Branch Retinal Artery Occlusions, Paracentral Acute Middle Maculopathy and Acute Macular Neuroretinopathy After COVID-19 Vaccinations

Abstract

Purpose: Potential retinal adverse events after COVID-19 vaccinations reported previously include paracentral acute middle maculopathy (PAMM), acute macular neuroretinopathy (AMN), and central serous chorioretinopathy. We report four cases of branch retinal artery occlusion (BRAO), one case of PAMM, and one case of AMN that occurred after administration of the Pfizer-BioNTech COVID-19 vaccine.

Patients and methods: We retrospectively reviewed the medical records of six patients who presented to Yame General Hospital or Oita University Hospital from July through October 2021.

Results: Four patients (2 males) presented with visual field defects associated with BRAO, one male patient with PAMM, and one female patient with AMN after receiving the Pfizer-BioNTech COVID-19 vaccine. The mean age was 59.3 years; the mean best-corrected visual acuity was 20/21. The mean time from the last vaccination to the onset of visual field defect was 22.8 days. Five patients had received two doses of the vaccine and one patient one dose. Patients' medical history included diabetes mellitus in case 2, hypertension in cases 2, 3 and 6, and Alport syndrome and end-stage renal disease in case 6 for which the patient was undergoing regular hemodialysis.

Conclusion: Although rare, retinal adverse events may occur after COVID-19 vaccinations. Further studies with a larger sample size should determine whether these retinal abnormalities are causally associated with COVID-19 vaccinations or just coincidental. Potential risks of BRAO/PAMM/AMN after COVID-19 vaccinations must be carefully weighed against the substantial benefit of COVID-19 vaccinations.

Keywords: Pfizer-BioNTech COVID-19 vaccine; acute macular neuroretinopathy; branch retinal artery occlusion; paracentral acute middle maculopathy; retinal adverse events.

Figure 1

Branch retinal artery occlusion (BRAO) after COVID-19 vaccinations. A fundus photograph of the right eye of case 1 shows superotemporal BRAO.

Figure 2

Branch retinal artery occlusion (BRAO) after COVID-19 vaccinations. A fundus photograph of the left eye of case 3 shows superotemporal BRAO.

Figure 3

Paracentral acute middle maculopathy (PAMM) after COVID-19 vaccinations. (A) A fundus photograph of the left eye of case 5 shows inferonasal parafoveal retinal whitening (arrow) consistent with PAMM. (B) A horizontal optical coherence tomography image of the left eye of case 5 demonstrates parafoveal hyperreflective band at the inner nuclear layer (between the arrows) consistent with PAMM corresponding to the area of retinal whitening seen in the fundus photograph.

Figure 4

Acute macular neuroretinopathy (AMN) after COVID-19 vaccinations. (A and B) En face optical coherence tomography angiography images of the superficial capillary plexus (A) and deep capillary plexus (B) of the left eye of case 6. (C) A horizontal optical coherence tomography image with angiographic flow (shown in red) of the left eye of case 6 shows possible flow deficits in the deep capillary plexus and hyperreflective lesions affecting the outer plexiform and outer nuclear layers with disruption of the ellipsoid zone (arrow) consistent with AMN.