Case Presentation
A 52-year-old woman presented with complete redness in the right and a slight color change in the left eye for one week (Figure 1). She had no history of hypersensitivity reaction or similar events. A week ago, she was vaccinated with the third dose of COVID-19 vaccine. The patient first developed right eye redness 3 days after the third dose of inactivated Sinopharm vaccine (BBIBP- CorV), which was slightly spread to the left side 3 days after. She presented to our clinic in the seventh day after her eye redness (Figure 2). No history of familial vasculopathies, or recent trauma to the eyes was detected. Moreover, on the first and second dose of vaccination, both Sinopharm, a year and 6 months before, in respect, she experienced no similar symptoms or infrequent adverse effects. Initially, she was prescribed a corticosteroid eye drop immediately after following the left eye erythema (on the sixth day after vaccination), causing no change in her condition (Figure 2). On physical examination, the vital signs of the patient were within normal limits and stable with no respiratory distress and fever. No history of previous fever and chills, night sweats or weight changes. No signs of lymphadenopathy or splenomegaly were detected. The neurological examination of the patient was unremarkable. Ophthalmic examination revealed no signs and symptoms of eye discharge, pain, photophobia, and itching. She had no exophthalmia or proptosis. Besides, her past medical history included pterygium on her left eye conjunctiva during the past year, which was well-controlled. According to the oculist, her previous visual acuity was reported to be 20/20 bilaterally before the presence of redness and the same in the presence of redness. Wide spread erythema and slight scleral edema was present only in the right eye. Intraocular pressures were reported 17 mmHg and 16 mmHg in the right and left eye, respectively. Fundus examination was normal in both eyes. Further slit lamp examination showed crisscrossed inflamed scleral vessels that were adherent to sclera in the right eye. The globe was tender to touch, particularly at right side, and phenylephrine test result was negative bilaterally. There was no sign of inflammation, scleral cells or injection, or necrosis bilaterally. Microvascular dilatation in various layers in conjunctiva, and also deep sclera at 3 and 9’o clock was seen at right. The examination of anterior and posterior chambers was unremarkable in both eyes. Additionally, there was no nodule, limbal phlycten, or AC cells.  All these findings were compatible with unilateral anterior scleritis of the right eye.
Further tests were conducted considering the infectious causes, autoimmune diseases, systemic inflammatory disorders such as vasculopathies, and connective tissue diseases. Laboratory results showed an increase in c-reactive protein, and erythrocyte sedimentation rate to 9.1 (positive: >9), and 39 (positive >30) respectively. Moreover, all tests of liver function, kidney function tests, albumin, total protein, anti-neutrophil cytoplasmic antibodies (P-ANCA), perinuclear anti-neutrophil cytoplasmic antibodies (C-ANCA), fluorescent antinuclear antibody (FANA), complement 3 (C3), C4, anti- double-stranded DNA (anti-dsDNA), serology tests for hepatitis C virus (HCV), hepatitis B virus (HBV), human immunodeficiency virus (HIV) tests were all negative or normal (Table 1). Also, the findings of stool examination and urinalysis did not reveal any findings in favor of renal disorders or infectious diseases. Radiological evaluation with Chest X-ray (CXR) and computed tomography scan did not reveal any remarkable findings. Echocardiography and electrocardiogram showed no abnormal findings without any systolic or diastolic dysfunction and with normal ejection fraction. Electromyography-nerve conduction velocity (EMG-NCV) were normal.
By merging all the information obtained from the patient's symptoms and clinical assessments, autoimmune diseases, systemic inflammatory disorders such as vasculopathies, as well as connective tissue diseases other than infectious causes have all been excluded. The lack of other symptoms or any history of musculoskeletal or mucocutaneous involvement, normal EMG-NCV, in addition to normal rheumatological examination and lab data, rule out connective tissue disease or vasculopathies. Infection was rendered less likely by negative viral tests, normal CXR, and the absence of further manifestations of infectious diseases such as fever, weight loss, gastrointestinal, respiratory, or genitourinary involvements. Normal tests for all the other underlying causes, according to the recent COVID-19 vaccine, scleritis as an autoimmune reaction induced by Sinopharm COVID-19 vaccination was approved. For anterior, non-necrotizing, non-infectious scleritis, non-steroid anti-inflammatory drugs (NSAIDs), or topical steroids would be a great choice. However, she presented with a progressive scleritis with no response to home analgesic intake, and ophthalmic steroid usage in four days. Thus, a tapering dose of prednisolone (0.5 mg/kg/day; 30 mg at the start) as the first line immunosuppression, in addition to azathioprine (2 mg/kg; 100 mg/day) was also added as a steroid-sparing immunosuppressive, were prescribed to control the episode.
After two weeks of follow-up, the scleritis was completely resolved, without any other complications. We continued azathioprine (100 mg/day) therapy for a year. During the next year, she was assessed three times for further signs or symptoms of autoimmune diseases, laboratory data on related auto-antibodies, and slit lamp examination. All were normal and the scleritis completely revealed with no further organ involvement.