Combined central retinal artery and vein occlusion shortly after mRNA-SARS-CoV-2 vaccination

Retinal vascular occlusion after COVID-19 vaccination: Analysis of the French pharmacovigilance database

Retinal vein occlusions and central retinal artery occlusions have been reported with coronavirus disease 2019 (COVID-19) vaccines. We aim to provide a descriptive analysis of cases reported in France until mid-2023, and recorded in the French pharmacovigilance database. An independent ophthalmologist reviewed all cases. We analyzed 290 cases (228 retinal vein occlusions, 58 central retinal artery occlusions, and four combinations). Retinal vein occlusions occurred with mRNA vaccines (68.0%) and adenovirus-vectored vaccines (32%), with an 11-day median onset delay. Almost half of the patients had retinal vein occlusion risk factors, mainly hypertension, and five had a positive rechallenge. Considering the lower adenovirus-vectored vaccines exposure in France, their proportion of retinal vein occlusions appears high. Among the 58 central retinal artery occlusion cases, most occurred with mRNA vaccines in patients with retinal artery occlusion risk factors (mainly hypertension), with a 17-day median onset delay. In conclusion, there was a temporal association in almost half of cases, but few cases with positive rechallenge, and many cases were confounded by risk factors (e.g., cardiovascular disorders, diabetes), which are also COVID-19 risk factors. Therefore, the risk of retinal vascular occlusion does not challenge the benefit-risk ratio of the vaccination, especially for mRNA vaccines.

Aetiology, Diagnosis and Treatment of Arterial Occlusions of the Retina-A Narrative Review

Arterial occlusions of the retina are potentially sight-threatening diseases which often result in profound visual loss. The aim of this narrative review is to provide an overview of the aetiology, discuss major risk factors, describe the management and systemic assessments and evaluate existing therapies. For this review, an extensive literature search in PubMed was performed. Emboli from the heart or the carotid arteries can cause ophthalmic artery occlusion (OAO), central retinal artery occlusion (CRAO) and branch retinal artery occlusion (BRAO). Most patients with arterial occlusions have vascular risk factors such as arterial hypertension, hyperhomocysteinaemia, carotid stenosis and atrial fibrillation, which also increase the risk of cerebral stroke and myocardial infarction. Therapies such as ocular massage, thrombolysis and anterior chamber paracentesis have been suggested but are still equivocal. However, it is evident that retinal artery occlusion should be immediately treated and accompanied by interdisciplinary collaboration, since early diagnosis and the proper treatment of possible risk factors are important to reduce the risk of further damage, recurrences, other vascular diseases and mortality.

Case report: A case of unilateral combined central retinal vein occlusion, incomplete central retinal artery occlusion, and papillitis following a third dose of COVID-19 vaccination

Purpose

The aim of this study was to present a case of severe visual loss due to retinal arteriovenous occlusion and papillitis in one eye following vaccination against coronavirus disease (COVID-19).

Methods

A 45-year-old man undergoing treatment for hypertension had severely reduced visual acuity in the right eye 1 day after receiving a third dose of a COVID-19 vaccine manufactured by Moderna. Clinical examination showed that the best-corrected visual acuity in the right eye was counting fingers. Other findings included circumferential retinal hemorrhage, perimacular ischemic color, severe macular edema, and severe optic disc swelling, indicating the presence of central retinal vein occlusion, incomplete central retinal artery occlusion, and papillitis. Based on the possibility of post-vaccination inflammation and/or abnormal immune response, three courses of steroid pulse therapy were administered, and the visual acuity slightly improved to 20/1,000.

Results

Three months after the onset of symptoms, macular edema disappeared; conversely, retinal thinning of the macula and extensive non-perfusion areas mainly on the nasal side were noted.

Conclusion

The findings in this case suggest that inflammation and abnormal immune response after receiving a COVID-19 vaccination may lead to combined retinal arteriovenous occlusion and papillitis.

