Shot in the dark

Abstract

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.

Keywords: COVID-19; SARS-CoV-2; adverse event; autoimmunity; optic neuritis; vaccine.

Fig 1

Optic disc photographs and optical coherence tomography at presentation. (A) Fundus photographs showing normal appearing optic discs in both eyes. (B) Peripapillary retinal nerve fiber layer thickness printout (132 µ right eye and 123 µ left eye).

Fig 2

Axial, T1 weighted, post contrast, fat suppressed magnetic resonance image demonstrating bilateral optic nerve sheath enhancement (arrows).

Fig 3

Optical coherence tomography and automated visual field testing 2 months after presentation (A) Peripapillary retinal nerve fiber layer thickness printout (69 µ right eye and 74 µ left eye). (B) Bilateral inferior visual field defects more pronounced in the right eye.

Fig 4

Optic disc photographs, optical coherence tomography and formal perimetry approximately 16 months after presentation. (A) Fundus photographs showing diffuse bilateral optic disc pallor. (B) Peripapillary retinal nerve fiber layer thickness printout (48 µ right eye and 53 µ left eye). (C) Static perimetry showing bilateral inferior visual field defects, right eye slightly worse compared to left eye.