Bilateral EK Rejection After COVID-19 Vaccine.

ABSTRACT: Owing to its rapid development, short-term and long-term effects of the COVID-19 vaccine are still not well understood. This case report highlights bilateral corneal endothelial graft rejection after administration of the Pfizer COVID-19 vaccine. A 73-year-old woman with bilateral Descemet stripping endothelial keratoplasty presented with bilateral decreased visual acuity, ocular pain, and photophobia after her second dose of the Pfizer-BioNTech COVID-19 vaccine. Two weeks after vaccine administration, the uncorrected visual acuity was 20/70 and 20/40. Central corneal thickness as measured by ultrasound was 809 and 825 µm and by Scheimfplug imaging was 788 and 751 µm at the pupil center. Slit-lamp biomicroscopy revealed quiet conjunctiva and sclera but was significant for thickened corneas with Descemet folds in both eyes. The patient was instructed to use prednisolone acetate 1% every 1 to 2 hours with Muro ointment at bedtime.

Impact of vaccination on keratoplasty.

PURPOSE OF REVIEW: Corneal graft rejection has been reported after coronavirus disease 2019 (COVID-19) vaccination. The purpose of this review is to evaluate the literature regarding corneal graft rejection after vaccination, including rejection rates and risk factors. We aim to create a framework to identify patients who are at higher risk for graft rejection and may warrant consideration of prophylactic interventions. RECENT FINDINGS: Graft rejection has been reported following administration of mRNA, viral vector, and inactivated whole-virion COVID-19 vaccines. Most cases had additional risk factors associated with rejection. Vaccination increases circulation of proinflammatory cytokines, CD4+ and CD8+ T-cell responses, and antispike neutralizing antibody, all of which may contribute to graft rejection. Two prospective studies have found no relationship between recent vaccination and rejection but 20% of cornea specialists report to have seen a vaccine-associated rejection and 22% recommend delaying vaccination in certain circumstances. Many specialists recommend prophylactic topical corticosteroids before and after vaccination to mitigate rejection risk but there is no evidence to support this practice on a wider scale. SUMMARY: Our framework identified 96.8% of penetrating keratoplasty patients with vaccine-associated rejection as higher risk. Further research is needed in order to develop evidence-based guidelines.

Eye banking and keratoplasty trend analysis during the COVID-19 pandemic: A South Indian observational study.

Purpose: To analyze the impact on eye donation and corneal transplantation during the COVID-19 pandemic in a tertiary eye hospital in south India. Methods: A retrospective analysis of the donor and recipient records during the study period from January 2020 to May 2021 was conducted and tabulated in Microsoft Excel 2013. Demographic details of the donor, utility rate, cause of death, culture characteristics, storage methods, wet lab usage, and the surgical donor outcomes were evaluated. Additionally, the postoperative workup of the recipients, diagnosis, graft infection and rejection episodes, development of COVID-19 postoperatively, and outcome in terms of visual acuity at one, three, and six months were also noted. Results: A total of 466 eyes from 249 donors were received during the study period. The mean age of the donor population was 62.43 years (20.9). The corneal transplantation utility rate was 36.4% (n = 170). Fifty-one percent of the total transplant surgeries were for therapeutic purposes. This was followed by penetrating optical keratoplasty (34%), Descemet's stripping endothelial keratoplasty (9%), and patch grafts (3%). Seventeen (10%) graft rejection episodes were noted and nine (53%) had complete resolution after medical treatment. Conclusion: Proper preventive measures are key to carrying out safe and efficient eye banking activities even during a deadly pandemic, as COVID-19 transmission via transplantation is rare.

Impact of pandemic COVID-19 lockdown on penetrating keratoplasty patients.

Purpose: To study the impact of the COVID-19 lockdown on the regular follow-up of keratoplasty patients. Methods: This retrospective interventional case series included 30 patients who had immunological corneal endothelial rejection out of 190 patients who came for post-PKP follow-up between September 15, 2019, and September 30, 2020. The demographics, primary diagnosis, surgical technique, time of presentation, recovery of graft, associated ocular problems, and visual acuity at 1 month were analyzed. Forward stepwise (likelihood ratio) binary logistic regression was used to find significant variables. Results: The study population had 19 males (63.33%) and 11 females (36.67%). The mean age of the study group was 42.83 ± 18.89 (8-80) years. Of 30 patients, 19 (63.3%) presented before and 11 (36.7%) after the COVID-19 lockdown. Overall, 23 (77%) showed a reversal of graft rejection. Logistic regression showed that preoperative indications, large-sized grafts, and deep corneal vascularization were significant risk factors for non-resolution of graft rejection. It was noted that patients who presented to the hospital late had poor recovery (P = 0.002). The delay in the presentation was a significant risk factor for non-resolution of graft rejection (P < 0.01). Z-test for proportions revealed that the difference in the non-resolution of rejection on immediate or delayed treatment in patients presenting during lockdown (P = 0.002) was significant. Conclusion: This article is to highlight the impact of the COVID-19 lockdown on graft rejection recovery of PKP patients due to delays in follow-up. Early treatment helps in the recovery of graft transparency and the reversal of immunological graft rejection. Also, primary diagnosis, deep vascularization, and large-sized grafts were significant risk factors for non-resolution of graft rejection.