Recovery From Central Retinal Artery Occlusion Accompanying Paracentral Acute Middle Maculopathy After COVID-19 Vaccination

Although ocular complications following COVID-19 vaccination have been reported, particularly retinal vascular occlusion and uveitis, their definitive causal relationships remain uncertain. This report presents a case of central retinal artery occlusion (CRAO) with paracentral acute middle maculopathy (PAMM) developed one day after receiving Pfizer COVID-19 vaccine, with a favorable outcome. The patient experienced sudden vision loss in her left eye, and her vision dropped to hand motion the day after vaccination. The initial examination suggested CRAO, but optical coherence tomography (OCT) revealed PAMM. We administered intravenous d-mannitol and acetazolamide and performed ocular massage. Two days later, her corrected visual acuity improved to 0.4, and further improvement to 1.2 occurred after 16 days. To the best of our knowledge, no reports have documented CRAO with PAMM following mRNA COVID-19 vaccination. The relationship between COVID-19 vaccination and retinal vascular occlusion remains unknown, highlighting the need for further research.

Ocular posterior segment complications following COVID-19 vaccination

BACKGROUND

The SARS-CoV-2 pandemic has had a significant impact on healthcare, including eye care, worldwide. Effective and safe vaccines have been developed using both conventional and novel technologies to combat SARS-CoV-2 infection. While vaccination has been shown to be remarkably effective in reducing the spread and associated morbidity and mortality of COVID-19 disease, there have been reports of complications to the posterior segment of the eye.

METHODS

We present a case-based analysis of reported complications of COVID-19 vaccination to the posterior segment of the eye. The study aims to highlight the diversity of possible complications and discuss the plausible involved pathophysiologic mechanisms.

RESULTS

The most significant complications reported were retinal macro or microvascular occlusions, uveitis, and central serous chorioretinopathy. These complications are rare but require prompt diagnosis and management to prevent serious visual morbidity.

CONCLUSIONS

Our study highlights the need for ophthalmologists to be aware of possible complications related to COVID-19 vaccination and the importance of prompt diagnosis and management. The findings of this study may help ophthalmologists to better understand and manage these rare complications.

Retinal Vein Occlusion Amongst People Vaccinated by mRNA- and Viral Vector- COVID-19 Vaccines: A Systematic Review

Vaccines are highly effective in lowering the mortality due to COVID-19. Although several suspected adverse events or side effects after vaccination including retinal vein occlusion (RVO) have been reported. We conducted a systematic review using PRISMA methods to analyze the occurrence of RVO among people vaccinated by COVID-19 mRNA- vs viral vector- vaccines on 4 databases from 1-1-2021 to 31-12-2022 using specified MeSH terms. All included studies were assessed using JBI critical appraisal tools for eligibility. The final included studies are 31 studies (n=78 cases from 75 patients; 3 of these patients suffered twice). The median age of the patients was 61 years (28 to 96 years old) and most of them were female (52.00%). Thirty-nine patients received the mRNA vaccine (52.00%), while 36 patients received the viral vector vaccine (48.00%) before the event. The RVO diagnoses are based on physical examination confirmed by Fluorescein Angiography (FA), and/or Optical Coherence Tomography (OCT). The median time interval between vaccination and RVO was 6 days in the mRNA vaccine group and 4 days in the viral vector vaccine group. Central retinal vein occlusion (CRVO) and Branch Retinal Vein Occlusion (BRVO) were tied as the most common diagnosis in the mRNA vaccine group (20.51% and 20.51%), whilst in the viral vector vaccine group CRVO was the most common diagnosis (17.94%). Most of these cases had good outcomes with improved visual impairment in one or both eyes. From this review, we could not ascertain that the RVO occurs due to the type of COVID-19 vaccines because of the detailed data on the dosage and the history of illness of each patient. However, the awareness that the RVO could develop after COVID-19 vaccination must be taken into consideration, even though it is rare.

