Corneal transplant rejection following COVID-19 vaccination

Acute corneal endothelial rejection is a possibility soon after either the first or second dose of the COVID-19 messenger RNA (mRNA) vaccine (Moderna), according to Amar P. Shah, MD, MBA, from the Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, and colleagues.

The investigators, who reported 4 such cases of acute corneal transplant rejection that were associated with patients having received COVID-19 mRNA vaccinations, suggested that in such cases immediate and aggressive topical steroid therapy be instituted to reverse the rejection episode.¹

These 4 patients had all undergone a previous keratoplasty and subsequently developed what was presumed to be an immunologic rejection associated with the mRNA-1273 vaccination.

The investigators reported that the patients had undergone the following procedures, all with rejection episodes that developed shortly thereafter:

Descemet membrane endothelial keratoplasty performed 6 months previously followed by endothelial graft rejection 3 weeks after the first vaccination (case 1); penetrating keratoplasty performed 3 years previously with acute endothelial rejection beginning 9 days after the second dose (case 2); Descemet stripping automated endothelial keratoplasty followed by symptoms of endothelial graft rejection 2 weeks after the second dose (case 3); and endothelial rejection of a penetrating keratoplasty graft 2 weeks after the second dose (case 4).

Results of steroid therapy
In all cases, the investigators prescribed frequent instillation of topical steroids, with beneficial results in all cases.

Specifically, they found that the rejection line in the endothelium in case 1 was less pronounced and the vision and corneal edema improved 5 weeks after the rejection episode was recognized; the corneal edema and rejection line resolved with treatment 6 weeks after the start of the rejection in case 2; and in the other 2 cases the clinical pictures showed initial improvement as the result of steroid therapy.

The authors concluded that immediate aggressive treatment with topical steroids may lead tocomplete resolution of the clinical signs and symptoms of rejection of corneal transplantations.

However, they also noted that the cause of the corneal graft rejection as it is related to the COVID-19 mRNA vaccination should be determined.

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Reference

1. Shah AP, Dzhaber D, Kenyon KR, et al. Acute corneal transplant rejection after COVID-19 vaccination. Cornea 2022;41:121-4; doi: 10.1097/ICO.0000000000002878