Researchers note a pair of cases of endothelial corneal transplant rejection after immunization with the SARS-CoV-2 messenger RNA (mRNA) vaccine, according to a study published in the British Journal of Ophthalmology. The cases appear to be the first reported temporal association between corneal transplant rejection following immunization against COVID-19 and the first report of Descemet’s membrane endothelial keratoplasty (DMEK) rejection following any immunization, investigators say. 

“Despite the immune privilege of the cornea, immune-mediated corneal allograft rejection does occur, especially after penetrating keratoplasty in high rejection risk eyes,” the report explains.

In the first reported case, a 66-year-old Caucasian woman had uneventful combined right phacoemulsification, lens implantation, and DMEK for Fuchs endothelial corneal dystrophy (FECD), receiving the first (of two) dose of SARS-CoV-2 mRNA vaccine BNT162b2 (Pfizer-BioNTech) on day 14 post-transplant. Seven days following vaccination, and day 21 post-transplant, symptoms began following compliance with all medication: “She presented with acute onset of blurred vision, redness and photophobia in the right eye.” The patient did have a well-controlled HIV infection (undetectable viral load, CD4+ >600cells/mm3) and was on antiretroviral therapy with Triumeq (abacavir/ dolutegravir/lamivudine). 


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The second case was of an 83-year-old woman who had DMEK and cataract surgery for FECD in the right eye 6 years earlier from rejection and in the left eye 3 years earlier with replacement of an earlier Descemet’s stripping endothelial keratoplasty (DSEK) graft. She’d had both doses of the Pfizer-BioNTech vaccine, starting at 2 months (first dose) and 3 weeks (second dose) before sudden onset of bilateral blurred vision, pain, photophobia and redness.

Rejections in both cases were treated, successfully, with topical corticosteroids. 

“We hypothesize that the allogeneic response may have been initiated by the host antibody response following vaccination,” according to the report.

These cases should not prevent those with corneal transplants from receiving the COVID-19 vaccines, investigators say, but can instead act as a note of caution.

“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,” investigators explain. “Patients should be counselled on the symptoms and signs that require urgent review to allow early treatment of any confirmed rejection episode.”

Reference

Phylactou M, Li JO, Larkin DFP. Characteristics of endothelial corneal transplant rejection following immunisation with SARS-CoV-2 messenger RNA vaccine. Br J Ophthalmol. Published online April 28, 2021. doi:10.1136/bjophthalmol-2021-319338