Retinal Vein Occlusion after COVID-19 Vaccination-A Review

Background Retinal vein occlusion (RVO) occurring after COVID-19 vaccination has been reported worldwide. Such a sight-threatening condition occurring after COVID-19 vaccination is a menace to ophthalmic health. This article reviews current evidence related to post-COVID-19 vaccination RVO. Method A total of 29 relevant articles identified on PubMed in January 2023 were selected for review. Observation All cases presented to ophthalmologists with visual loss shortly after COVID-19 vaccination. Mean and median age were both 58. No sex predominance was observed. RVO was diagnosed from findings on dilated fundal examination and ophthalmic imaging. AstraZeneca and BNT vaccines accounted for most cases. Vascular risk factors, e.g., diabetes mellitus and hypertension, were common. Most laboratory tests requested came back unremarkable. Most patients responded well to standard treatment, except those with ophthalmic comorbidities. Visual prognosis was excellent on short-term follow-up. Discussion The causality between RVO and COVID-19 vaccination is undeterminable because of the nature of articles, heterogenous reporting styles, contradicting laboratory findings and co-existing vascular risk factors. Vaccine-induced immune thrombotic thrombocytopenia, retinal vasculitis and homocysteinaemia were proposed to explain post-vaccination RVO. Large-scale studies have demonstrated that the incidence of RVO following COVID vaccination is very low. Nevertheless, the effects of boosters on retinal vasculature and ophthalmic health are still unclear. Conclusions The benefits of COVID-19 vaccination are believed to outweigh its ophthalmic risks. To ensure safe vaccination, the prior optimisation of comorbidities and post-vaccination monitoring are important. COVID-19 vaccines (including boosters) should be offered with reasonable confidence. Further studies are warranted to elucidate the ophthalmic impact of vaccines.

Retinal vascular occlusions in COVID-19 infection and vaccination: a literature review

PURPOSE

Abnormal hypercoagulability and increased thromboembolic risk are common in patients with coronavirus disease (COVID-19). COVID-19 has been suggested to cause retinal vascular damage, with several studies on COVID-19 patients with retinal vascular occlusions. We reviewed and investigated studies on retinal vascular occlusions in patients diagnosed with COVID-19 and in those vaccinated for COVID-19.

METHODS

Studies that reported retinal vascular occlusion in COVID-19 patients or in vaccinated people were identified using the terms "retinal occlusion," together with "severe acute respiratory syndrome coronavirus 2", "SARS-CoV-2," "COVID-19," "coronavirus," and "vaccine," through systematic searches of PubMed and Google Scholar databases until January 7, 2022.

RESULTS

Thirteen cases of retinal artery occlusion (RAO) and 14 cases of retinal vein occlusion (RVO) were identified among patients diagnosed with COVID-19. Half of the patients with RAO or RVO revealed no systemic disorders except current or past COVID-19, and ocular symptoms were the initial presentation in five cases. Among patients with RAO, most presented with central RAO at 1-14 days of COVID-19 diagnosis, with abnormal coagulation and inflammatory markers. Among those with RVO, two-thirds presented with central RVO and one-third with RVO. Eleven cases with acute macular neuroretinopathy (AMN) and/or paracentral acute middle maculopathy (PAMM) were reported among patients with COVID-19, presenting scotoma resolved spontaneously in most cases. Among the 26 cases vaccinated with either mRNA or adenoviral vector vaccines for COVID-19 and presenting retinal vascular occlusions, there were more RVO cases than RAO cases, and ocular symptoms mostly occurred within 3 weeks after vaccination. One case presented bilateral AMN and PAMM after COVID-19 vaccination.

CONCLUSION

Retinal vascular occlusions might be a manifestation of COVID-19, although rare, especially in patients at risk of systemic hypercoagulability and thromboembolism. For COVID-19 vaccines, the causal relationship is controversial because there are few case reports of retinal vascular occlusions after COVID-19 vaccination.

