Visual impairment after each COVID-19 shot?

A 53-year-old man came to the hospital after losing sight in his left eye. He explained that he had received a second dose of Pfizer’s COVID vaccine (Comirnaty) 10 days ago. He said he experienced similar symptoms 7 days after receiving the first dose of the vaccine.

The clinician found that the man’s right eye also had a high degree of defect. He didn’t see a doctor because he explained that it improved naturally. But he added that his vision hadn’t returned to normal.

He had no other symptoms and had no associated past medical history. As a result of the examination, the clinician found that his left eye had the most corrected visual acuity (BCVA, equivalent to the Snellen chart) of 20/40. They also pointed out a relative afferent pupillary defect. A fundus examination revealed a large optic disc swelling with some bleeding. The BCVA of the patient’s right eye was 20/20, with mild papillary edema with pupil laziness and two bleedings.

Clinicians performed optical coherence tomography (OCT) to confirm the presence of bilateral papilledema and a slight loss of ganglion cells in the right eye only. Visual field disturbance was noted in both eyes: the left eye had a contracted peripheral vision and the right eye had an incomplete lower nose scotoma.

Further work-up included the SARS-CoV-2 PCR nasal swab test, which was negative. Based on their suspicion that the patient had bilateral anterior ischemic optic neuropathy, clinicians made further assessments. Neurological examination did not reveal anything unusual.

Serological examination showed no infection. The patient’s blood cell count suggested iron deficiency anemia. However, this diagnosis was ruled out if there was no evidence of active bleeding and the patient’s platelet count was within normal limits. The erythrocyte sedimentation rate and C-reactive protein were also found to be normal. The test did not evaluate antibodies against platelet factor 4 (PF4). There is no evidence of anti-neutrophil cytoplasmic antibody or antinuclear antibody, and the tumor markers alpha 1 fetoprotein, carcinoembryonic antigen, cancer antigen 19, cancer antigen 125, cytokeratin fragment 21.1, and neuron-specific enolase are normal. It was within range. The supraclavicular blood vessel Echo Doppler was also normal.

Clinicians performed MRI of the brain and orbit with and without gadolinium to assess potential optic neuritis, but the findings were unnoticeable. The patient underwent lumbar puncture and had an open pressure of 38 cmH2O. Cerebrospinal fluid (CSF) tests showed normal protein and glucose levels, and infectious serology tests were negative. The findings of the whole body CT scan were also inconspicuous.

Based on the potential discovery of CSF, which suggests increased intracranial pressure, clinicians prescribed acetazolamide at 750 mg / day. However, the patient reported that his eyesight had not improved at that time, even three months later.

At a 3-month follow-up, clinical evaluation showed that the patient’s visual acuity was 20/20 in the right eye and 20/40 in the left eye, with lazy pupils and normal eye movements. A fundus examination showed no bleeding and pale disks in both eyes. OCT identified a slight loss of bilateral ganglion cells and there was evidence of atrophy in the retinal nerve fiber layer. The visual field of the right eye did not change, and there was a slight improvement in the left eye. There was no evidence of typical high-grade defects, but clinicians made a diagnosis of NA-AION based on test results and clinical changes.

Discussion

Clinician presenting this case In non-arteritic anterior ischemic optic neuropathy after Pfizer vaccination (one of the first two published), this case was “not the cause between NA-AION and COVID-19 vaccination”. Explaining the relationship. ” However, they found that, in addition to “timing between the vaccine and the onset of ischemic optic neuropathy,” the onset of patient symptoms in one eye after the first dose and in the other eye after the second dose. The COVID-19 vaccine in the etiology of this condition is plausible in these two cases, which stated that it plays a potential role. “

Vaccination with Pfizer (BNT162b2 mRNA), Moderna (mRNA-1273), Johnson & Johnson (Ad26. COV2.S), and AstraZeneca (AZD1222) vaccines helps prevent SARS-CoV-2 infection. However, the case author writes that it is also associated with some rare but serious secondary effects, including thromboembolic events.

