Ocular Manifestations after Receiving COVID-19 Vaccine: A Systematic Review

Uveitis following COVID-19 vaccination in the pediatric population: Experience at a tertiary referral hospital

OBJECTIVE

To determine the incidence and outcomes of uveitis following coronavirus (COVID-19) vaccination in the pediatric population.

METHODS

A case series of all patients under the age of 18years diagnosed with uveitis within 28days of COVID-19 vaccination.

RESULTS

Out of 33 patients under the age of 18years who presented with uveitis from July 2021 until May 2022, eight (24.2%) developed uveitis following COVID-19 vaccination within 28days. Four had a previous history of uveitis. The mean time interval from COVID-19 vaccination to uveitis diagnosis was 14.75days. The most common anatomic diagnosis was anterior uveitis in four children, followed by panuveitis in two and posterior uveitis in two. Seven children were treated with systemic steroids/immunomodulatory agents. Improved or unaffected visual acuity was noted in all children at the final follow-up.

CONCLUSION

The pediatric population may demonstrate uveitis following COVID-19 vaccination. All children were treated successfully, and good final visual acuity was achieved.

The Review of Ophthalmic Symptoms in COVID-19

The COVID-19 pandemic caused by SARS-CoV-2 had a significant impact on the health of the global human population, affecting almost every human organ, including the organ of vision. Research focus on understanding the pathophysiology, identifying symptoms and complications of the disease. Eye-related pathologies are important foci of research due to the potential for direct impact of the virus. Ophthalmologists around the world are reporting various symptoms of eye infections and ocular pathologies associated with SARS-CoV-2. The review of ophthalmic symptoms was conducted to help physicians of various specialties recognize possible ophthalmic manifestations of this viral disease. A literature review was conducted from January 2020 to July 2023 in the PubMed, MEDLINE, Science Direct, Scopus, Scielo and Google Scholar databases. The review of the literature showed that conjunctivitis is the most common ophthalmic symptom observed during the course of COVID-19 and can occur at any stage of the disease. Changes in the eye may result from the direct effect of the virus, immune response, prothrombotic states, comorbidities, and medications used. Symptoms related to the organ of vision can be divided into: changes affecting the protective apparatus of the eye, the anterior eye segment, the posterior eye segment, neuro-ophthalmic, and orbital changes. Ocular symptoms may suggest COVID-19 infection or appear several weeks after recovery. Following COVID-19 vaccinations, a diverse range of ophthalmic symptoms was observed in various locations and at different times, mirroring the ocular symptoms experienced throughout the course of the COVID-19 illness. It is important for physicians of all specialties to be aware of possible potential connections between eye diseases and SARS-CoV-2, in order to effectively diagnose and treat patients.

Immunogenicity and Safety of Half-Dose Heterologous mRNA-1273 Booster Vaccination for Adults Primed with the CoronaVac® and ChAdOx1-S Vaccines for SARS-CoV-2

Coronavirus disease 2019 (COVID-19) has been extensively researched, particularly with regard to COVID-19 vaccines. However, issues with logistics and availability might cause delays in vaccination programs. Thus, the efficacy and safety of half-dose heterologous mRNA should be explored. This was an open-label observational study to evaluate the immunogenicity and safety of half-dose mRNA-1273 as a booster vaccine among adults aged >18 years who underwent a complete primary SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) vaccination regimen with CoronaVac® and ChAdOx1-S. Adverse events (AEs), seropositivity rate, seroconversion, geometric mean titer (GMT) of SARS-CoV-2 antibodies, neutralizing antibodies, and T cells (CD4+ and CD8+) specific for SARS-CoV-2 were analyzed. Two hundred subjects were included in the final analysis, with 100 subjects in each priming vaccine group. Most of the AEs were mild, with systemic manifestations occurring between 1 and 7 days following vaccination. A significant difference was observed in the GMT and seropositivity rate following booster dose administration between the two groups. CD8+/CD3+, IFN (interferon)-producing CD8+, and TNF (tumor necrosis factor)-producing CD8+ cells showed significant increases in both groups. The administration of the half-dose mRNA-1273 booster is safe and effective in increasing protection against SARS-CoV-2 infection.

Intrapapillary hemorrhage with adjacent peripapillary subretinal hemorrhage of both eyes after COVID-19 infection: a case report

BACKGROUND

Intrapapillary hemorrhage with adjacent peripapillary subretinal hemorrhage is commonly observed in myopia with tilted optic disc. It presents with typical features on the fundus and follows a self-limiting course. However, due to its complex etiology, clinicians sometimes lack sufficient understanding of it which can easily lead to misdiagnosis or overtreatment. In this case report, we describe a rare case of intrapapillary hemorrhage with adjacent peripapillary subretinal hemorrhage in both eyes.

