Case Report: Acute Posterior Multifocal Placoid Pigment Epitheliopathy after SARS-CoV-2 Vaccination

Abstract

SIGNIFICANCEAcute posterior multifocal placoid pigment epitheliopathy is an uncommon inflammatory chorioretinopathy that has been reported after vaccination. This is the first reported case, to our knowledge, after vaccination for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in a healthy adolescent boy.PURPOSEThis report aimed to inform the eye care community about a possible ocular sequela of SARS-CoV-2 vaccination.CASE REPORTA 17-year-old boy presented to a clinic for a second opinion after sudden-onset blind spots in his right eye. His medical history was remarkable for receiving the first dose of the Pfizer-BioNTech SARS-CoV-2 vaccine 2 weeks before symptom onset. He had no history of ocular inflammation, autoimmune disease, or systemic infection. A diagnosis of unilateral acute posterior multifocal placoid pigment epitheliopathy was made based on the presence of typical fundus lesions and noninvasive imaging with fundus autofluorescence, retinal optical coherence tomography, and optical coherence tomography angiography. The diagnosis was further confirmed with fluorescein angiography. The patient developed an anterior vitritis in the right eye 42 days after initial symptom onset. His unilateral intraocular inflammation resolved after a 5-week course of prednisone.CONCLUSIONSAcute posterior multifocal placoid pigment epitheliopathy is a self-limited inflammatory condition of the outer retina that usually affects young adults and often does not require treatment. It has been reported to occur after vaccination for influenza, polio, hepatitis B, meningococcus C, and varicella zoster virus. This is the first known case to occur after SARS-CoV-2 vaccination in a healthy adolescent boy.

Bilateral Acute Posterior Multifocal Placoid Pigment Epitheliopathy With Bacillary Layer Detachment Following Sinopharm COVID-19 Vaccination: A Case Report

“…Ocular manifestations post-COVID-19 vaccination have been documented, spanning conditions like facial and abducens nerve palsy, macular neuroretinopathy, CSCR, CRVO, uveitis, and Grave’s disease. The presented case aligns with these reports, specifically describing APMPPE, an inflammatory eye condition affecting the posterior pole [ 3 - 5 , 7 , 8 ].…”

The characteristics of white dot syndromes following COVID-19 Vaccines: a systematic review

“…(Fig. 1 ) Thirty-two were case reports (71.11%) [ 12 , 18 , 20 , 24 – 26 , 35 – 64 ] and 13 were case series (31.11%). [ 17 , 65 – 76 ] Sixty-four patients were included.…”

“…The choroidal thickness (CT) in the RE was 4 times more than normal and LE was 2 times more than normal Covishield 2 9 Twenty-four hours post-vaccination he had severe frontal Headache, ocular pain, mild pain at the injection site and generalized myalgia for the first two days Fowler et al [ 44 ] Mélanie H. et al [ 45 ] NA Peripheral nonperfusion and vasculitis OU, as well as a peripapillary pigment epithelial detachment OD Dilated fundus examination was normal OU without signs of macular edema, chorioretinitis, optic nerve edema, granulomas, or vascular sheathing.2 weeks later dilated fundus exam showed spillover of cells in the anterior vitreous with vascular sheathing OU and two yellowish infiltrates along the inferior arcade OD Pfizer-BioNTech-BioNTech 1 2 NA Mélanie H. et al [ 45 ] Ahmed et al [ 46 ] EZ disruption superior to fovea Early hyperfluorescent spots, circumferentially distributed around fovea Fundoscopy (Spread of spots OS > OD, vitreous cells OS > OD) BNT162b2 mRNA vaccine 2 3 NA Ahmed et al [ 46 ] Ahmed et al [ 70 ] Hyperreflective lesions affecting the outer plexiform and outer nuclear layers with disruption of the ellipsoid zone NA OCTA OS possible flow deficits in the deep capillary plexus Pfizer-BioNTech-BioNTech 2 8 NA Ahmed et al [ 70 ] Azar et al [ 12 ] Focal areas of disruption of the ellipsoid layer, outer retina, and retinal pigment epithelium Early hypofluorescence and late staining of the placoid lesions in the OD Fundoscopy: multiple flat, creamy white placoid subretinal lesions within the posterior pole and temporal midperipheral retina of the OD, FAF confirmed APMPPE demonstrated multip...…”

“…prednisolone 1% every hour. At follow-up 4.5 months later, the patient was successfully tapered to 5 mg of oral prednisone and prednisolone 1% twice daily with timolol once daily for IOP control PHVA was 20/30 + 1 OD and 20/30 + 2 OS, complication: fluorescein angiography showed a peripheral avascular zone with staining temporally OU, the same asymptomatic peripapillary pigment epithelial detachment OD, and suspicion of a single peripheral neovascularization OD so follow up with vitreoretinal specialist 18 weeks Ahmed et al [ 46 ] 110 MEWDS Unilateral 3 days Blurred vision Neomycin & Betamethasone sodium phosphate VA same, fundus lesions absent, complication: NA 8 weeks Ahmed et al [ 70 ] 111 AMN Unilateral 3 days Visual field disturbance NA NA, complication: NA NA Azar et al [ 12 ] 113 APMPPE Unilateral NA Sudden blind spots Observation for 42 days till anterior vitritis developed then oral prednisolone tapered for 5 weeks 20/20 OU, placoid lesions were replaced by pigmented scars, and the anterior vitritis was completely resolved, complication: NA 16 weeks Azar et al [ 88 ] 114 AMN Unilateral NA Temporal paracentral scotoma NA NA, complication: NA NA Azar et al [ 88 ] 114 AMN Unilateral NA Blurred vision, and photopsia NA Resolution, complication: NA ...…”

“…White Dot Syndromes (WDS) are rare diseases of chorioretinopathy that have an annual incidence of 0.45 per 100,000 per year and typically affect young, healthy adults [11]. It has been reported that WDS can happen after vaccination for a number of diseases, including influenza, hepatitis B, polio, human papillomavirus (HPV), measles, mumps, rubella, and COVID-19 [12][13][14][15][16][17][18]. In fact, there growing evidence linking COVID-19 vaccinations and subtypes of WDS.…”