A 79-year-old male was referred to our hospital on the day after receiving the third dose of a messenger RNA (mRNA) COVID-19 vaccine. He first noticed blurred vision with floaters in the right eye during his return home immediately after vaccination.
At the initial examination, best-corrected visual acuity (BCVA) was 0.03 in the right eye and 1.0 in the left eye. Intraocular pressure was 13 mm Hg in the right eye and 17 mm Hg in the left eye. The patient reported no flu-like symptoms (e.g., fever, sore throat) and no COVID-19-specific symptoms (e.g., loss of taste). He was taking an anticoagulant due to atrial fibrillation. Past medical history included bronchial asthma. His vaccination history included the first and second doses of the BNT162b2 (Pfizer-BioNTech) mRNA COVID-19 vaccine and the third dose of the mRNA-1273 (Moderna TX, Inc.) mRNA COVID-19 vaccine.
Slit-lamp examination revealed the presence of inflammation, seen as cells, grade 2+ in the right eye and 1+ in the left eye and flare grade 1+ in both eyes, with mild, fine keratic precipitates in the anterior chamber. Funduscopic examination revealed grade 1+ vitreous haze and severe retinal vasculitis, with sheathing of the artery and vein in both eyes (Fig. 1a), suggestive of FBA. In addition, significant blot hemorrhages were found on the entire retina. Fluorescein angiography revealed dye staining and slight leakage from the retinal veins in both eyes (Fig. 1b). Optical coherence tomography of the macula showed retinal edema and retinal detachment in the right eye (Fig. 1c).
To exclude retinal vasculitis related to autoimmune disease or typical viral infection, medical examination and PCR assays of the aqueous humor were performed. There were no abnormal findings indicative of autoimmune disease. Tests for various viruses commonly associated with uveitis, i.e., cytomegalovirus, herpes simplex virus, varicella-zoster virus, human immunodeficiency virus, tuberculosis, and toxoplasmosis, were negative. PCR assay of the aqueous humor detected Epstein-Barr virus (EBV), and antibody against the EBV viral capsid antigen was positive for IgM. We were able to detect EBV in the aqueous humor, but our laboratory equipment was not able to quantify it.
The day after the initial visit, the patient complained of blurred vision in the left eye, and BCVA in the left eye worsened to 0.08. Funduscopic findings revealed expanded retinal vasculitis and development of macular edema in the left eye (Fig. 2). Pulse steroid therapy (methylprednisolone 1,000 mg/day for 3 days) and intravenous infusion of acyclovir (1,500 mg/day) were started immediately. The first course of pulse steroid therapy did not have an adequate therapeutic effect, so a second course was started 4 days after the first. The second course was successful, and the funduscopic findings improved (Fig. 3). Although the BCVA also gradually improved to 0.15 in the right eye and 0.6 in the left eye, irreversible damage remained in the right eye, which had severe macular edema. Fluorescein angiography was repeated 14 days later and showed both decreasing inflammation in the retinal vessels and ischemia in the periretinal area. At the time of this report (5 months after the COVID-19 vaccination), BCVA was maintained 0.15 in the right eye and 0.7 in the left eye. The CARE Checklist has been completed by the authors for this case report, attached as online supplementary material (for all online suppl. material, see https://doi.org/10.1159/000530794).