CASE PRESENTATION

An 18-year-old female who has no past medical history experienced sudden black shadow blocking of her right eye in the right eye for the past 2 days after a 5-day history of COVID-19 infection. The best corrected visual acuity is 0.5 in the right eye and 0.6 in the left eye. Optical coherence tomography (OCT) showed tilted optic discs in both eyes, bulged nasal optic discs, and the presence of strong reflective material under the parafoveal retina of the optic discs. Fundus fluorescein angiography (FFA) showed subretinal fluorescence occlusion above and nasolateral to the optic disc in the right eye, with hypofluorescence below the optic disc; the subretinal below the optic disc was obscured by vitreous hemorrhage; hypofluorescence was seen in the optic disc region of the left eye.COVID-19 antigen was positive. The patient was in the early stage of the third COVID-19 infection when the disease occurred. We speculate that it may be related to it. After 5 months of conservative treatment, the patient's hemorrhage disappeared in both eyes and her best corrected visual acuity returned to normal.

CONCLUSIONS

Intrapapillary hemorrhage with adjacent peripapillary subretinal hemorrhage usually occurs in myopia with tilted optic disc. In most patients, the cause of the bleeding is unknown, but it can gradually resolve under clinical observation or conservative treatment.

Acute abdomen following COVID-19 vaccination: a systematic review

Purpose

Conduct a systematic review of case reports and case series regarding the development of acute abdomen following coronavirus disease 2019 (COVID-19) vaccination, to describe the possible association and the clinical and demographic characteristics in detail.

Materials and Methods

This study included case report studies and case series that focused on the development of acute abdomen following COVID-19 vaccination. Systematic review studies, literature, letters to the editor, brief comments, and so forth were excluded. PubMed, Scopus, EMBASE, and Web of Science databases were searched until June 15, 2023. The Joanna Briggs Institute tool was used to assess the risk of bias and the quality of the study. Descriptive data were presented as frequency, median, mean, and standard deviation.

Results

Seventeen clinical case studies were identified, evaluating 17 patients with acute abdomen associated with COVID-19 vaccination, which included acute appendicitis (n=3), acute pancreatitis (n=9), diverticulitis (n=1), cholecystitis (n=2), and colitis (n=2). The COVID-19 vaccine most commonly linked to acute abdomen was Pfizer-BioNTech (messenger RNA), accounting for 64.71% of cases. Acute abdomen predominantly occurred after the first vaccine dose (52.94%). All patients responded objectively to medical (88.34%) and surgical (11.76%) treatment and were discharged within a few weeks. No cases of death were reported.

Conclusion

Acute abdomen is a rare complication of great interest in the medical and surgical practice of COVID-19 vaccination. Our study is based on a small sample of patients; therefore, it is recommended to conduct future observational studies to fully elucidate the underlying mechanisms of this association.

COVID-19 vaccination and corneal allograft rejection- a review

Aim

To provide a comprehensive literature review on the perceived correlation between COVID-19 vaccination and corneal allograft rejection, and to characterize risk factors, time course, graft outcomes and proposed immunological basis.

Methods

A literature review was conducted in August 2023 using 4 electronic databases: PubMed, EMBASE, MEDLINE and Scopus. Articles were sourced using key words associated with COVID-19 vaccination and corneal graft. All articles were screened for relevance by abstract review. Duplicates and articles related to COVID-19 infection were excluded. No time limits were set. Additional literature searches regarding cause of corneal graft rejection, rates of graft rejection associated with other vaccines and the cellular mechanism of rejection were also performed.

Results

262 articles were identified from the literature search. 37 papers were included in the analysis based on defined inclusion criteria. This consisted of systematic reviews (n=6), review articles (n=5), retrospective studies (n=3), case series (n=8), letter to the editor (n=1) and case reports (n= 14). The majority of reported allograft rejections were in penetrating keratoplasties. Risk factors for COVID-19 vaccination associated rejection were previous allograft rejection episodes, repeat grafts and penetrating keratoplasty. Most reported rejection episodes were mild and resolved with treatment. Notably, several studies reported nil increase in corneal allograft rejection episodes over the COVID-19 vaccination period. Rejection episodes are associated with a broad spectrum of other vaccines and the complete pathophysiology is undetermined.

