Optic nerve MRI was normal.
Neck, thoracic, abdominal, and pelvic CT scans were normal.
He was treated with 1000mg/IV/day methylprednisolone for 5 days followed
by 70 mg/day oral prednisolone. Ophthalmological examination showed that
disappearing of the bilateral optic disc swelling, without any
improvement of visual capacity. The headache disappeared.
Another course of methylprednisolone pulse therapy for 5 days and 750
mg/IV/M2 cyclophosphamide every 15 days had been initiated, in addition
to 5 courses of plasmapheresis. His visual function showed no
improvement after the 6 doses of cyclophosphamide and 60 mg/day
prednisone.
Discussion:
Many complications following vaccination, including ocular
manifestations had been seen. Uveitis, vision loss, papilledema, central
serous retinopathy, central retinal vein occlusion, and others, have
been reported (4,5). ON after vaccination against influenza, polio,
hepatitis B, diphtheria, tetanus, and others, giving rise to permanent
visual loss in some cases has also been mentioned (3,6).
Molecular mimicry, superantigen stimulation, and bystander activation,
may play a role in the development of demyelinating lesions of the
nervous systems (7). Immune complex may cause vascular damage, leading
to perivascular inflammation, vascular permeability, and blood-brain
barrier disruption, and the last event allows antibodies to enter the
brain causing demyelination (8).
The mechanism of ON following mRNA vaccination is still unclear.
Increased serum cortisol, free extracellular mRNA, and polyethylene
glycol may be the cause (4,9).
Here, an autoimmune response leading to bilateral ON was triggered by
mRNA COVID-19 vaccination, while it is difficult to prove the
association with the causation of vaccines (2,3,6,7).
Critical visual loss occurrs suddenly with pain, and Only 0.4% of
patients develop symptoms in both eyes simultaneously (5,7,9), as in our
case. VEP studied, the visual function, and Magnetic Resonance Imaging
considered as a sensitive indicator of demyelination in ON (10,11), as
in our patient.
A Cochrane review evaluating the beneficial effects of corticosteroids
in terms of visual recovery, and visual field.
When these patients had poor response to steroids, immunotherapy,
plasmapheresis or intravenous immunoglobulin should be initiated at the
earliest (4,5,7).
The long-term visual outcome of ON is good, although one in three
patients remains visually impaired, and this is usually accompanied by
more extensive lesions on magnetic resonance imaging and lower levels of
VEP (4,5,7). In our case, the prognosis was very poor ended with
blindness even there were no extensive lesions on magnetic resonance
imaging.
Conclusion :
Optic neuritis following COVID-19 vaccination against rarely reported in
the literature. Only a total of 8 reports on 9 patients have been
published to date, 8 of 9 were females (5,7,9,11). Our case is the third
case of post-COVID-19 vaccination optic neuropathy in a male. The cases
affect young females more, with improvement with IV methylprednisolone
therapy for most of them, after 6-14 days after the COVID-19
vaccination, meanwhile, our patient is a male who developed ON after 10
days of vaccination and did not respond to IV methylprednisolone therapy
In conclusion, several cases of optic neuropathy have been reported,
with good prognoses with treatments. Additional studies are
recommended.