A recent paper reveals that clinicians and patients should be aware of the potential of corneal graft rejection associated with COVID-19 vaccine administration and consider vaccination in advance of planned non-urgent keratoplasties. The researchers believe that their study is the first report of temporal association between corneal transplant rejection following immunization against COVID-19 and the first report of DMEK rejection following any immunization. They hypothesize that the allogeneic response may have been initiated by the host antibody response following vaccination.1

In one case, DMEK was performed around the time of vaccination, but it had taken place years earlier in the other. In both cases, one unilateral and the other bilateral, the transplant rejection was treated successfully with topical corticosteroids.

In the first case, a 66-year-old woman underwent an uneventful DMEK in her right eye. Her history was notable for HIV infection that was well controlled (undetectable viral load). Two weeks after DMEK, she received the first dose of Pfizer’s COVID vaccine. She presented a week later with acute-onset blurred vision, redness and photophobia in her right eye. Clinical examination found indications typical of acute endothelial graft rejection. The frequency of topical steroid (dexamethasone 0.1%) was increased from four times daily to every hour. Signs and symptoms began to resolve after three days, and by four weeks after the rejection onset, visual acuity was good and there was no active inflammation.

In the second case, an 83-year-old woman had undergone DMEK in her right eye six years earlier and in her left eye three years earlier. She presented with symptoms of rejection two months after receiving her first COVID vaccine dose and three weeks after the second dose. Bilateral simultaneous acute endothelial graft rejection was diagnosed, and she was put on hourly steroid drops. Seven days later, signs of inflammation were reduced and both grafts were functioning well, at which time the frequency of topical dexamethasone was reduced.1

In an email to Reuters Health, the authors speculated that, “The patient’s antibody response triggered by vaccination caused immunological injury to the internal (endothelial) surface of the transplanted donor cornea.”2

Nevertheless, their report states, “Patients with corneal transplants and their clinicians should not be deterred from COVID-19 vaccination.”1

1. Phylactou M, Li JPO, Larkin DFP. Characteristics of endothelial corneal transplant rejection following immunisation with SARS-CoV-2 messenger RNA vaccine. Br J Ophthalmol. April 28, 2021. [Epub ahead of print].

2. Baltic S. SARS-CoV-2 mRNA vaccine might trigger corneal-transplant rejection. Medscape. www.medscape.com/viewarticle/950985. May 13, 2021. Accessed May 26, 2021.