Conclusion

Corneal allograft rejection appears to be a rare complication of COVID-19 vaccination most frequently observed in high-risk corneal transplants. The true extent of this correlation remains controversial; however, clinician awareness of this risk is essential to its mitigation. Patient counselling around symptom monitoring following vaccination and discussion around topical steroid prophylaxis may be prudent.

COVID and COVID vaccine-related corneal morbidity: A review

Systemic coronavirus disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus has had several ocular consequences. Many vaccines have been developed against the disease, with adverse events being reported as well. Various ocular adverse events secondary to coronavirus disease 2019 (COVID-19) vaccines have also featured in literature in recent times. This review features the reported corneal-related effects of COVID infection and vaccination. These include direct effects on corneal grafts and unilateral or bilateral corneal melts. The compilation of reported experiences from across the world in this systematic review will help clinicians recognize the possible presentations, pathogenesis, and management of the same.

Considerations of COVID-19 in Ophthalmology

Since its emergence in early 2020, the SARS-CoV-2 infection has had a significant impact on the entire eye care system. Ophthalmologists have been categorized as a high-risk group for contracting the virus due to the belief that the eye may be a site of inoculation and transmission of the SARS-CoV-2 infection. As a result, clinical ophthalmologists, optometrists, and eyecare professionals have had to familiarize themselves with the ocular manifestations of COVID-19, as well as its treatments and vaccines. The implementation of measures to prevent the transmission of the virus, such as restrictions, lockdowns, telemedicine, and artificial intelligence (AI), have led to substantial and potentially irreversible changes in routine clinical practice, education, and research. This has resulted in the emergence of a new mode of managing patients in a routine clinical setting. This brief review aims to provide an overview of various aspects of COVID-19 in ophthalmology, including the ocular manifestations related to the disease, the modes of transmission of SARS-CoV-2 infection, precautions taken in ophthalmic practice to prevent the spread of the virus, drugs, and vaccines used in the treatment of COVID-19, the impact of the pandemic on patients, clinicians, and the eye care system as a whole, and the future of ophthalmology conditioned by this global pandemic experience.

Acute Uveitis Following AstraZeneca COVID-19 Vaccination

PURPOSE

To report a case of bilateral acute uveitis following the first and subsequent doses of Oxford-AstraZeneca COVID-19 vaccination.

METHOD

A case report.

RESULTS

A 74-year-old Caucasian woman was presented with a one-day history of blurred vision, pain, photophobia, and redness in both eyes after receiving her first dose of the Oxford-AstraZeneca COVID-19 vaccine. Clinical evaluation confirmed bilateral anterior and intermediate uveitis six days later. Targeted diagnostic testing excluded infectious or autoimmune etiologies. After treatment with topical and oral corticosteroids, the patient had a resolution of symptoms with the recovery of visual function within seven weeks. Subsequently, she developed a recurrence of uveitis following the second dose of the Oxford-AstraZeneca COVID-19 vaccine, which required similar treatment, with slower tapering of corticosteroids over ten weeks. The patient had a full visual recovery.

CONCLUSION

Our case highlights the possibility of uveitis as an ocular complication of Oxford-AstraZeneca COVID-19 vaccination.

A Case of Neuroretinitis Following COVID-19 Vaccination

PURPOSE

To present a case of neuroretinitis following an mRNA COVID-19 vaccination.

CASE REPORT

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.

CONCLUSIONS

This is the first report of unilateral neuroretinitis following COVID-19 vaccination, implying a potential association between the mRNA vaccine and neuroretinitis.

Macular optical coherence tomography angiography analysis in diabetes mellitus patients with a history of Covid-19

PURPOSE

There is evidence of decreased vessel density in optical coherence tomography angiography (OCTA) after Covid-19. We aimed to investigate whether the outcome of retinal vasculopathy would be worse if patients with diabetes mellitus (DM) were infected with coronavirus using OCTA to assess retinal vessels.

METHODS

One eye of each subject was included in the study. Diabetic patients without retinopathy and non-diabetic controls were divided into four groups according to their Covid-19 history: group 1=DM(-)Covid-19(-); group 2=DM(+)Covid-19(-); group 3=DM(-)Covid-19(+); and group 4=DM(+)Covid-19(+). All Covid-19 patients were not hospitalised. Macular OCTA scans were performed in a 6 × 6 mm area.

