Vision-Threatening Ocular Adverse Events after Vaccination against Coronavirus Disease 2019

Abstract

A single-center retrospective observational case series was conducted. This case series enrolled patients who showed ophthalmic manifestations within one week after COVID-19 vaccination at Korea University Guro Hospital in Seoul, Korea, from May 2021 to January 2022. The medical records of patients who complained of ocular symptoms and showed ophthalmic adverse events within one week after COVID-19 vaccination were reviewed. Seventeen eyes from 16 patients with a mean age of 63.8 (range 33-83) years were included in the case series, and all symptoms developed within 1-7 days following inoculation. Retinal vein occlusion in nine eyes (52.9%), retinal artery occlusion in one eye (5.9%), newly developed anterior uveitis in one eye (5.9%), exacerbation of previously diagnosed panuveitis in two eyes (11.8%), and angle-closure attack with high intraocular pressure in four eyes (23.5%) were included. Twelve patients (75%) had been vaccinated with the AstraZeneca (AZD1222) and four (25%) with the Pfizer (BNT162b2) vaccines. Of these, 10 patients (62.5%) experienced ocular disease exacerbation after the first dose, 4 (25%) after the second dose, and 2 (12.5%) after the third dose (booster shot). Eleven patients (64.7%) underwent tests for hematological abnormalities, and three of them tested positive for anti-PF4 antibodies, but no abnormal findings were noted. A causal relationship between vaccination and the ocular manifestations could not be determined, which is a limitation of this study. However, clinicians should consider the effect of COVID-19 vaccination on ophthalmic disease. Further studies are required to elucidate the possible effects of COVID-19 vaccination on the eye.

Keywords: COVID-2019; SARS-CoV-2; angle-closure glaucoma; ocular adverse events; uveitis; vaccination; vascular occlusions.

Figure 1

(A) (Patient 1) A 64-year-old man, who had no previously diagnosed disease, visited our clinic complaining of reduced visual acuity (VA) in the right eye one day after AZD1222 inoculation. (Left) Severe vessel tortuosity with scattered blot retinal hemorrhage was observed during a fundus examination of the right eye. (Right upper) Early phase (arterial phase) delay and arterio-venous transit time were found during fluorescein angiography, indicating central retinal vein occlusion. (Right lower) Multiple focal leaks and disc hyperemia in the late phase were also observed. (B) (Patient 4) A 63-year-old woman was diagnosed with central retinal vein occlusion in her left eye in January 2021 at our hospital and underwent pan-retinal photocoagulation of the left eye and four intravitreal anti-vascular endothelial growth-factor injections. (Left) At her last visit just before vaccination, the retinal hemorrhage in the left eye was hardly visible, vessel tortuosity was not severe, and a focal intraretinal cyst was observed on OCT images. Additionally, her VA was 20/360. (Right) The patient reported that three days after AZD1222 vaccination, her vision had deteriorated, and her visual acuity as measured at the outpatient clinic was 20/360. It was confirmed via fundus examination that the vessel tortuosity was also greatly increased, and there was macular edema present on OCT images. (C,D) (Patient 5) A 62-year-old man visited the hospital complaining that one-third of his visual field in the left eye was blurred (VA 20/63) one day after AZD1222 vaccination. (C) During fundus examination, retinal whitish ischemic changes at the superotemporal arcade were observed, and inner retinal swelling due to acute ischemia was confirmed on OCT images. (D) During the FA examination, a filling delay in the superior retinal arteries in the early phase was observed, and in the wide FA photograph, non-perfusion of the relevant area was observed in the late phase. Notably, both eyes had mild vascular leaks, suggesting vasculitis.

Figure 2

(A) (Patient 11) A 62-year-old man, previously diagnosed with panuveitis with human leukocyte antigen B51 positivity and who was taking an oral steroid and cyclosporin (Left), shows well-controlled uveitis, although vitreous opacity remains (visual acuity 20/40). (Right) The patient reported a decrease in visual acuity (VA) in the right eye one day after AZD1222 inoculation, documented as 20/100. An increase in vitreous opacity in the right eye was confirmed during fundus examination, and keratic precipitates and inflammatory cells in the anterior chamber during the slit-lamp examination were observed. (B) (Patient 12) The disease of a 79-year-old woman, who was diagnosed with panuveitis 20 years prior and undergoing follow-up, was well-controlled without topical and systemic medications (right eye VA 20/63). (Left) A relatively clear vitreous without signs of inflammation during fundus examination was observed at the last visit. (Right) The patient was inoculated with BNT162b2, and three days later, she complained of decreased VA in the right eye (20/200) and stiff pain in both eyes. During fundus examination, vitreous opacity and focal retinal infiltration were observed in her right eye.

Figure 3

(Patient 14) A 71-year-old woman with hypertension presented to the emergency department with a two-day history of pain and redness in the left eye (visual acuity 20/50). (A) An ophthalmic examination revealed a high IOP of 36 mmHg associated with shallowing of the anterior chamber peripherally in the left eye. (B) Anterior-segment OCT images show anterior bowing of the peripheral iris and closing of the iridocorneal angle in the left eye. Her axial length was 21.86 mm in the right eye and 21.84 mm in the left eye, and her spherical equivalents were −1.13 and −3.63 diopters, respectively. An acute attack of angle closure was diagnosed, and treatment with laser peripheral iridotomy was attempted but failed. The next day, phacoemulsification with goniosynechialysis was performed and her IOP dropped to 7 mmHg.

Figure 4

(Patient 17) (A) Right eye of a 64-year-old man, who had no previously diagnosed disease. He visited our clinic complaining of pain and redness in the right eye 6 days after AZD1222 inoculation. (B) His left eye shows a normal peripheral angle and no zonule laxity. His initial IOP was 34 mmHg associated with shallowing of the anterior chamber peripherally in the right eye. His bio-microscopy images show anterior bowing of the peripheral iris and ciliary swelling in the right eye than the left eye, which caused phacodonesis of the right eye and closure of the iridocorneal angle in the right eye. An acute attack of angle closure was diagnosed, treatment with laser peripheral iridotomy was attempted, and his IOP dropped to 10 mmHg.