SARS-CoV-2 vaccination campaigns document a satisfactory high profile of protection against Covid-19 infection, but auto-immune/inflammatory diseases have been reported following Covid-19 vaccines. A 65-year-old woman reported two days following her first dose of the BNT162b2 mRNA vaccine tearing, eye irritation, conjunctival redness, peri-orbital swelling, spontaneous hematoma of the right lower eyelid, right greater than left proptosis, with a spontaneous improvement of symptoms during the following two weeks. She received the second dose of BNT162b2 vaccine after 6 weeks and noted an aggravation of the right proptosis. An ophthalmic examination noted high intraocular pressure on the right eye (30 mmHg) and brinzolamide, timolol and latanoprost eye drops were progressively introduced. After 3 months, Hertel values were 25 and 19 mm and palpebral fissures 12 and 11 mm for right and left eyes, respectively. The clinical activity score (CAS) was 4/7, but visual acuity, ocular motility and color vision test were normal. TSH concentration was 0.83 mU/l, and anti-thyroid antibodies were negative. CT and MRI scans confirm an asymmetric proptosis with a diffuse infiltration of the orbital fat and hypertrophy of extra-ocular muscles in the right orbit. At 4th month, she reported a visual acuity loss of the right eye (20/30) but fundus examination and optical coherence tomography were normal. She had intravenous 500 mg methylprednisolone infusion every two days and she reported transitory improvement of symptoms. Then she received iv 500 mg methylprednisolone once weekly for 4 weeks. She noted a transient improvement of pain and eyelid edema after each infusion, without reduction of proptosis and CAS after the first 6 intravenous infusions. Then the patient had intravenous 250 mg methylprednisolone infusion once weekly for 4 weeks until an orbital bone-wall decompression of the right orbit was performed. One month after surgery, ophthalmic evaluation reported Hertel value (23 mm), intraocular pressure (17 mmHg) and CAS (2/7) for right eye. To our best knowledge, there is the first report of an orbital inflammatory disease following mRNA SARS-CoV-2 vaccination. The temporal relationship between Covid-19 vaccination and onset of orbital symptoms suggest that SARS-CoV-2 mRNA vaccine can probably be associated with this orbital inflammatory disease. The mechanisms of occurrence of this orbital inflammatory side effect are a manner of debate (molecular mimicry, bystander activation, autoimmune/inflammatory syndrome induced by adjuvants). There is no treatment consensus when patients do not respond to first-line glucocorticoids (immunomodulatory therapy, orbital radiation, decompressive surgery).
21 May 2022 - 24 May 2022