RESULTS

Diabetes had no effect on the area of the foveal avascular zone (FAZ), but Covid-19 caused an increase in FAZ area. Diabetes and Covid-19 had an effect on both the superficial capillary plexus (SCP) and the deep capillary plexus (DCP) in the fovea. Eta squared (ƞ2) is a measure of effect size. The effect size of Covid-19 (ƞ2=0.180) was found to be greater than that of diabetes (ƞ2=0.158) on the SCP, whereas the effect size of diabetes (ƞ2=0.159) was found to be greater than that of Covid-19 (ƞ2=0.091) on the DCP.

CONCLUSIONS

The percentage of vessel density was lower in the fovea and the FAZ area was enlarged in the diabetic patients who recovered from Covid-19. In diabetic patients Covid-19 may lead to deterioration of vascular metrics.

New Onset or Deterioration of Thyroid Eye Disease After mRNA SARS-CoV-2 Vaccines: Report of 2 Cases and Literature Review

CONTEXT

Occurrence of Graves' disease (GD) has been reported following SARS-CoV-2 vaccine administration, but little is known about thyroid eye disease (TED) after SARS-CoV-2 vaccination.

OBJECTIVE

We describe 2 cases of TED activation following mRNA SARS-CoV-2 vaccination and review additional cases reported in the literature.

METHODS

We report 2 cases of TED activation following SARS-CoV-2 vaccination: 1 case of TED worsening in a patient with GD, and 1 of de novo active TED progressing to dysthyroid optic neuropathy in a patient with a history of Hashimoto hypothyroidism. Our literature search revealed 8 additional reported TED cases associated with SARS-CoV-2 vaccination until June 2022. We review the characteristics, duration, and management of TED following SARS-CoV-2 vaccination in these cases.

RESULTS

Of all 10 reported TED cases following SARS-CoV-2 vaccination, 4 developed new-onset TED and 6 previously stable TED cases experienced significant deterioration. Six patients had known GD and 2 patients had Hashimoto thyroiditis. Two cases progressed to dysthyroid optic neuropathy, 6 had moderate/severe active disease, and 2 had mild disease that did not require treatment. Seven TED cases received teprotumumab and had a favorable response, 2 of whom had prior limited response to initial prednisone or methylprednisolone and tocilizumab therapy.

CONCLUSION

New diagnosis or deterioration of TED after mRNA SARS-CoV-2 vaccination can occur, with most cases described in patients with underlying autoimmune thyroid disease. Our report raises awareness to this potential complication to promote early recognition and prompt management of TED associated with mRNA SARS-CoV-2 vaccines. Further studies are needed to explore the mechanism, risk factors, prevention, and treatment of TED following mRNA SARS-CoV-2 vaccination.

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.

Posner-Schlossman syndrome relapse following inactivated COVID-19 vaccination in China

Introduction

This retrospective study aims to present the characteristics of Posner-Schlossman syndrome (PSS) relapse following inactivated COVID-19 vaccination.

Methods

From 2020 to 2022, 12 out of 106 PSS patients undergoing relapses after any dose of inactivated COVID-19 vaccines were enrolled. Medical histories, information on the vaccination and systemic adverse events were collected. Patients were treated with corticosteroids, intraocular pressure (IOP)-lowering drugs and systemic immunosuppressive agents (if needed). Daily regimen and release course were noted.

Results

The recurrence rate after vaccination was 11.32% (12/106, 95% CI: 5.29%-17.35%) among 106 PSS patients we surveyed. All the 12 patients were inoculated with inactivated COVID-19 vaccines developed by Sinopharm, China. The mean time of relapse was 5.27 ± 3.72 days (range: 1-13 days, median: 4 days). Higher IOP and more keratic precipitates (KPs) were seen in the relapse following vaccination (33.55 ± 12.99 mmHg, 91.67% had KPs compared to 25.38 ± 3.80 mmHg, 33.33% had KPs in previous relapse, P = 0.009). The mean release course was 30.71 ± 34.74 days for the relapse following vaccination and 7.33 ± 6.51 days for previous relapses. The attack frequency before and after vaccination was 3.56 ± 2.07 and 9.11 ± 7.34 times per year (P = 0.044). Higher daily doses of corticosteroids, IOP-lowering drugs and ganciclovir were needed to maintain stable course, though the difference did not reach statistical significance.

Discussion

More frequent relapses and harder control of IOP were found in PSS relapse following COVID-19 vaccination. Ophthalmologists need to be aware of the group vulnerability and take precautions, though the pathogenesis is still under investigation.

