Keratoprosthesis Using Tibial Bone For Severe Ocular Cicatricial Pemphigoid Flare Up After Rna Covid Vaccine

Oftalvist Clinic (Barcelona) and Oftalvist Clinic (Tarragona) in collaboration with Joan XXIII Hospital (Tarragona), Spain. Informed consent was obtained from the patient for this presentation.

This is a case report of a previously stable ocular cicatricial pemphigoid that developed massive ocular surface scarring after COVID vaccination. Keratoprosthesis surgery was the only option to regain eyesight. Complete eye exam, slit lamp photographs, B-scan, A-scan, anterior segment OCT were serially done for case documentation. Bibliographic review of ocular surface fibrosis flare ups associated with COVID vaccination in autoimmune cases is also done.

A 72-year-old man treated with mycophenolate mofetil had clinical stability, good visual acuity 0.6 and transparent cornea in both eyes since diagnosis of ocular cicatricial pemphigoid in 2016. One month after receiving the 3rd dose of the covid-19 mRNA vaccine (1st and 2nd Pfizer BioNTech but 3rd Moderna Lonza) in 2021, he developed massive conjunctival inflammation in both eyes. He did not respond to immunosuppressive treatments (rituximab, methylprednisolone, cyclophosphamide, gammaglobulin, azathioprine, prednisone, etc), ending up in end stage scarring of the ocular surface and hand motion visual acuity. Osteokeratoprosthesis surgery with tibial bone was performed in in his left eye achieving best corrected visual acuity of 1.0.

RNA vaccines activate immunological pathways that may generate intense immune response. Cases of onset or worsening of autoimmune diseases have been described after the administration of RNA vaccines as in our case report of ocular cicatricial pemphigoid flare up ending up in severe scarring of the ocular surface. Keratoprosthesis surgery may be the only option in these cases and autologous tissue (canine tooth or tibial bone) have shown to be the gold standard in the long term to regain eyesight.