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Ophthalmic consequences of the H1N1 flu vaccine raise concern among surgeons
Three cases of graft rejection shortly after vaccination alert corneal, refractive surgeons.
The H1N1 flu vaccine may have immune-related ophthalmic consequences in specific cases, according to anecdotal reports from surgeons worldwide.
One patient in the U.S. was reported by two corneal specialists at the Bascom Palmer Eye Institute in Palm Beach Gardens, Fla., as having had bilateral graft rejection 1 day after vaccination.
The patient was 25 years old and had undergone penetrating keratoplasty for keratoconus in both eyes, the left eye in 2004 and the right eye in 2009. In October, she was administered the live attenuated H1N1 vaccine intranasally.
?The following day she woke up with swollen, painful eyelids, low vision, photophobia ? more accentuated in the right eye,? Jonathan Etter, MD, said. ?She came to see us, and we found that visual acuity, which was previously 20/25 in both eyes, had dropped to 20/30 in the left eye and to count fingers in the right eye. We also found keratic precipitates and numerous anterior chamber cells in both eyes. The graft was diffusely edematous, more in the right than in the left eye.?
The initial treatment was to boost topical steroid therapy. The patient was already on topical prednisolone 1% four times a day in the right eye. The dosage was increased to one drop every hour in both eyes. In a few days, the rejection episode had resolved in the left eye, but not in the right eye. She was started on oral steroids and the graft had a mild improvement: Vision recovered, but the cornea was still edematous. The cornea later cleared.
David A. Goldman
?We definitely believe that this episode was linked to the vaccination,? David A. Goldman, MD, said.
Corneal graft rejection after vaccination with influenza vaccine was previously reported by several authors, but the time between vaccination and rejection ranged between 2 weeks and 8 weeks. The fast onset of rejection in this case, only a few hours, is unique, according to Dr. Goldman.
?It may be due to the use of live attenuated, rather than killed, vaccine and also to the proximity of the administration site, the nostrils, to the eye,? he said. ?However, it may also represent a more robust immune reaction to a relatively new vaccine.?
A clear cause-effect relationship
Two cases of graft rejection after injection of the killed vaccine were reported by Jorge L. Ali?, MD, PhD, of the Vissum Institute in Alicante, Spain.
Jorge L. Ali?
One patient, aged 30 years, underwent unilateral corneal transplantation 1.5 years before vaccination and experienced graft rejection 3 days after injection with the vaccine. The other patient, aged 45 years, underwent unilateral transplantation 4 years before vaccination and experienced symptoms of early rejection 5 days after vaccination with a confirmed diagnosis of endothelial corneal graft rejection.
?Both patients presented with blurred vision, red eye and the typical signs of endothelial cell rejection, with few endothelial precipitates and mild uveitis. A significant decrease in visual acuity was found,? Dr. Ali? said.
In both cases, aggressive topical steroid treatment prevented corneal decompensation. The patients both regained their best corrected visual acuity, although a significant number of endothelial cells were lost.
?There is a clear cause-effect relationship of these rejection cases with the vaccine. Nothing new, but it is possible that the type of immunization produced by the H1N1 vaccine is more aggressive for a good reason, which an expert on vaccines might be able to explain,? Dr. Ali? said.
Other cases of graft rejection after H1N1 vaccination are likely to have occurred around the world.
Information plays a critical role
The three surgeons expressed concerns about the potential consequences of the H1N1 vaccination in refractive surgery patients.
?An increased immune response can be associated with regression, diffuse lamellar keratitis and even corneal melting,? Dr. Etter said.
Both patients and physicians should be aware of the risk of receiving H1N1 vaccination before or just after refractive procedures and, if this cannot be avoided, should consider a more frequent and prolonged course of topical steroid therapy.
?Given the rapidity of onset of the immune reaction, all ocular procedures should be considered at higher risk of complications if performed around the time of H1N1 vaccination if inflammation is not adequately controlled,? Dr. Goldman said.
Information plays a critical role, Dr. Ali? said. The ophthalmic community should be alert, and anyone noticing vaccine-related ophthalmic complications should report and publicize their cases as much as possible. ? by Michela Cimberle
?Jorge L. Ali?, MD, PhD, can be reached at Vissum, Instituto Oftalmologico de Alicante, Avda. de Denia, s/n, 03016 Alicante, Spain; +34-965-150-025; fax: +34-965-151-501; e-mail: jlalio@vissum.com.
?David A. Goldman, MD, and Jonathan Etter, MD, can be reached at Bascom Palmer Eye Institute, 7101 Fairway Drive, Palm Beach Gardens, FL 33418, U.S.A.; +1-561-515-1543; fax: +1-561-515-8600; e-mail: dgoldman@med.miami.edu.