In this group, this patient’s intracranial hypertension may be associated with bilateral papilledema, but his atypical symptoms with only acute visual symptoms were that the patient suffered from ischemic optic neuropathy. A prone optic nerve with a congested structure due to increased intracranial pressure that has increased the likelihood or explained that the vaccine may have caused an ischemic event. “

The NA-AION is the most common cause of acute optic neuropathy in individuals over the age of 50, and the team observed that the annual incidence in the United States is 2.3 to 10.3 per 100,000 people overall. Although the cause is not explained in most cases, they pointed to specific etiologies associated with sleep apnea syndrome, medications such as interferon and sildenafil, and optic disc dolsen. In addition, some data suggest pathophysiological involvement of predisposing risk factors such as optic disc anatomy, nocturnal hypotension, or risk factors for angiopathy.

A recent large-scale meta-analysis reported the following, in addition to the medical history of taking cardiovascular medications: Risk factor Significantly associated with NA-AION:

• Male gender (OR 1.67, 95% CI 1.50-1.85)
• Hypertension (RR 1.28, 95% CI 1.20-1.37)
• Hyperlipidemia (RR 1.43, 95% CI 1.26-1.62)
• Diabetes (RR 1.53, 95% CI 1.36-1.73);
• Coronary heart disease (RR 1.68, 95% CI 1.24-2.27)
• Sleep apnea (RR 3.28, 95% CI 2.08-5.17)
• Factor V Leiden heterozygotes (RR 2.21, 95% CI 1.19-4.09)

The authors of the case stated that vaccination was suspected as a predisposing factor for the development of NA-AION due to the timing of acute optic neuropathy immediately after vaccination.Despite their rarity, they quoted another Similar case This follows the COVID-19 vaccine, with four reported following influenza vaccination.

Similarly, the group listed previous secondary ocular effects that may be associated with COVID-19 vaccination, but their etiology is not clearly understood and may change. Said-these include superior scleritis, scleritis, uveitis (both anterior and posterior), acute macular retinopathy, paracentral acute medial macular disease, corneal transplant rejection, central Serous chorioretinopathy, and arterial ischemic anterior optic neuropathy.

This group referred to the only published report on cases of arterial anterior ischemic optic neuropathy. This may be due to the cross-reactivity of neutralizing antibodies to the SARS-CoV2 pesplomer with arterial antigens, which may result in presumed autoimmune phenomena. “Case author The validity of this proposed mechanism is supported by fever, elevated C-reactive proteins, elevated erythrocyte sedimentation rates, and patient presentation with positive findings on temporal artery biopsy, diagnosing Horton’s disease. I commented that it led to.

They said that in two patients, the autoimmune mechanism was “unlikely” based on the lack of systemic symptoms and normal blood test findings, but “local eye autoimmune events are still considered. May be done. “

In addition, the authors point to a rare report of cerebral venous sinus thrombosis (CVST) after SARS-CoV-2 vaccination as a result of immunothrombotic thrombocytopenia (VITT), potential thrombotic triggers. I paid attention to the role.

This group says, “VITT is triggered by antibodies that bind PF4 to platelets, also known as CXCL4. These antibodies are via the low-affinity platelet FcgIIa receptor, a receptor on the surface of platelets that binds to Fc. It is an immunoglobulin G (IgG) molecule that activates. Part of the IgG molecule). ”This activation of platelets, with the potential involvement of neutrophils and other cells, stimulates the coagulation system and SARS- It can cause clinically significant thromboembolic complications that are already well known to be associated with both CoV-2 infection and COVID-19 vaccination. Indeed, ischemic optic neuropathy has also been reported in patients with COVID-19, citing six previously reported cases, they said.

“The occurrence and importance of autoimmune symptoms after viral vaccine administration is controversial,” said a recent report examining whether the COVID-19 recombinant mRNA vaccine has serious eye inflammatory side effects. Citing, the case author stated.Real or coincidenceIts analysis of cytokine secretion showed that IFN-γ and IL-2 levels were increased after SARS-CoV-2 vaccination compared to controls, but IL-4 and IL-13 levels were unchanged. , Mainly showed T-Helper 1’s response, their authors observed.

Features of VITT Arterial thrombosis is described in reports of three cases of ischemic stroke after COVID-19 vaccination, pointing out that immune coagulopathy can also cause arterial thrombosis. Not very common. VITT has been observed more frequently with adenoviral vector vaccines, and the authors state that there is only one reported case of catastrophic thrombosis following a second dose of Modern RNA vaccine.

The authors of the cases acknowledged that “this pathogenic mechanism cannot be completely ruled out” because neither patient has been evaluated for antibodies to PF4. They concluded that further studies are needed to better understand the pathophysiological processes underlying the association between ischemic optic neuropathy and mRNA-based COVID-19 vaccination.