Posterior ocular manifestations following BNT162b2 mRNA COVID-19 vaccine: a case series

Abstract

Purpose: To report the occurrence of posterior ocular adverse events following the administration of the BNT162b2 mRNA vaccine against SARS-CoV-2.

Methods: A retrospective consecutive case series, in which the medical files of patients presenting with ocular adverse events within 30 days of the vaccine inoculation, were analyzed.

Results: Four patients (2 females) were included in the study. The diagnoses included: posterior scleritis, paracentral acute middle maculopathy, herpes panuveitis, and Vogt-Koyanagi-Harada (VKH)-like uveitis. Three of the patients had no relevant ocular history, but the patient who developed scleritis was in remission without medical therapy for four years, until the flare-up, which occurred one day after the vaccine. All patients improved with treatment.

Conclusion: Though a causal relationship cannot be definitively established, the temporal relationship suggests a possible link between the COVID-19 vaccine and the posterior ocular complications. The benefits of vaccination clearly outweigh the potential adverse effects; however, ophthalmologists should be aware of the potential for vaccine-associated uveitis.

Keywords: COVID-19; Herpes; Ocular inflammation; PAMM; SARS-CoV-2; Scleritis; Uveitis; Vaccine.

Fig. 1

Patient #1—bilateral anterior and posterior scleritis. External eye photos at presentation showing anterior scleritis more pronounced in the right eye (a) than in the left (b). Ultrasound B-scan at presentation showing thickened sclera and choroid with a positive “T” sign bilaterally, with scleral thickness of 2.70 mm in the RE (c), and 2.35 mm in the LE (d). After 9 months of follow-up, scleral thickening had resolved, as measured by Ultrasound B-scan to be 1.75 mm in the RE (e) and 1.50 mm in the LE (f)

Fig. 2

Patient #2—paracentral acute middle maculopathy. a Fundus photo of the left eye at presentation showing no obvious pathology. b Infrared image of the left eye at presentation showing a hyporeflectant area (red arrow) superotemporally to the fovea. c SD-OCT of the left eye at presentation section through the affected area reveals a hyperreflective band (yellow brackets) at the junction of the outer plexiform layer and inner nuclear layer. d After 6 weeks of follow-up, OCT revealed characteristic thinning of the area

Fig. 3

Patient #3—herpetic panuveitis in the left eye. a Slit lamp image of large keratic precipitates at presentation to uveitis clinic, 3 weeks after onset of symptoms. b Ultra-wide field fundus imaging showing extensive peripheral perivascular sheathing. c External photograph showing sectoral iris atrophy five months after initial presentation. d 8 months after initial presentation vascular sheathing is markedly reduced

Fig. 4

Patient #4—Vogt–Koyanagi–Harada-like uveitis—Ultra-wide field fundus imaging of the right eye. Imaging shows clear vitreous, hyperemic optic disk, a localized area of exudative retinal detachment along the inferotemporal arcade (arrows) (a) and fine grayish-white choroidal lesions in superior peripheral retina (b)

Fig. 5

Patient #4—Vogt–Koyanagi–Harada-like uveitis—optical coherence tomography (OCT). Swept-source OCT (Topcon DRI OCT Triton) of the right macula: a At presentation, showing subretinal fluid in the fovea, irregularities along the ellipsoid zone and marked choroidal thickening (arrow). b Two weeks later, showing resolution of subretinal fluid and better demarcation of thickened choroid. c Eight weeks after presentation, showing restoration of the ellipsoid zone and resolution of the choroidal thickening (arrow). d OCT angiography (Topcon DRI OCT Triton) of the right macula shows at presentation at the level of the choriocapillaris (arrow) multiple hyporeflective round-to-oval lesions, representing areas of flow void or choriocapillaris hypoperfusion corresponding to the hypofluorescent lesions observed in the early phase of fluorescein angiogram. e Flow void areas resolved 8 weeks later (arrow)