Covid-19 and its relation to the human eye: transmission, infection, and ocular manifestations

BACKGROUND

The world is suffering from a new strain of the coronavirus family-Covid-19. This virus strain affected different organs in the human body with a wide range of mild symptoms and moderate signs to severe and deadly ones. Multiple organs can be infected, and one of these organs is the eye. The eye is a vital organ that consists of vascular tissues and is connected to the respiratory tract through the tears and the nasolacrimal duct.

METHODS

Recent papers and research from PubMed, Researchgate, and Google Scholar were cited and thoroughly discussed. These papers were chosen based on their relevancy, reliability, publication year, published journal, and ease of accessibility to the paper itself.

RESULTS

The theory concluded that the ocular surface might consider a pathway for the virus attack and infection causation through the tears and the angiotensin-converting enzyme 2 located in the eye. This article thoroughly reviewed the history, the existing aspects of Covid-19, the ocular system features, and the claims about the possible involvement of the eye in the virus transmission along with the eye infection. There was no consensus on the eye's involvement theory.

CONCLUSION

The authors highlighted the extra work and research needed to be conducted to prove or deny these claims to provide a better understanding of the immune response of the eye to Covid-19 infection.

Optic disc hemorrhage in a young female following mRNA coronavirus disease 2019 vaccination: a case report

BACKGROUND

Since the development of the coronavirus disease 2019 vaccine, there have been many reports of its adverse effects. While respiratory symptoms are common, many other symptoms in various organs have been reported. Herein, we report a case of optic disc and retinal hemorrhage that developed immediately after coronavirus disease 2019 vaccination.

CASE PRESENTATION

A healthy 18-year-old Japanese female noticed floater in the left eye 1 day after the second vaccination for coronavirus disease 2019 (Pfizer Inc.). Her visual acuity was 20/20 in the left eye, and Goldmann visual field test showed a relative scotoma around blind spot and in the temporal lower quadrant. It was considered due to subretinal hemorrhage and optic disc swelling. Fundus examination revealed retinal and optic disc hemorrhage. Pupillary reflex was intact and central critical flicker was not impaired, indicating that optic nerve was not involved. There was no sign of inflammation, vascular abnormality, nor history of an intense Valsalva maneuver. The hemorrhage resolved spontaneously within 5 months.

CONCLUSION

This case expands the clinical presentation of coronavirus disease 2019 vaccination-associated ocular adverse events, and it should be kept in mind when patients with similar symptoms visit clinics. The case report will help clinicians avoid unnecessary and invasive examinations and treatment.

Bilateral choroidal effusion following vaccination against SARS-CoV-2 virus

An 80-year-old systemically stable female presented with sudden blurring of vision post the first dose of Covishield^TM, a non-replicating viral vector vaccine. On examination, she was found to have bilateral serous choroidal effusions. A thorough systemic and ocular workup was performed to rule out other causes of choroidal effusion. The effusions resolved with tapering doses of oral and systemic steroids. To the best of our knowledge, at the time of submission, this is the first case of choroidal effusion being reported after the coronavirus disease 2019 (COVID-19) vaccine.

Corneal Complications after COVID-19 Vaccination: A Systemic Review

Multiple vaccines are now being used across the world, and several studies have described cases of corneal graft rejection following the administration of the COVID-19 vaccine. The purpose of this article is to review the corneal adverse event that occurred following COVID-19 vaccine administration. The literature search was conducted in March 2022 using MEDLINE, PubMed, and the Cochrane Database of Systematic Reviews. A total of 27 articles, including 37 cases, have documented corneal adverse events that occurred following COVID-19 vaccination. The mean age was 60 ± 14.9 years (range, 27-83 years). The most common events were acute corneal graft rejection (n = 21, 56.8%), followed by herpes zoster ophthalmicus (n = 11, 29.7%) and herpes simplex keratitis (n = 2, 5.4%). The mean time from vaccination to the event was 10 ± 8.5 days (range, 1-42 days) after the first or second dose of vaccine. All patients with corneal graft rejection, immune-mediated keratolysis, and peripheral ulcerative keratitis (PUK) (n = 24, 64.9%) were managed topically with or without oral corticosteroids. Patients with herpes zoster ophthalmicus and herpes simplex keratitis were managed with oral antiviral agents. Two patients received penetrating keratoplasty due to keratolysis after invalid topical treatment. Disease resolution was noted in 29 patients (78.3%), whereas 3 (8.1%) had persistent corneal edema after graft rejection, 1 (2.7%) had corneal infiltration after HZO, and 4 (10.8%) were not mentioned in the articles. Corneal adverse events could occur after COVID-19 vaccination. After timely treatment with steroids or antiviral agents, most of the events were mild and had a good visual outcome. Administrating or increasing steroids before vaccination may be useful for the prevention of corneal graft rejection. However, the prophylactic use of antiviral treatments in patients with a herpes viral infection history is not recommend.