Retinal vascular occlusion following SARS-CoV-2 vaccination: A VAERS database analysis

Purpose

To evaluate the cases of retinal vessel occlusion following COVID-19 vaccination and evaluate the onset interval and clinical presentations in patients diagnosed with vaccine associated retinal artery occlusion (RAO) and retinal vein occlusion (RVO).

Design

Retrospective study of the cases reported to the Centers for Disease Control and Prevention (CDC) Vaccine Adverse Events Reporting System (VAERS) between December 11, 2020 and July 1, 2022.

Participants

Patients diagnosed with retinal vessel occlusion following vaccination with BNT162b2, mRNA-1273, and Ad26.COV2.S globally.

Methods

We performed a descriptive analysis of the patient demographics and clinical presentation in patients with retinal vessel occlusion. The correlation between the vaccines and continuous and categorical variables were assessed. We performed the post-hoc analysis to evaluated the association between RAO and RVO onset post-vaccination, and vaccine and dosage. Finally, a 30-day reverse analysis for RAO and RVO onset following administration of vaccine. A major limitation in the methods of this study is the lack of control group for assessing the risk of retinal vessel occlusive disease in patients who received the vaccine compared to the patients who were unvaccinated.

Main Outcome Measures

The crude reporting rate of retinal vessel occlusion following SARS-CoV-2 vaccine. The ocular and systemic presentations, onset duration and short term risk of RAO and RVO following vaccination.

Results

During the study period, 1351 retinal vessel occlusion cases were reported globally. The crude reporting rates of retinal vessel occlusion for BNT162b2, mRNA-1273, and Ad26.COV2.S were 0.36, 0.41, and 0.69, respectively. The majority of the retinal vessel occlusion cases were reported following BNT162b2 (n=606, 74.17%). The mean age of patients with RVO and RAO was 58.54 ± 16.06 years and 64.63 ± 16.16 years, respectively. In the cohort, 817 and 433 patients were diagnosed with RVO and RAO, respectively. Most cases of RVO (41.12%) and RAO (48.27%) were reported within the first week post-vaccination. We observed that the mean onset interval for RVO was significantly longer in patients who received Ad26.Cov2.S (54.07 ± 88.98 days) compared to BNT162b2 (18.07 ± 28.66 days) and mRNA-1273 (22.85 ± 38.13 days) vaccines (p<0.0001). This was further confirmed by post-hoc analysis, which revealed a significantly longer onset duration for the Ad26.Cov2.S compared to BNT162b2 and mRNA 1273 vaccines (p<0.0001). The reverse Kaplan Meier 30-day risk analysis showed a significant a higher risk of RVO onset following BNT162b2 compared to other vaccines(p<0.0001).

Conclusions

The low crude reporting rate highlights a low safety concern for retinal vessel occlusion following SARS-CoV-2 vaccination. This study provides insights into possible temporal association between reported retinal vessel occlusion events with SARS-CoV-2 vaccines, however further insights are needed to understand the underlying immunopathological mechanisms that promote thrombosis of retinal vasculature on vaccine administration.

COVID-19, post-acute COVID-19 syndrome (PACS, "long COVID") and post-COVID-19 vaccination syndrome (PCVS, "post-COVIDvac-syndrome"): Similarities and differences

Worldwide there have been over 760 million confirmed coronavirus disease 2019 (COVID-19) cases, and over 13 billion COVID-19 vaccine doses have been administered as of April 2023, according to the World Health Organization. An infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can lead to an acute disease, i.e. COVID-19, but also to a post-acute COVID-19 syndrome (PACS, "long COVID"). Currently, the side effects of COVID-19 vaccines are increasingly being noted and studied. Here, we summarise the currently available indications and discuss our conclusions that (i) these side effects have specific similarities and differences to acute COVID-19 and PACS, that (ii) a new term should be used to refer to these side effects (post-COVID-19 vaccination syndrome, PCVS, colloquially "post-COVIDvac-syndrome"), and that (iii) there is a need to distinguish between acute COVID-19 vaccination syndrome (ACVS) and post-acute COVID-19 vaccination syndrome (PACVS) - in analogy to acute COVID-19 and PACS ("long COVID"). Moreover, we address mixed forms of disease caused by natural SARS-CoV-2 infection and COVID-19 vaccination. We explain why it is important for medical diagnosis, care and research to use the new terms (PCVS, ACVS and PACVS) in order to avoid confusion and misinterpretation of the underlying causes of disease and to enable optimal medical therapy. We do not recommend to use the term "Post-Vac-Syndrome" as it is imprecise. The article also serves to address the current problem of "medical gaslighting" in relation to PACS and PCVS by raising awareness among the medical professionals and supplying appropriate terminology for disease.

