Short-Term Ocular Adverse Events Occasionally Follow COVID-19 Vaccination

The possibility of short-term ocular adverse events resulting from vaccination was likely far from the minds of pathologists, optometrists, and patients alike during the height of the COVID-19 pandemic. As researchers scrambled to curtail a disease that ultimately infected 767,972,961 individuals worldwide and resulted in a confirmed 6,950,655 deaths, officials were tasked with developing, manufacturing, and distributing hundreds of millions of novel vaccines doses.^1,2 As vaccination rates increased — almost 70% of individuals residing in the US have completed their primary series — and masks, gloves, and constant disinfection became less prevalent in everyday life, researchers have given greater consideration to some of the adverse events that may follow COVID-19 vaccination.³ 

Cardiac adverse events have come under some scrutiny and include cases of thrombocytopenia, hypertension, and tachycardia following vaccination.^4,5 However, it may not be possible to establish causality due to the presence of these adverse events in individuals who have not undergone any interventions.⁵ Similarly, a growing body of evidence suggests that a variety of short-term ocular adverse events may follow COVID-19 vaccination. Similar to the research investigating adverse cardiovascular events, many of the studies exploring ocular adverse events lack long-term follow up and cannot definitively establish causality. 

Corneal and Ocular Surface Adverse Events

A 2022 study highlighted concerns of ocular inflammation among individuals who underwent COVID-19 vaccination, which included anterior uveitis, posterior uveitis, and scleritis.⁶ Although there were some reported complications involving lesions, scarring, and edema, a majority of study participants (92.9%) did not experience any changes in vision.⁶ Additionally, more than half of individuals enrolled in the investigation had a history of ocular inflammatory events.⁶ The researchers stated these findings do not detract from the vaccine’s safety.

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“[T]here is no evidence from this study to suggest that individuals should avoid getting vaccinated because of ophthalmic-related adverse events,” the study authors explained. “It is not the aim of the authors to impede or curtail the vaccination efforts, but rather to educate physicians and patients about rare but potential ocular inflammatory events after the COVID-19 vaccination.”⁶

Research also shows that some thyroid-related complications following vaccination have been documented. A systematic review identified 57 individuals with Graves disease, a majority of whom were women (75%) and individuals presenting with palpitations (63%) or weight loss (35%).⁷ While a previous history of Graves disease was not a factor for the majority of participants — patients with new-onset disease comprised 74% of the study sample — the investigation failed to note whether a majority of participants had a previous SARS-CoV-2 infection, a variable that could potentially confound the results.⁷ 

Potential Retinal Concerns

A 2023 study investigated instances of retinal vascular occlusion and found a very small incidence (0.003%) within 21 days of messenger ribonucleic acid (mRNA) vaccination.⁸ The research team determined that individuals undergoing these vaccinations experienced a risk similar to those receiving influenza (relative risk [RR], 0.74; 95% CI, 0.54-1.01) and pertussis vaccinations (RR, 0.78; 95% CI, 0.44-1.38).⁸   

Another investigation suggested that COVID-19 vaccination may significantly alter superficial capillary plexus (SCP) and deep capillary plexus (DCP) density.⁹ After performing optical coherence tomography-angiography (OCT-A) assessment among a cohort of 40 health care workers before and 3 days following COVID-19 vaccination, researchers noted significant reductions in SCP total (P <.0001), SCP parafoveal (P <.0001), SCP perifoveal (P =.001), and DCP perifoveal (P =.04) vascular densities.⁹ The investigators attributed these changes to vascular endothelial damage and inflammation in individuals undergoing vaccination and noted that these changes may be similar to those experienced by patients with a history of COVID-19.⁹

While some studies are limited by the inclusion of only 1 vaccine brand, a 2022 investigation found a potential association between optic neuropathy and mRNA, viral vector, and inactivated viral vaccines.¹⁰ However, among the cohort of individuals who developed anterior ischemic optic neuropathy, optic neuritis, autoimmune optic neuropathy, or Leber hereditary optic neuropathy within a mean 9.6 days following COVID-19 vaccination, the condition was frequently self-limiting or resulted in favorable prognosis when treatment was necessary.¹⁰ 

No Reason For Concern

While short-term ocular adverse events are possible following COVID-19 vaccination, they are extremely rare, and many clinicians may have limited or no experience treating patients who have experienced them. Nathan Lighthizer, OD, associate professor and dean at the Northeastern State University College of Optometry states that other than a few cases of conjunctivitis that may have been related to COVID-19 vaccination, he has not observed any significant ocular adverse events within his clinical practice. 

