SARS-CoV-2 mRNA Vaccine Might Trigger Corneal-Transplant Rejection

By Scott Baltic

May 13, 2021

NEW YORK (Reuters Health) - Two older women who underwent a Descemet's membrane endothelial keratoplasty (DMEK) transplant and later received a COVID-19 mRNA vaccine have presented with symptoms and signs of endothelial graft rejection, according to a new U.K. report.

In one case, the DMEK was recent at the time of vaccination, but in the other it had taken place years earlier. In both cases, one unilateral and the other bilateral, the transplant rejection was treated successfully with topical corticosteroids.

The authors believe this to be both "the first report of temporal association between corneal transplant rejection following immunisation against COVID-19 and the first report of DMEK rejection following any immunization," they write in the British Journal of Ophthalmology.

Among corneal transplants, DMEK is the least likely to result in rejection, note Dr. Maria Phylactou of Moorfields Eye Hospital, in London, and colleagues.

"Clinicians and patients should be aware of the potential of corneal graft rejection associated with vaccine administration and may wish to consider vaccination in advance of planned non-urgent keratoplasties," they advise. "Patients should be counseled on the symptoms and signs that require urgent review to allow early treatment of any confirmed rejection episode."

In the first case, a 66-year-old woman underwent an uneventful DMEK in her right eye. Her history was notable for HIV infection that was well controlled (undetectable viral load) with Triumeq.

Fourteen days after DMEK, she received the first dose of mRNA vaccine BNT162b2 (Pfizer-BioNTech).

This patient presented a week later with acute-onset blurred vision, redness and photophobia in her right eye. Clinical examination found indications typical of acute endothelial graft rejection.

The frequency of topical steroid (dexamethasone 0.1%) was increased from four times daily to every hour. Signs and symptoms began to resolve after three days, and by four weeks after the rejection onset, visual acuity was good and there was no active inflammation.

In the second case, an 83-year-old woman had undergone DMEK in her right eye six years earlier and in her left eye three years earlier. She presented with symptoms of rejection two months after receiving her first dose of BNT162b2 and three weeks after the second dose.

Bilateral simultaneous acute endothelial graft rejection was diagnosed, and hourly steroid drops were begun. Seven days later, signs of inflammation were reduced and both grafts were functioning well, at which time the frequency of topical dexamethasone was reduced.

In a joint email to Reuters Health, Dr. Phylactou and her two coauthors, Drs. Olivia Li and Frank Larkin, also of Moorfields Eye Hospital, noted that "simultaneous immunological rejection of donor corneas from two different donors in the right and left eyes is exceptionally rare, further increasing the probability of a casual association with vaccination."

They speculated that "the patient's antibody response triggered by vaccination caused immunological injury to the internal (endothelial) surface of the transplanted donor cornea."

They continued: "The question as to why corneal transplant rejection has not yet been widely reported may relate to the fact that vaccination campaigns are in early stages in many countries. We expect to hear of further such reported cases."

Their report states, "Patients with corneal transplants and their clinicians should not be deterred from COVID-19 vaccination . . . and should note that both patients responded well to topical steroid treatment."

Dr. Viral Juthani, director of ophthalmology at the Montefiore Health System's Hutchinson campus, in New York City, told Reuters Health by email, "The fact that Case 2 reported by the authors was a bilateral, simultaneous graft rejection event is suspicious for causality, as this is rarely seen in clinical practice, and especially after DMEK surgery."

He emphasized that "the benefits of vaccination outweigh the potential risks. However, as the authors mention, it is reasonable to restart or increase rejection prophylaxis with topical steroids in the peri-vaccination period for existing transplants, and to delay future transplantation until after vaccination and an immunization period has elapsed."

SOURCE: British Journal of Ophthalmology, online April 28, 2021.