Ophthalmic consequences of the H1N1 flu vaccine raise concern among surgeons
Three cases of graft rejection shortly after vaccination alert corneal, refractive surgeons.
The H1N1 flu vaccine may have immune-related ophthalmic consequences in specific cases, according to anecdotal reports from surgeons worldwide.
One patient in the U.S. was reported by two corneal specialists at the Bascom Palmer Eye Institute in Palm Beach Gardens, Fla., as having had bilateral graft rejection 1 day after vaccination.
The patient was 25 years old and had undergone penetrating keratoplasty for keratoconus in both eyes, the left eye in 2004 and the right eye in 2009. In October, she was administered the live attenuated H1N1 vaccine intranasally.
?The following day she woke up with swollen, painful eyelids, low vision, photophobia ? more accentuated in the right eye,? Jonathan Etter, MD, said. ?She came to see us, and we found that visual acuity, which was previously 20/25 in both eyes, had dropped to 20/30 in the left eye and to count fingers in the right eye. We also found keratic precipitates and numerous anterior chamber cells in both eyes. The graft was diffusely edematous, more in the right than in the left eye.?
The initial treatment was to boost topical steroid therapy. The patient was already on topical prednisolone 1% four times a day in the right eye. The dosage was increased to one drop every hour in both eyes. In a few days, the rejection episode had resolved in the left eye, but not in the right eye. She was started on oral steroids and the graft had a mild improvement: Vision recovered, but the cornea was still edematous. The cornea later cleared.
David A. Goldman
?We definitely believe that this episode was linked to the vaccination,? David A. Goldman, MD, said.
Corneal graft rejection after vaccination with influenza vaccine was previously reported by several authors, but the time between vaccination and rejection ranged between 2 weeks and 8 weeks. The fast onset of rejection in this case, only a few hours, is unique, according to Dr. Goldman.
?It may be due to the use of live attenuated, rather than killed, vaccine and also to the proximity of the administration site, the nostrils, to the eye,? he said. ?However, it may also represent a more robust immune reaction to a relatively new vaccine.?
A clear cause-effect relationship
Two cases of graft rejection after injection of the killed vaccine were reported by Jorge L. Ali?, MD, PhD, of the Vissum Institute in Alicante, Spain.
Jorge L. Ali?
One patient, aged 30 years, underwent unilateral corneal transplantation 1.5 years before vaccination and experienced graft rejection 3 days after injection with the vaccine. The other patient, aged 45 years, underwent unilateral transplantation 4 years before vaccination and experienced symptoms of early rejection 5 days after vaccination with a confirmed diagnosis of endothelial corneal graft rejection.
?Both patients presented with blurred vision, red eye and the typical signs of endothelial cell rejection, with few endothelial precipitates and mild uveitis. A significant decrease in visual acuity was found,? Dr. Ali? said.
In both cases, aggressive topical steroid treatment prevented corneal decompensation. The patients both regained their best corrected visual acuity, although a significant number of endothelial cells were lost.
?There is a clear cause-effect relationship of these rejection cases with the vaccine. Nothing new, but it is possible that the type of immunization produced by the H1N1 vaccine is more aggressive for a good reason, which an expert on vaccines might be able to explain,? Dr. Ali? said.
Other cases of graft rejection after H1N1 vaccination are likely to have occurred around the world.
Information plays a critical role
The three surgeons expressed concerns about the potential consequences of the H1N1 vaccination in refractive surgery patients.
?An increased immune response can be associated with regression, diffuse lamellar keratitis and even corneal melting,? Dr. Etter said.
Both patients and physicians should be aware of the risk of receiving H1N1 vaccination before or just after refractive procedures and, if this cannot be avoided, should consider a more frequent and prolonged course of topical steroid therapy.
?Given the rapidity of onset of the immune reaction, all ocular procedures should be considered at higher risk of complications if performed around the time of H1N1 vaccination if inflammation is not adequately controlled,? Dr. Goldman said.
Information plays a critical role, Dr. Ali? said. The ophthalmic community should be alert, and anyone noticing vaccine-related ophthalmic complications should report and publicize their cases as much as possible. ? by Michela Cimberle
?Jorge L. Ali?, MD, PhD, can be reached at Vissum, Instituto Oftalmologico de Alicante, Avda. de Denia, s/n, 03016 Alicante, Spain; +34-965-150-025; fax: +34-965-151-501; e-mail: jlalio@vissum.com.
?David A. Goldman, MD, and Jonathan Etter, MD, can be reached at Bascom Palmer Eye Institute, 7101 Fairway Drive, Palm Beach Gardens, FL 33418, U.S.A.; +1-561-515-1543; fax: +1-561-515-8600; e-mail: dgoldman@med.miami.edu.