Characteristics of endothelial corneal transplant rejection following immunisation with SARS-CoV-2 messenger RNA vaccine

Abstract

AimWe report two cases of endothelial corneal allograft rejection following immunisation with SARS-CoV-2 messenger RNA (mRNA) vaccine BNT162b2 and describe the implications for management of transplant recipients postvaccination for COVID-19.MethodsA 66-year-old woman with Fuchs endothelial corneal dystrophy (FECD) and a unilateral Descemet’s membrane endothelial keratoplasty (DMEK) transplant received COVID-19 mRNA vaccine BNT162b2 14 days post-transplant. Seven days later, she presented with symptoms and signs of endothelial graft rejection. An 83-year-old woman with bilateral DMEK transplants for FECD 3 and 6 years earlier developed simultaneous acute endothelial rejection in both eyes, 3 weeks post second dose of COVID-19 mRNA vaccine BNT162b2. Rejection in both cases was treated successfully with topical corticosteroids.ConclusionsWe believe this is the first report of temporal association between corneal transplant rejection following immunisation against COVID-19 and the first report of DMEK rejection following any immunisation. We hypothesise that the allogeneic response may have been initiated by the host antibody response following vaccination. 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. Patients should be counselled on the symptoms and signs that require urgent review to allow early treatment of any confirmed rejection episode.

Ocular Adverse Events After COVID-19 Vaccination

“… A case report of reactivation of Vogt-Koyanagi-Harada disease post-vaccination BNT162b2 2 6 weeks Photophobia, ocular pain n = 1 Phylactou et al . 34 Characteristics of endothelial corneal transplant rejection following immunisation with SARS-CoV-2 messenger RNA vaccine. A case report of Descemet membrane endothelial keratoplasty (DMEK) patients with graft rejection post-vaccination BNT162b2 1, 2 7 days to 3 weeks Blurred vision, red eye, photophobia n = 2 Rabinovitch et al .…”

“…Four articles described corneal graft rejection soon after receiving a COVID-19 vaccination. 25 , 34 , 36 , 43 Phylactou et al . 34 reported two cases of allograft rejection following Descemet’s membrane endothelial keratoplasty (DMEK); both were female.…”

“…25 , 34 , 36 , 43 Phylactou et al . 34 reported two cases of allograft rejection following Descemet’s membrane endothelial keratoplasty (DMEK); both were female. A 66-year-old woman received the BNT162b2 vaccine 14 days after grafting and developed endothelial graft rejection 7 days later (day 21 post-transplant).…”

Plague rampant: two sides of the coin

“…Although corneal transplantation rejection triggered by vaccination has been reported (mainly after the influenza vaccine), it is considered a rare event. The present report of two cases of endothelial corneal allograft rejection following immunisation with SARS-CoV-2 mRNA vaccine raises 18 the issue of a relationship between the vaccine which elicits an immunological response to the spike protein, the expression of the ACE2 receptor by corneal endothelial cells and the rejection reaction targeting the corneal endothelium. It is worth thinking that a recent study into COVID-19 vaccine response, which includes mRNA vaccine in 187 solid organ transplant recipients, did not report any episodes of acute rejection.…”

“…As ophthalmologists, we should be alert for possible postvaccination rejection and report cases to the relevant authorities and professional journals. At the time of earliest reports of ophthalmic complications such as corneal allograft rejection reported in this issue by Phylactouet al, 18 proof of a causal relationship with vaccination can be difficult. Similar to adverse reactions to drugs, recognition of a true association depends on subsequent reporting of similar complications by colleagues.…”