Risk of New Retinal Vascular Occlusion After mRNA COVID-19 Vaccination Within Aggregated Electronic Health Record Data

Importance

New-onset retinal vascular occlusion (RVO) occurring acutely after messenger RNA (mRNA) COVID-19 vaccination has been described in recent literature. Because RVO can cause vision loss or blindness, an epidemiologic investigation evaluating this potential association is of great importance to public health.

Objective

To investigate how often patients are diagnosed with new RVO acutely after the mRNA COVID-19 vaccine compared with influenza and tetanus, diphtheria, pertussis (Tdap) vaccines.

Design, Setting, and Participants

A retrospective population-based cohort design using the TriNetX Analytics platform, a federated, aggregated electronic health record (EHR) research network containing the deidentified EHR data of more than 103 million patients, was used to examine aggregate EHR data. Data were collected and analyzed on October 20, 2022. Data on patients within the TriNetX Analytics platform were searched for the presence of vaccination Common Procedural Technology codes, and instances of newly diagnosed RVO within 21 days of vaccination were recorded and reported. Propensity score matching based on demographic characteristics (age, sex, race and ethnicity) and comorbidities (diabetes, hypertension, and hyperlipidemia) was performed between vaccination groups for evaluation of relative risks (RRs).

Main Outcomes and Measures

The appearance of a new-encounter diagnosis of RVO within 21 days of the mRNA COVID-19 vaccination was the primary outcome. Historical comparison cohorts of patients receiving influenza and Tdap vaccinations allowed for evaluation of the RRs for RVO.

Results

Of 3 108 829 patients (mean [SD] age at vaccination, 50.7 [20.4] years; 56.4% women) who received the mRNA COVID-19 vaccine, 104 (0.003%; 95% CI, 0.003%-0.004%) patients had a new diagnosis of RVO within 21 days of vaccination. After propensity score matching, the RR for new RVO diagnosis after the first dose of COVID-19 vaccination was not significantly different from that after influenza (RR, 0.74; 95% CI, 0.54-1.01) or Tdap (RR, 0.78; 95% CI, 0.44-1.38) vaccinations, but was greater when compared with the second dose of the COVID-19 vaccination (RR, 2.25; 95% CI, 1.33-3.81).

Conclusions and Relevance

The findings of this study suggest that RVO diagnosed acutely after mRNA COVID-19 vaccination occurs extremely rarely at rates similar to those of 2 different historically used vaccinations, the influenza and Tdap vaccines. No evidence suggesting an association between the mRNA COVID-19 vaccination and newly diagnosed RVO was found.

Bilateral Branch Retinal Vein Occlusion after mRNA-SARS-CoV-2 Booster Dose Vaccination

PURPOSE

We report a case of a patient with a bilateral branch retinal vein occlusion (BRVO) 24 h after a booster vaccination with the mRNA-1237 vaccine.

OBSERVATIONS

Fluorescein angiography, performed at three weeks follow-up, showed vascular leakage and blockage, corresponding to hemorrhage areas associated with ischemic areas in the macula and along the arcades involved in the occlusion.

