic retinal milieu in patients who received these vaccines though it remains unclear whether there is a shared mechanism between systemic response to the COVID-19 spike protein and the highly pro-thrombotic state seen in COVID-19 infections. In the case of our patients, we postulate their immunologic responses to the vaccines - and possibly a resultant pro-thrombotic state - may have precipitated their ischemic retinal events. We thus recommend that patients with ocular symptoms after COVID-19 vaccination undergo comprehensive ophthalmologic evaluation.