A Curious Case of Occlusive Retinal Vasculitis in a Young Individual Associated with COVID-19 Vaccination

A 23-year-old man presented with the blurring of vision in the left eye for 4 days. Best-corrected visual acuity was 6/6 N6 in both eyes. Examination revealed an unremarkable right eye while the left eye showed occlusive retinal vasculitis with no retinitis, choroiditis, or macular involvement. Fundus fluorescein angiography confirmed the same. History revealed the patient had received 2nd dose of Covishield vaccination 4 weeks before the onset of symptoms. Blood investigations were negative for infectious or any systemic autoimmune disease. Serum homocysteine and serum CMV IgG levels were grossly increased while tests for antiphospholipid syndrome were weakly positive. He responded well to a combination of intravitreal and oral antivirals, oral steroids for vasculitis and tablets Clopilet and Homin. This case is extremely intriguing in terms of the involvement of the adenoviral vector vaccine either as a causative factor or being just a coincidental finding.

Ocular effects caused by viral infections and corresponding vaccines: An overview of varicella zoster virus, measles virus, influenza viruses, hepatitis B virus, and SARS-CoV-2

Many viral infections can affect vision and the visual system. Vaccination to prevent diseases is commonplace today, acting by stimulating an immune response without developing the pathology. It involves the production of persisting antibodies against the pathogen and the activation of T cells. Certain diseases have already been eradicated by rigorous vaccination campaigns, while others are hoped to be eliminated soon. Vaccines currently available on the market are largely safe, even if they can rarely cause some adverse effects, such as ocular complications. Analyzing existing literature, we aimed to compare the pathological effects on the eye due to the most common viral infections [in particular varicella zoster virus (VZV), measles virus, influenza viruses, hepatitis B virus, and SARS-CoV-2] with the possible ocular adverse effects of their relative vaccines, in order to establish a risk-benefit relationship from an ophthalmological point of view.

Herpetic endotheliitis and stromal keratitis following inactivated COVID-19 vaccination

Given the scarcity of data regarding ocular complications following COVID-19 vaccination, the approach toward patients with suggestive symptoms and established clinical practice is lacking. Herein, we report the first case of herpetic endotheliithis and secondary stromal keratitis following inactivated COVID-19 vaccination who experienced a relapse due to poor adherence.

Ocular manifestations of recent viral pandemics: A literature review

Viral pandemics often take the world by storm, urging the medical community to prioritize the most evident systemic manifestations, often causing ocular manifestations to go unnoticed. This literature review highlights the ocular complications of the Monkeypox, SARS-CoV-2, MERS, Ebola, H1N1, and Zika viruses as the most recent viral pandemics. Research into the effects of these pandemics began immediately. Moreover, it also discusses the ocular complications of the vaccines and treatments that were used in the scope of the viral pandemics. Additionally, this review discusses the role of the eye as an important route of viral transmission, and thereafter, the International recommendations to reduce the incidence of viral transmission were mentioned. Lastly, this paper wants to lay out a platform for researchers who want to learn more about how viruses show up in the eye.

Shot in the Dark

A 43-year-old woman presented with decreased vision in the right eye associated with painful eye movements 10 days after receiving her first dose of Pfizer-BioNTech coronavirus disease 2019 (COVID-19) vaccine (Pfizer Inc, New York, NY). Two days later she developed painful loss of vision in the left eye. Clinical presentation and magnetic resonance imaging findings were consistent with bilateral optic perineuritis transitioning to optic neuritis. Extensive evaluation including aquaporin-4 immunoglobin G (IgG), myelin oligodendrocyte glycoprotein IgG, and lumbar puncture was unrevealing. Visual acuity at nadir was counting fingers in both eyes, but after receiving intravenous steroids and plasma exchange vision eventually improved to 20/20 in each eye, although she was left with inferior visual field defects and bilateral optic disc pallor. This case highlights the diagnostic challenge in the evaluation of atypical optic neuritis with a review of post-COVID-19 vaccination-associated optic neuritis.

