Multiple Evanescent White Dot Syndrome Following COVID-19 mRNA Vaccination

Comprehensive insights into COVID-19 vaccine-associated multiple evanescent white dot syndrome (MEWDS): A systematic analysis of reported cases

Considering the widespread use of COVID-19 vaccines as a preventive measure against the spread of the virus, it's necessary to direct attention to the adverse effects associated with vaccines in a limited group of populations. Multiple evanescent white dot syndrome (MEWDS) following COVID-19 vaccination is a rare adverse reaction associated with COVID-19 vaccines. In this systematic review, we collected 19 articles with 27 patients up to November 1, 2023, summarizing the basic information, clinical manifestations, examinations, treatments, and recoveries of the 27 patients. The 27 enrolled patients (6 males, 21 females) had a median age of 34.1 years (15-71 years old) and were mainly from 5 regions: Asia (8), the Mediterranean region (8), North America (7), Oceania (3) and Brazil (1). Symptoms occurred post-first dose in 9 patients, post-second dose in 14 (1 with symptoms after both), post-third dose in 1, and both post-second and booster doses in 1, while details on 2 cases were not disclosed. Treatments included tapered oral steroids (6), topical steroids (3), tapered prednisone with antiviral drugs and vitamins (1), and valacyclovir and acetazolamide (1), while 16 received no treatment. All patients experienced symptom improvement, and nearly all patients ultimately recovered. Moreover, we summarized possible hypotheses concerning the mechanism of COVID-19 vaccine-associated MEWDS. The findings provide insights into the clinical aspects of COVID-19 vaccine-associated MEWDS. More attention should be given to patients with vaccine-associated MEWDS, and necessary treatment should be provided to patients experiencing a substantial decline in visual acuity to improve their quality of life.

A COVID-19 perspective of multiple evanescent white dot syndrome (MEWDS)

Multiple evanescent white dot syndrome (MEWDS) is a rare form of posterior uveitis characterized by involvement in the posterior pole and mid-periphery. A viral etiology that provokes an immune-mediated response has been hypothesized to be the inciting factor of the pathology. Recently, there has been an increase in the literature regarding new-onset uveitis and reactivation of previously diagnosed cases of uveitis following COVID-19 vaccinations. The COVID-19 vaccination has been speculated to trigger an immunomodulatory shift in recipients, resulting in an autoimmune event. MEWDS following COVID-19 vaccination was reported in 31 patients. It was most commonly observed following the first dose, affecting 15 patients, and least commonly after the booster dose, in only one patient. MEWDS-like disease following anti-SARS-CoV-2 vaccinations was reported the most in 16 cases after the Pfizer-BioNTech vaccination (BNT162b2 mRNA). Most of these cases had Primary MEWDS without any previous history of a similar event in the past.

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.

Multimodal Imaging in Diagnosing Multiple Evanescent White Dot Syndrome following Human Papillomavirus Vaccine Immunization

Purpose. This study presents a case of multiple evanescent white dot syndrome (MEWDS) following the administration of the second dose of a human papillomavirus vaccine (HPV). We conducted a review of the literature on vaccine-associated MEWDS. Observations. A 23-year-old Chinese female reported central scotomata in the left eye persisting for 3 weeks. Upon further inquiry, she had received the second dose of the human papillomavirus vaccine (Gardasil-9) three days before the onset of symptoms. A diagnosis of MEWDS was established based on clinical and multimodal imaging (MMI) data. Symptoms resolved after twelve weeks of oral prednisone treatment. Conclusion and Importance. This case highlights a typical case of MEWDS closely associated with HPV vaccination, demonstrating a favorable prognosis with MMI. Given the self-limiting nature of MEWDS, there is a risk of clinical misdiagnosis or oversight. While further studies are warranted to establish a definitive link between the HPV vaccine and MEWDS, this case suggests a potential connection. Healthcare practitioners should remain vigilant regarding possible ocular side effects associated with immunizations.

Presumed Müller Cell Activation in Multiple Evanescent White Dot Syndrome

Purpose

The purpose of this study was to investigate the foveal changes occurring in multiple evanescent white dot syndrome (MEWDS) using multimodal imaging techniques with a specific focus on hyper-reflective dots (HRDs).

Methods

This was a retro-prospective observational study including 35 eyes with active MEWDS. Structural and en face optical coherence tomography (OCT) was performed, with follow-up visits at 2 weeks, 6 weeks, and 2 months from baseline. HRD percentage area (HRD % area) was calculated in a 600 µm fovea centered circle on en face OCT, after background subtraction and image binarization. HRD % area was compared with 23 fellow control eyes. Longitudinal changes in the HRD % areas were assessed using repeated-measure statistics.

Results

HRDs were observed as scattered hyper-reflective spots on the vitreoretinal interface on en face OCT images, colocalizing with HRDs or vertical hyper-reflective lines on structural OCT images. The baseline evaluation showed a significantly higher HRD % area in MEWDS eyes compared to fellow eyes (0.10 ± 0.03 vs. 0.08 ± 0.04, P = 0.01). The HRD % area correlated positively with LogMAR visual acuity and inversely with the duration of symptoms. Longitudinal analysis revealed a significant reduction in the HRD % area over time. There was no significant interaction between the rate of HRD disappearance and clinical or demographic factors at baseline.

Conclusions

As HRD potentially represents the end-feet projections of activated Müller cells on the retinal surface, this study supports the involvement of Müller cells in the pathogenesis of the disease. The findings highlight the potential of en face OCT imaging for monitoring the progression of MEWDS.

Multiple Evanescent White Dot Syndrome Following Adenovirus Vector-Based COVID-19 Vaccine (Covishield)

PURPOSE

To report a case of multiple evanescent white dot syndrome (MEWDS) following adenovirus vector-based Coronavirus disease 2019 (COVID-19) vaccine, Covishield and to present a summary of previously reported cases of MEWDS following COVID-19 vaccines.

METHODS

Retrospective case report and review of literature.

RESULTS

A 22-year-old Indian female presented with blurred vision, scotomata, and photopsias in her left eye, a day after administration of second dose of Covishield vaccine. Her clinical findings and imaging features confirmed the diagnosis of MEWDS. Her symptoms resolved spontaneously after 2 weeks.

CONCLUSION

This is the first reported case of MEWDS following an adenovirus vector-based COVID-19 vaccine. Comparison with previously reported cases of MEWDS following COVID-19 vaccination showed that patients are generally healthy, young to middle-aged women, who develop symptoms after a median time of one week and recover spontaneously over a median period of 4 weeks.