FEATURE 16 EWAP MARCH 2023 Same patient at 1 month following treatment of HSV immune stromal keratitis and uveitis that flared up 2 weeks after second dose of COVID19 vaccine. resources wasted. Dr. Chan presented on the topic of vaccination and the possibility of graft rejection during the Lindstrom Symposium at the 2022 ASCRS Annual Meeting. In her presentation, titled “Are We Seeing More Inflammatory Corneal Events?” she shared cases she had encountered of corneal complications after COVID-19 vaccination. Because of the pandemic, Dr. Chan said there were a number of variables to consider: A lot of patients missed their follow-up appointments; prescriptions were not being renewed; there was a fear of steroids causing “immune compromise”; there was a fear of coming to the hospital clinic “where COVID patients go;” and there was a push for mass vaccination. The first case Dr. Chan shared was that of a DMEK rejection in a 69-year-old male. The patient had his first DMEK in 2019 for Fuchs dystrophy in the left eye, and it was a routine surgery. However, the patient stopped his steroid drop. Rejection led to DMEK failure, persistent corneal edema, and vision down to 20/200. In 2020, the patient had his second DMEK in the same eye, which was an uneventful surgery. Dr. Chan said he was doing fine postoperatively, but 4 months later came in complaining of a red eye. The patient reported symptom onset about 3 weeks after his first dose of the COVID-19 vaccine. Given his history, Dr. Chan was more aggressive and added oral steroids as well as topical. He was on prednisolone and cyclosporine, and BCVA was 20/40. Dr. Chan increased topical steroids, which resolved the symptoms. Her second case was that of a keratolimbal allograft rejection in a 73-year-old patient who had been stable for the last 6 years. There had been a lot of work done with this patient’s eye to reconstruct it because he had stem cell disease. He had undergone keratolimbal allograft, stem cell transplant from a deceased donor. Then he had a penetrating keratoplasty and cataract surgery. The patient had total limbal stem cell deficiency (LSCD) from a chemical injury before treatment. He had baseline UCVA 20/60 and was on cyclosporine, dorzolamide/timolol, brimonidine, prednisone, and oral tacrolimus. He was doing great, Dr. Chan said, but came in 3 weeks after the first dose of his vaccine and had engorged vessels in each of the keratolimbal segments. Dr. Chan had to be very aggressive and stepped up topical steroids and systemic immunosuppression. The patient refused to take oral prednisone due to a fear of steroids, making him further immunosuppressed. Her third case was that of an 81-year-old female with HSV immune keratitis flare and LSCD progression. She had stable BCVA 20/50 for 5 years. She received dose two of the vaccine 2 weeks prior to complaints of a red eye and decreased vision. She presented with counting fingers, AC 1+ cells, corneal edema, and active haze. Dr. Chan said the cornea was severely inflamed, so she bumped up topical steroid and oral antivirals. A month later, the corneal swelling had cleared, but her LSCD progressed further. Whorl-like late staining passed beyond the pupil, and vision was decreased permanently. But Dr. Chan noted that her other eye was good, so the patient didn’t want anything done. The final case Dr. Chan shared was that of a 54-year-old male who was stable with medically managed Crohn’s disease. He had recent shingles immune stromal keratitis 3 months prior and was on valacyclovir and loteprednol. He was still somewhat immunocompromised but was stable. The patient complained of pain, redness, tearing, and blurry vision OD 2 weeks after getting the vaccine. He had a flare-up of shingles immune corneal keratitis. Dr. Chan stepped up his steroid, and a week later, the corneal edema had unusual dendritic-like epithelial lesions. Given the history of cold sores, she thought it was a herpes simplex complication or zoster. Dr. Chan had to balance the topical steroid with oral antiviral continued on page 39
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