Ocular inflammatory manifestations following COVID-19 vaccinations in Taiwan: A case series

As a continuing demand for booster shots against SARS-CoV-2, ocular adverse events following the coronavirus disease-2019 (COVID-19) vaccines can cause significant visual impairment, and they warrant a high awareness and detailed documentation of possible ocular inflammatory manifestations. We present a case series of 11 patients presenting with ocular manifestations relevant to vaccine-associated autoimmune response within 6 weeks after the vaccination of the Oxford-AstraZeneca, the Moderna, and Pfizer-BioNTech vaccines at the main tertiary referral center in the most populated and most vaccinated city in Taiwan. Their diagnosis included five acute anterior uveitis, two multiple evanescent white dot syndrome, one probable Vogt-Koyanagi-Harada disease, one anterior scleritis, one relapsed idiopathic panuveitis, and one autoantibody-related central retinal artery occlusion. This report presented a broad spectrum of the ocular inflammatory events following the vaccination of COVID-19. Early recognition of the clinical manifestations mentioned herein with prompt management is crucial in recovering the patients' vision.

Possible Association between Vogt-Koyanagi-Harada Disease and Coronavirus Disease Vaccine: A Report of Four Cases

Vogt-Koyanagi-Harada (VKH) syndrome is an autoimmune, multisystemic disease characterized by severe bilateral granulomatous posterior, which can occur due to viral infection or vaccination. We report four cases that had a likely association between VKH disease and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. Two patients had VKH symptoms within 1 and 2 weeks after receiving the ChAdOx1 nCoV-19 vaccine. One patient presented with VKH symptoms 5 days after receiving the BNT162b2 vaccine, and one patient had symptoms within 4 weeks after receiving the CoronaVac vaccine. Early diagnosis and treatment of VKH disease are essential for the visual prognosis of this aggressive disease. Further in-depth studies are necessary to investigate this likely association to enable ophthalmologists to identify new assumed correlations between the diseases described in this study.

Acute corneal allograft rejection following SARS-CoV-2 vaccination-A systematic review

All documented cases of acute corneal allograft rejection following SARS-CoV-2 vaccination were examined, to characterize possible risk factors and graft outcomes. Comprehensive search (4 electronic databases: PubMed, CENTRAL, ClinicalTrials.gov, Google Scholar, plus manual search in articles' reference lists) until March 1st 2022 to identify studies reporting acute corneal allograft rejection following SARS-CoV-2 vaccination; study protocol was developed in line with PRISMA statement. We analysed demographics, allograft type, rejection prophylaxis regime at the time of vaccination, transplantation-to-vaccination time (G-Vt), vaccination-to-immune reaction onset time (V-Rt), management, best-corrected visual acuity before and after rejection, and graft survival. Of 169 titles/abstracts screened, 16 studies (n  = 36 eyes) met the inclusion criteria. Fourteen eyes (38.9%) had received >1 graft, and 11.1% of cases had history of immune reactions; 52.9% of cases occurred after the first dose. Median (P25-P75) G-Vt was 48 (10-78) months; median V-Rt was 9 (7-14) days. In eyes with resolved rejection, median time-to-resolution was 3 (1-4) weeks. Four eyes (11.1%) had partial resolution of corneal decompensation, and 5 grafts (13.9%) failed. Acute corneal allograft rejection after SARS-CoV-2 vaccination is a rare event, but may occur any time post-keratoplasty. Early recognition and prompt, aggressive treatment is warranted to optimize vision and graft survival. Well-known risk factors for rejection may be confounding factors, including the high proportion of cases with a history of previous grafts and the rejection prophylaxis regimes at the time of vaccination. Increasing immunosuppressants in the peri-vaccination period may decrease the risk of immune reactions, especially in high-risk cases.

Impact of vaccination on keratoplasty

PURPOSE OF REVIEW

Corneal graft rejection has been reported after coronavirus disease 2019 (COVID-19) vaccination. The purpose of this review is to evaluate the literature regarding corneal graft rejection after vaccination, including rejection rates and risk factors. We aim to create a framework to identify patients who are at higher risk for graft rejection and may warrant consideration of prophylactic interventions.

RECENT FINDINGS

Graft rejection has been reported following administration of mRNA, viral vector, and inactivated whole-virion COVID-19 vaccines. Most cases had additional risk factors associated with rejection. Vaccination increases circulation of proinflammatory cytokines, CD4+ and CD8+ T-cell responses, and antispike neutralizing antibody, all of which may contribute to graft rejection. Two prospective studies have found no relationship between recent vaccination and rejection but 20% of cornea specialists report to have seen a vaccine-associated rejection and 22% recommend delaying vaccination in certain circumstances. Many specialists recommend prophylactic topical corticosteroids before and after vaccination to mitigate rejection risk but there is no evidence to support this practice on a wider scale.

