Corneal graft rejection following COVID-19 vaccine

Corneal graft rejection following COVID-19 vaccine

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In February 2021, a 68-year-old woman attended the eye casualty with a 1-day history of left painful red eye and rapid deterioration of vision. Four days earlier, she received her first dose of mRNA-based BNT162b2 COVID-19 vaccine (Pfizer-BioNtech). On the next day, she developed moderate systemic reactions, including chills, myalgia, and tiredness, followed by unexpected ocular symptoms on the third day.

Her past ocular history included a bilateral lamellar Descemet Stripping Automated Endothelial Keratoplasty (DSAEK) for Fuchs’ corneal endothelial dystrophy and a left re-do penetrating keratoplasty (PKP) for failed DSAEK in October 2020. There was no other relevant past ocular/medical history. At 2-month post-PKP, her left eye best-corrected visual acuity (BCVA) was 6/18 with a clear corneal graft. She was maintained on topical prednisolone 0.5% QID for the left eye and dexamethasone 0.1% OD for the right eye.

At presentation, her left BCVA was counting fingers. Slit-lamp examination confirmed the diagnosis of acute corneal endothelial graft rejection, evidenced by conjunctival hyperaemia, diffuse corneal punctate staining, corneal graft oedema, Descemet’s folds, scattered keratic precipitates, and anterior chamber activity (Fig. 1). The right corneal graft remained healthy.

Fig. 1: A case of acute corneal endothelial graft rejection after COVID-19 vaccine.
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A, B Slit-lamp photography demonstrating conjunctival hyperaemia, corneal graft haze, diffuse corneal epithelial, and stromal oedema (within the graft), Descemet’s folds, scattered keratic precipitates (KPs), and 1+ cells in anterior chamber. An unusual distribution of fluorescein staining with coarse punctate epitheliopathy over the corneal graft was observed. The central corneal thickness (CCT) was 730 μm. C, D At 3-week post treatment, the corneal graft rejection was successfully treated with considerable improvement in the graft transparency, reduction in epithelial and stromal oedema, and resolution of epitheliopathy and anterior chamber inflammation. The best-corrected visual acuity improved to 6/12, with a CCT of 609 μm.

The patient was immediately treated with hourly topical dexamethasone 0.1% and a week of oral acyclovir 400 mg 5x/day (to cover for any possible underlying herpes simplex keratitis), with no treatment modification in the right eye. Significant improvement was noted by 3-week post-treatment with complete resolution of corneal graft rejection (Fig. 1C, D).

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Sasha Terry