CONCLUSIONS

The patient was scheduled for urgent injections of intravitreal ranibizumab and laser photocoagulation of the ischemic areas. To the best of our knowledge, this is the first case described of concomitant bilateral RVO after COVID-19 vaccination. The rapid onset of the side effects in a patient with multiple risk factors for thrombotic events suggests that vulnerable microvascular conditions require detailed investigations before administration of a COVID-19 vaccine.

Central Retinal Vein Occlusion in a Young Woman with Diabetes and Hypertension after mRNA-Based COVID-19 Vaccination-A Case Report and Brief Review of the Literature

A 25-year-old female with diabetes and hypertension presented with progressive painless blurred vision in her left eye ten days after she received her third dose of the SARS-CoV-2 mRNA vaccine BNT162b2 (Pfizer-BioNTech). The clinical examination confirmed the diagnosis of Central Retinal Vein Occlusion (CRVO) complicated with macular edema. Three doses of anti-vascular endothelial growth factor (VEGF) were injected intravitreally. Visual acuity was improved from 20/100 to 20/30, but recurrence was noted at 6 months. Several cases of retinal vein occlusion (RVO) after COVID-19 vaccination have been reported. However, the present case is the youngest female individual documented to have CRVO after SARS-CoV-2 vaccination. This case demonstrates that the macular edema might be recurrent in patients with risk factors for CRVO who receive SARS-CoV-2 vaccination, suggesting the need for careful consideration of the treatment strategy and close follow-up. Although the definite pathogenesis still needs to be carefully determined, this report highlights the possible association between RVO and mRNA-based COVID-19 vaccination, even in young individuals.

Ocular Vascular Events following COVID-19 Vaccines: A Systematic Review

The main aim of this study is to investigate the current evidence regarding the association between COVID-19 vaccination and ocular vascular events. The protocol is registered on PROSPERO (CRD42022358133). On 18 August 2022, an electronic search was conducted through five databases. All original articles reporting individuals who were vaccinated with COVID-19 vaccines and developed ophthalmic vascular events were included. The methodological quality of the included studies was assessed using the NIH tool. A total of 49 studies with 130 ocular vascular cases were included. Venous occlusive events were the most common events (54.3%), which mostly occurred following the first dose (46.2%) and within the first five days following vaccination (46.2%). Vascular events occurred more with the Pfizer and AstraZeneca vaccines (81.6%), and mostly presented unilaterally (73.8%). The most frequently reported treatment was intravitreal anti-VEGF (n = 39, 30.4%). The majority of patients (90.1%) demonstrated either improvement (p = 0.321) or persistence (p = 0.414) in the final BCVA. Ophthalmic vascular events are serious vision-threatening side effects that have been associated with COVID-19 vaccination. Clinicians should be aware of the possible association between COVID-19 vaccines and ocular vascular events to provide early diagnosis and treatment.

Central retinal artery occlusion after vaccination with whole virion inactivated SARSCoV- 2 vaccine Covaxin

Coronavirus disease 2019 (COVID-19) vaccinations have been associated with a higher risk of thromboembolic events. There have been no reports of central retinal artery occlusion (CRAO) after vaccination with the indigenously developed Covaxin, and worldwide, there has been only one such isolated case after administration of the AstraZeneca vaccine. We report a case of a 44-year-old healthy man who presented with sudden painless vision loss in his left eye 10 days after receiving Covaxin. His best-corrected visual acuity was minimal perception of light, with a relative afferent pupillary defect. Fundus examination revealed arterial attenuation and macular cherry red spot, suggesting an acute CRAO. Optical coherence tomography showed macular swelling and disorganization of the inner layers due to ischemic sequelae. Blood work was normal and cardiovascular examination was unremarkable. The patient was kept on follow-up. To our knowledge, this is the first case of an isolated CRAO after Covaxin administration, but further studies are needed to evaluate this potential association.