SUMMARY

Our framework identified 96.8% of penetrating keratoplasty patients with vaccine-associated rejection as higher risk. Further research is needed in order to develop evidence-based guidelines.

Case Report: Acute Posterior Multifocal Placoid Pigment Epitheliopathy after SARS-CoV-2 Vaccination

SIGNIFICANCE

Acute posterior multifocal placoid pigment epitheliopathy is an uncommon inflammatory chorioretinopathy that has been reported after vaccination. This is the first reported case, to our knowledge, after vaccination for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in a healthy adolescent boy.

PURPOSE

This report aimed to inform the eye care community about a possible ocular sequela of SARS-CoV-2 vaccination.

CASE REPORT

A 17-year-old boy presented to a clinic for a second opinion after sudden-onset blind spots in his right eye. His medical history was remarkable for receiving the first dose of the Pfizer-BioNTech SARS-CoV-2 vaccine 2 weeks before symptom onset. He had no history of ocular inflammation, autoimmune disease, or systemic infection. A diagnosis of unilateral acute posterior multifocal placoid pigment epitheliopathy was made based on the presence of typical fundus lesions and noninvasive imaging with fundus autofluorescence, retinal optical coherence tomography, and optical coherence tomography angiography. The diagnosis was further confirmed with fluorescein angiography. The patient developed an anterior vitritis in the right eye 42 days after initial symptom onset. His unilateral intraocular inflammation resolved after a 5-week course of prednisone.

CONCLUSIONS

Acute posterior multifocal placoid pigment epitheliopathy is a self-limited inflammatory condition of the outer retina that usually affects young adults and often does not require treatment. It has been reported to occur after vaccination for influenza, polio, hepatitis B, meningococcus C, and varicella zoster virus. This is the first known case to occur after SARS-CoV-2 vaccination in a healthy adolescent boy.

COVID-19 Vaccines in Inherited Retinal Degenerations (IRD), Fears, Ideas and Real Interactions

Purpose

In the COVID-19 pandemic era, vaccines are one of the most efficient weapons, as well established by WHO, that humans have, in all their variants (mRNA, AAV or others). Unfortunately, in western nations skepticism within different groups has been generated by the fast approval processes, driven by the urgent need to confront the rapid increase of hospitalized patients and number of deaths by regulation authorities as FDA and EMA. Moreover, several scientific and non-scientific perplexity, also amplified by the media, created hard no-vax strategies, that lead many patients to refuse vaccine administration. Also in this selected population higher rate of COVID-19 infections and severe diseases are registered and consequently there was an increase of death number. Furthermore, to avoid vaccine shots, people frequently ask exemption querying ophthalmological and systemic diseases, in this situation most patients affected with orphan ophthalmological conditions as inherited retinal degenerations have profound fears and doubt. The goal of our study was to ascertain if these fears are based on real facts and if there are interactions or severe visual impairment after each shot of vaccinations.

Methods

Five hundred randomically selected patients affected by IRD at each patient was asked anonymously, number of vaccine administrations and eventually reported side effects.

Results

Of 500 selected patients 61 (12,2%) did not underwent to Covid-19 vaccination, reasons were various (fear, laziness, caregiver unavailability etc.). Remaining 439 patients (87,8%) had first shot of vaccine. Only 30% of patients complained side effects of vaccine, none of them was serious.

Conclusion

The number of patients is wide enough to draw some considerations: In IRD vaccination is safe, in all doses ocular side effects were reported only in one third of subjects and this is not different from the percentage shown by normal people, COVID-19 effects may be more dangerous than vaccine.

Susac Syndrome Following COVID-19 Vaccination: A Case Report

Due to the COVID-19 pandemic, numerous vaccines have been developed for the disease. However, with large-scale vaccination has come the gradual emergence of immunological phenomena caused by these new vaccines. Herein, we report a 48-year-old female with a sudden onset of inferior visual field defects in the left eye following her first dose of the ChAdOx1 vaccine. Dilated fundus examination combined with optical coherence tomography and fluorescein angiography confirmed the diagnosis of branch retinal artery occlusion. Within 4 weeks following vaccination, symptoms associated with hearing impairment developed, and magnetic resonance imaging revealed leptomeningeal enhancement. The diagnosis of Susac syndrome (SS) was confirmed. The development of SS may be caused by endotheliopathy resulting from the molecular mimicry of the ChAdOx1 vaccine. Clinicians should be aware of the symptoms of SS, which may develop after COVID-19 vaccination. Further experimental surveillance and case–control studies are required to confirm this relationship.