COVID-19 Vaccination May Not Increase Rates of Corneal Graft Rejection.

PURPOSE: The aim of the study was to present the rates of rejection from 2018 to 2021 and evaluate the purported association between COVID-19 vaccination and corneal graft rejection. METHODS: Cases of corneal graft rejection diagnosed between January 2018 and December 2021 were reviewed. The conditional Poisson regression model of the self-controlled case series method was used to estimate the incidence risk ratio of graft rejection after COVID-19 vaccination risk period compared with the control period. Based on outcomes of eyes that underwent keratoplasty from January 2018 to December 2020, Cox proportional hazard models were fitted with previous COVID-19 vaccination as a time-varying covariate. RESULTS: Over the past 4 years, the annual tally of diagnosed cases of graft rejection (19 cases in year 2018, 19 cases in year 2019, 21 cases in year 2020, and 18 cases in year 2021) has remained relatively stable. Using the conditional Poisson regression analysis, no significant increase in the incidence rate of rejection in the risk period after COVID-19 vaccination was found (incidence risk ratio = 0.56, 95% confidence interval [CI] = 0.13-2.28, P = 0.70). Fitted as a time-varying covariate, previous COVID-19 vaccination was not associated with graft rejection in both unadjusted (hazard ratio =0.77, 95% CI = 0.29-5.46, P = 0.77) and adjusted Cox models (hazard ratio = 0.75, 95% CI = 0.10-5.52, P = 0.78). CONCLUSIONS: No notable increase in rates of corneal graft rejection was noted in year 2021 when COVID-19 vaccination was broadly implemented. The apparent temporal relationship between COVID vaccination and corneal graft rejection may not represent a causative association.

Lasting Effects: Seven Year Results of the Castrop Nomogram for Femtosecond Laser-Assisted Paired Corneal Arcuate Incisions.

PURPOSE: Long-term results of arcuate incisions are rarely reported. This is unfortunate as long-term stability of astigmatic correction is of great interest to surgeons performing astigmatic correction. This study investigates the 7 year stability of results after application of femtosecond laser-assisted arcuate incisions with the Castrop nomogram. METHODS: Prospective interventional case series at the Augen- und Laserklinik, Castrop-Rauxel, Germany. Single site, single surgeon study. Seven year results of cataract patients with low to moderate corneal astigmatism receiving femtosecond laser-assisted arcuate incisions using a TechnolasVictus SW 2.7 (Bausch & Lomb Inc, Dornach, Germany) were assessed and compared to 1 year results. Outcome evaluation was based on astigmatic vector analysis, manifest refraction, and visual acuity. RESULTS: The study analyzed 19 eyes of 19 patients 7 years after surgery. Ocular residual astigmatism changed from -0.26 to -0.39 D. Preoperative corneal astigmatism was -1.51 D. Correction Index changed from 1.0 to 1.16. The magnitude of difference vector changed from 0.26 to 0.39 D. The index of success changed from 0.20 to 0.29. Spherical equivalent remained stable. A slight tendency to change toward astigmatic overcorrection was mainly observed for patients with preoperative with the rule astigmatism, but not with patients with against the rule astigmatism. CONCLUSIONS: The Castrop nomogram showed stable results 7 years after surgery. Similar to toric IOL surgery, it is advisable to be less aggressive when correcting with the rule astigmatism, to avoid overcorrection over a long period.

A case of acute endothelial corneal transplant rejection following immunization with ChAdOx1 nCoV-19 coronavirus vaccine.

A 28-year-old female who underwent an uneventful femtosecond laser enabled keratoplasty (FLEK) in her left eye presented with pain, redness, and blurring of vision in the operated eye two weeks after getting immunized with COVID-19 vector vaccine (ChAdOx1 nCoV19 Vaccine Recombinant COVISHIELD, AstraZeneca). Slit-lamp examination showed donor stromal edema with Descemet's membrane folds and Khodadoust line (KP's on endothelium) with anterior chamber cells and flare. The patient was diagnosed with acute corneal graft rejection and advised hourly topical steroids with cycloplegics and oral steroids. The patient responded to treatment and there was progressive reversal of graft rejection with the patient achieving best spectacle-corrected visual acuity (BSCVA) of 20/30 after five weeks of treatment. Our case highlights possible immune corneal graft rejection after COVID19 vaccination and the need to step up topical steroids before vaccination.

Five Cases of Corneal Graft Rejection After Recent COVID-19 Vaccinations and a Review of the Literature.