Central Retinal Vein Occlusion Following the First Dose of COVID Vaccine

The reports of vascular adverse events in the eye following COVID-19 vaccination are infrequent. We report the case of a healthy male who developed central retinal vein occlusion in his left eye three days following administration of the first dose of Covishield vaccine. As the underlying systemic and ocular risk factors were absent and laboratory investigations were normal, vein occlusion appeared to probably result from the vaccine. The patient developed retinal hemorrhages and non-perfusion ischemic areas all over the fundus. The macular edema was reduced with intravitreal triamcinolone acetonide, but the visual gain was not much, which appears to be due to the time lag in his initial presentation to the Ophthalmology Department. A close watch should be kept for ophthalmic adverse events to have an early intervention.

Acute Unilateral Central Serous Chorioretinopathy after Immunization with Pfizer-BioNTech COVID-19 Vaccine: A Case Report and Literature Review

INTRODUCTION

A 43-year-old Caucasian male presented to our ophthalmology clinic with blurry vision and metamorphopsia in his right eye, 24 hours after receiving the first dose of the Pfizer-BioNTech COVID-19 vaccine.

METHODS

Clinical examination and imaging tests were consistent with acute unilateral central serous chorioretinopathy (CSCR) that completely resolved after 2 months without any treatment. He had no significant ophthalmic or medical history. He also lacked the classical risk factors for CSCR such as recent psychosocial stressors, Type-A personality traits, history of exogenous steroid use, connective tissue disorders and obstructive sleep apnea.

RESULTS

This appears to be only the second reported case of CSCR, temporally associated with a recombinant COVID-19 mRNA vaccine. We also present a summary of published reports demonstrating intraocular complications associated with the novel recombinant COVID-19 mRNA vaccines.

CONCLUSION

Findings in this report should not deter COVID-19 vaccinations given the rarity of aforementioned ocular complications and the greater benefit of protection from COVID-19 infection. Medical practitioners, however, should remain mindful of potential ocular complications, given the greater likelihood of occurrence with increasing vaccination booster rates.

Retinal venous occlusion following COVID-19 vaccination: Report of a case after third dose and review of the literature

A 28-year-old, healthy male presented with blurring of vision in the right eye following third dose of the AstraZeneca/COVISHIELD vaccine. Further examination revealed ischemic central retinal vein occlusion, and subsequent laboratory investigations were inconclusive for his eye disease. He responded to pulse corticosteroid and tapering doses of oral corticosteroids without requiring any intra-vitreal injection. Twelve articles were identified with the help of a PubMed literature search, and a short review of these patients was performed. Retinal vein occlusion can occur because of inflammation-induced thrombosis after coronavirus disease 2019 vaccination and may respond to anti-inflammatory therapy.

Branch retinal vein occlusion in a healthy young man following mRNA COVID-19 vaccination

Purpose

To report a case of a branch retinal vein occlusion (BRVO) following mRNA COVID-19 vaccination.

Observations

A 34-year-old healthy male presented with blurriness in the inferior visual field, intermittent photopsia, multiple retinal hemorrhages, dilated and tortuous retinal vessels, and cotton wools spots in the right eye. The clinical examination and ancillary tests confirmed the diagnosis of a right eye BRVO. The visual symptoms started 2 days following first dose COVID-19 vaccination with the BNT162b2 (Pfizer-BioNTech) mRNA vaccine.

Conclusions and importance

This is a rare case of BRVO in an otherwise healthy young man, presenting after vaccination for COVID-19 in the absence of other coagulable risk factors. As the literature on venous thrombosis after COVID-19 vaccinations remains sparse, it is critical to raise awareness that BRVO could be a vaccine-related thrombotic adverse event. We highlight that as more of the population is vaccinated, an increased incidence of BRVO may confirm the link to COVID-19 vaccination.

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.

Retinal vascular occlusion and SARS-CoV-2 vaccination

PURPOSE

To assess the clinical and retinal imaging features of patients in whom retinal vascular occlusion (VO) had developed in temporal associations with COVID-19 vaccination.

METHODS

In this retrospective case series, all consecutive adult patients with new onset VO within 6 weeks of vaccination against COVID-19 were included in the study between May 1 and October 31, 2021. All patients had a systemic medical health assessment, full ophthalmic evaluation, and complete fundus imaging.