“Anything is possible, and rare events can occur, but it is very rare that an ocular adverse event would happen from the COVID-19 vaccine,” Dr Lighthizer explained. “It’s very rare and wouldn’t stop me from getting the vaccine from an ocular perspective.”

Research supports Dr Lighthizer’s assertion that such events are extremely rare. One investigation revealed ocular surface adverse event prevalence rates of 0.9, 0.2, and 0.3 cases per million or less for uveitis, scleritis, and episcleritis, respectively.¹¹ Retinal adverse events included macular edema, macular degeneration, maculopathy, and chorioretinopathy, which occurred in 0.1, .01, 0.03, and 0.05 cases per million, respectively.¹¹ 

In many ways, a “return to normal” appears to have taken place and adverse events related to COVID-19 vaccination, whether ocular or other, have not significantly disrupted life after the pandemic. Individuals rarely experience these short-term ocular adverse events following vaccination, and those who do can often expect favorable clinical outcomes, with or without treatment. While optometrists may not expect these patients to routinely present for care, an increased awareness of these ocular adverse adverse events will enable clinicians to provide expert care and reassure their patients of the frequently good prognostic outcomes.

References

1. WHO coronavirus (COVID-19) dashboard. World Health Organization. Accessed July 20, 2023. https://covid19.who.int/
2. Michaud J, Kates J. Distributing a COVID-19 vaccine across the U.S. – a look at key issues. KFF. Published October 20, 2020. Accessed July 20, 2023. https://www.kff.org/report-section/distributing-a-covid-19-vaccine-across-the-u-s-a-look-at-key-issues-issue-brief/ 
3. COVID-19 vaccinations in the United States. Centers for Disease Control and Prevention. Updated May 11, 2023. Accessed July 21, 2023. https://covid.cdc.gov/covid-data-tracker/#vaccinations_vacc-people-booster-percent-pop5
4. Li X, Burn E, Duarte-Salles T, et al. Comparative risk of thrombosis with thrombocytopenia syndrome or thromboembolic events associated with different covid-19 vaccines: international network cohort study from five European countries and the US. BMJ. Published online October 26, 2022. doi:10.1136/bmj-2022-071594
5. Jeet Kaur R, Dutta S, Charan J, et al. Cardiovascular adverse events reported from COVID-19 vaccines: a study based on WHO database. Int J Gen Med. Published online July 27, 2021. doi:10.2147/IJGM.S324349
6. Testi I, Brandão-de-Resende C, Agrawal R, Pavesio C. Ocular inflammatory events following COVID-19 vaccination: a multinational case series. J Ophthalmic Inflamm Infect. 2022;12(1):4. doi:10.1186/s12348-021-00275-x
7. Triantafyllidis KK, Giannos P, Stathi D, Kechagias KS. Graves‘ disease following vaccination against SARS-CoV-2: a systematic review of the reported cases. Front Endocrinol. Published online September 27, 2022. doi:10.3389/fendo.2022.938001
8. Dorney I, Shaia J, Kaelber DC, Talcott KE, Singh RP. Risk of new retinal vascular occlusion after mRNA COVID-19 vaccination Within aggregated electronic health record data. JAMA Ophthalmol. 2023;141(5):441-447. doi:10.1001/jamaophthalmol.2023.0610
9. Gedik B, Erol MK, Suren E, et al. Evaluation of retinal and optic disc vascular structures in individuals before and after Pfizer-BioNTech vaccination. Microvasc Res. Published online February 4, 2023. doi:10.1016/j.mvr.2023.104500
10. Elnahry AG, Al-Nawaflh MY, Gamal Eldin AA. COVID-19 vaccine-associated optic neuropathy: a systematic review of 45 patients. Vaccines. 2022;10(10):1758. doi:10.3390/vaccines10101758
11. Wang MTM, Neiderer RL, McGhee CNJ, Danesh-Meyer HV. COVID-19 vaccination and the eye. Am J Ophthalmol. Published online February 25, 2022. doi:10.1016/j.ajo.2022.02.011

This article originally appeared on Optometry Advisor