PURPOSE: The purpose of this study was to report 5 cases of acute corneal graft rejection after COVID-19 vaccination and perform a review of the literature. METHODS: This was a case series and review of literature dated on the October 10, 2021. RESULTS: We describe 5 cases-2 patients with Descemet stripping automated endothelial keratoplasty (for Fuchs endothelial dystrophy) who presented with acute corneal graft rejection after their first dose of mRNA (BNT162) vaccine. The other 3 patients who had penetrating keratoplasty performed more than 10 years ago for keratoconus presented with acute graft rejection-2 patients after their second dose of adenovirus vector (AZD1222) vaccine and 1 patient after first dose of mRNA (BNT162) vaccine. Three patients were not using any topical steroid treatment at the time of diagnosis of graft rejection. The mean duration between vaccination and onset of symptoms was 16.86 ± 6.96 days for the mRNA vaccine and 17 ± 11.89 days for the adenovirus vector vaccine. CONCLUSIONS: Corneal graft rejection has recently been reported after COVID-19 vaccination. Patients with keratoplasty need to be advised regarding the risk of corneal graft rejection and warning symptoms of rejection after COVID-19 vaccination. Seeking early referral to the emergency department and increasing topical steroids pre-COVID-19 and post-COVID-19 vaccination may reduce the risk of rejection.

Acute graft rejection in a high-risk corneal transplant following COVID-19 vaccination: A case report.

As COVID-19 vaccination is being undertaken all over the world, its side effects are materializing slowly. One such emerging side effect is acute graft rejection in corneal transplant (CT) cases post COVID-19 vaccination. We report a case of left eye (LE) repeat penetrating keratoplasty presenting with diminished vision in LE within 2 days of COVID-19 vaccination (ChAdOx1 nCoV-19 Corona Virus Vaccine Recombinant, COVISHIELD™). The patient was diagnosed with acute graft rejection post vaccination and was treated with topical and systemic immunosuppression therapy with successful outcome in terms improvement of visual acuity and corneal graft clarity. Timely presentation, diagnosis, and management may help to survive acute rejection episodes post vaccination.

Acute Corneal Transplant Rejection After COVID-19 Vaccination.

PURPOSE: The purpose of this report was to describe 4 cases of acute corneal transplant rejection occurring in association with coronavirus disease 2019 (COVID-19) mRNA vaccination. METHODS: Four patients with prior keratoplasty developed presumed immunologic rejection after the mRNA-1273 vaccination for coronavirus 2 (SARS-CoV-2). Case 1 had received Descemet membrane endothelial keratoplasty 6 months ago and presented with endothelial graft rejection 3 weeks after the first vaccine dose. Case 2 had undergone penetrating keratoplasty 3 years previously and presented with acute endothelial rejection 9 days after the second vaccine dose. Case 3 had prior Descemet stripping automated endothelial keratoplasty (DSAEK) and began experiencing symptoms of endothelial graft rejection 2 weeks after the second vaccine dose. Case 4 presented with endothelial rejection of the penetrating keratoplasty graft 2 weeks after the second vaccine dose. RESULTS: Frequent topical corticosteroids alone were initiated in all 4 cases. In case 1, the endothelial rejection line appeared fainter with improvement in visual acuity and corneal edema 5 weeks after diagnosis. Case 2 experienced complete resolution of corneal stromal edema and rejection line 6 weeks after diagnosis. Cases 3 and 4 have both experienced initial improvement with steroid treatment as well. CONCLUSIONS: These cases suggest acute corneal endothelial rejection may occur soon after either dose of the COVID-19 mRNA vaccine. Prompt initiation of aggressive topical steroid therapy may result in complete resolution of clinical signs and symptoms. Further studies are needed to elucidate the causal mechanism of corneal graft rejection after COVID-19 vaccination.

Bilateral Immune-Mediated Keratolysis After Immunization With SARS-CoV-2 Recombinant Viral Vector Vaccine.

PURPOSE: The purpose of this study was to report an unusual case of bilateral immune-mediated corneal melting and necrosis after ChAdOx1 nCoV-19 (Covishield) vaccination. METHODS: This is a case report and literature review. RESULTS: A 48-year-old man presented to the ophthalmic emergency department with progressive bilateral corneal melting 5 weeks after receiving the first dose of ChAdOx1 nCoV-19 (Covishield) vaccine. Systemic complaints of fever, diarrhea, and vomiting were noted in the first 2 weeks, which subsided before the onset of ocular symptoms at day 21 of vaccine administration. The patient could only perceive light bilaterally and demonstrated features of bilateral keratolysis with choroidal detachment on ultrasonography. The microbiological scraping specimen did not reveal growth of any microorganism. Tectonic penetrating keratoplasty was performed, and the host corneal tissue was sent for histopathology, bacterial culture, fungal culture, polymerase chain reaction for herpes simplex virus, varicella zoster virus, cytomegalovirus, adenovirus, and SARS-CoV-2. Microbial culture was sterile, and viral polymerase chain reaction reports were negative. Histopathological examination revealed dense inflammatory cell infiltration. Detailed systemic workup revealed no underlying systemic or autoimmune pathology. CONCLUSIONS: Immune-mediated keratolysis after ChAdOx1 nCoV-19 (Covishield) vaccination is a rare entity, and we believe that this is the first report of a temporal association between a serious ocular adverse event after a single dose of any SARS-CoV-19 vaccine. It may be included as a possible adverse event associated with this vaccine.