RESULTS

Fifteen eyes of VO (14 patients) after COVID-19 vaccinations were identified. The median time between vaccination and symptoms onset was 14 days (range 7-42 days). The mean best-corrected visual acuity (BCVA) was 20/55 with a range of 20/20 to 20/200. Eleven of 15 eyes (73.3%) had visual acuity improvement after intravitreal treatment at 60-90 days (range, 45-105 days) from the presentation. Four of 5 cases without systemic risk factors for VO had a mean BCVA > 20/32 at presentation and > 20/25 at the latest evaluation. Between May 1 and October 31, 2021, a temporal association was found between the 15 reported cases and COVID-19 vaccination out of a total of 29 VO (p = 0.05). The incidence of VO was higher in the considered period compared to the equivalent 6-month period in 2019 (1.17% vs 0.52%, respectively; p = 0.0134).

CONCLUSIONS

Retinal vascular occlusion with different grades of severity are reported in temporal association with COVID-19 vaccination. The exact pathogenic mechanism needs to be further studied. No certain causal relationship can be established from this case series.

Case Report: Recanalization of Branch Retinal Artery Occlusion Due to Microthrombi Following the First Dose of SARS-CoV-2 mRNA Vaccination

Background: We report on a patient with a branch retinal artery occlusion (RAO) and its recanalization based on multimodal retinal and angiographic images after he was administered the first dose of the SARS-CoV-2 mRNA vaccine.

Case summary: A 64-year-old man complained of a right, painless, inferior field defect 3 days after the first dose of BNT162b2 vaccination. Fundus examination revealed decolorization of the right upper macula, including microthrombi in the superior proximal branch of the retinal artery. Optical coherence tomography angiography revealed upper macular hypoperfusion. Fluorescein angiography revealed prolonged arteriovenous transit to the macula. After paracentesis with antiplatelet medications, the artery was recanalized as the thrombi dissolved, and the right visual field was recovered. Re-occlusion did not occur during the 3 months after the second mRNA vaccination.

Conclusion: Non-embolic thrombotic RAO may develop shortly after the SARS-CoV-2 mRNA vaccine. Ophthalmologists should consider RAO as a possible post-vaccination adverse event. The temporal association between mRNA vaccination and RAO onset with evidence of microthrombi might provide additional clues to elucidate the unpredictive arterial thrombosis following SARS-CoV-2 mRNA vaccination.

Retinal Hemorrhage after SARS-CoV-2 Vaccination

To report retinal vein occlusion (RVO) and age-related macular degeneration (AMD)-related submacular hemorrhage developing after administration of SARS-CoV-2 vaccines, a single-center, retrospective observational case series was conducted. Clinical data including fundus photographs and optical coherence tomography (OCT) scans were reviewed. Twenty-three eyes of 21 patients were included with the median age at symptom presentation being 77 years (range: 51-85 years). Twelve eyes (52.2%) had submacular hemorrhage and 11 (47.8%) had RVO. Twelve patients (60.9%) had been vaccinated with the Pfizer vaccine (BNT162b2) and 8 with the AstraZeneca (ChAdOx1) vaccine. Sixteen patients (76.2%) experienced ocular disease exacerbation after the first vaccination and 4 (19.0%) after the second vaccination. The median visual acuity (logarithm of the minimal angle of resolution; logMAR) before symptom development was 0.76 (interquartile range: 0.27-1.23); the median logMAR at symptom presentation was 1.40 (interquartile range 0.52-1.70). The median time between vaccination and symptom exacerbation was 2.0 days (interquartile range: 1.0-3.0 days). Five patients (23.8%) underwent tests for hematological abnormalities, including the presence of anti-PF4 antibodies; all were negative. Further studies with larger patient group for evaluation of effect of SARS-CoV-2 vaccination on retinal hemorrhage are necessary.