Comment on: 'Acute macular neuroretinopathy following COVID-19 vaccination'.

To the Editor:

Recently, Bohler et al., described the first report of acute macular neuroretinopathy (AMN) following Vaxzevria (formerly ChAdOx1 nCoV-19, Oxford–AstraZeneca, UK) providing a possible causal association with COVID-19 innoculation [1]. Through mid 2021, there are 5 reported cases of AMN following vaccination with Vaxzevria [1-4]. We describe the first AMN case following use of an alternate mRNA vaccine.

A 21-year-old Caucasian female was referred for assessment of ongoing left paracentral scotomas. Her only medication was a combined oral contraceptive (ethinylestradiol 0.02mg-levonorgestrel 0.1mg). Ten weeks previously she had received her first COVID-19 vaccine injection (BNT162b2 mRNA, Pfizer-BioNTech). Three days post-injection, she developed acute chills, myalgia, headache and two left scotomas either side of fixation. Systemic symptoms resolved quickly. The patient reported a gradual decrease in scotoma intensity with time.

Uncorrected visual acuity was 6/6 bilaterally and right eye examination normal. Left fundus examination demonstrated barely visible oval parafoveal lesions with slight hyper-fluorescence on imaging (Optos, MA, USA). Infrared reflectance imaging (Cirrus, Zeiss, Germany) confirmed two parafoveal oval hypo-reflective lesions. Findings were consistent with left AMN (Figs. 1–2).

Fig. 1

Documented clinical changes at follow up visit.

A (Left) Fundus image of left eye indicating oval parafoveal lesions on autofluorescence imaging. B (Right): Corresponding visual field note parafoveal depressions corresponding to fundus imaging.

Fig. 2

Documented OCT changes at follow up visit.

A (Top): OCT imaging focal areas of paracentral hyper-reflectivity of the outer plexiform layer and outer nuclear layer with disruption of the ellipsoid zone. B (Bottom): oval hypo-reflective lesions located inferonasal and superotemporal to the fovea via Infrared reflectance imaging.

Paracentral scotomas have been described in almost three-quarters of AMN cases (73%), remaining symptomatic at final follow-up in over half of these patients [5]. Decreased acuity remains less common (12–16%) [5]. Exact pathophysiology is unknown but a potential mechanism is ischemia in the deep retinal capillary plexus or choriocapillaris [5]. Dominant associated factors are recent infection, febrile illness and use of oral contraceptives [1].

All reported cases of AMN following Vaxzevria COVID-19 vaccination have noteworthy similarities to our case [1-4]. All cases involved females aged 21 to 28 years taking oral contraceptives. Acute paracentral scotomas developed 2 or 3 days following the initial vaccination. In all but one case, ocular symptoms were coexistent with systemic flu-like symptoms. Our case represents the first following BNT162b2 (Pfizer-BioNTech) injection.

The occurrence of AMN following COVID-19 vaccination is rare; however, with minimal impact on acuity and often subtle retinal signs, it may be under-reported. Our case supports Bohler et al., lending support to the hypothesis that marked systemic inflammation following vaccination may represent a possible risk factor for AMN in young women on oral contraceptives.