Sex: F
Vaccine: COVID19, HPVX, HPVX
Symptoms: Periphlebitis, Photopsia, Retinal white dots syndrome, Slit-lamp examination, Symptom recurrence
Clinical narrative: Multiple Evanescent White Dot Syndrome/Contralateral Recurrences of Post-vaccination Multiple Evanescent White Dot Syndrome; Disease recurrance/ Contralateral Recurrences of Post-vaccination Multiple Evanescent White Dot Syndrome/ bilateral recurrences of MEWDS; photopsia/ flashes in right eye; blurred vision in left eye; mild periphlebitis in the nasal midperiphery; flashes in right eye/recurrence of flashes; This case was reported in a literature article and described the occurrence of multiple evanescent white dot syndrome in a 17-year-old female patient who received HPV 16-18 (HPV vaccine) for prophylaxis.    Co-suspect products included HPV 16-18 (HPV vaccine) for prophylaxis and tozinameran (Covid-19 Vaccine (Bnt162b2)) for covid-19 prophylaxis.   Concurrent medical conditions included covid-19 (six weeks after her initial presentation), anosmia (mild) and nasal congestion (mild).   On an unknown date, the patient received the 1st dose of HPV vaccine, the 2nd dose of HPV vaccine and Covid-19 Vaccine (Bnt162b2) at an unknown dose and frequency. On an unknown date, 16 days after receiving HPV vaccine and less than 9 months after receiving HPV vaccine, the patient experienced multiple evanescent white dot syndrome (serious criteria GSK medically significant), disease recurrence, photopsia, blurred vision, periphlebitis and symptom recurrence. On an unknown date, the outcome of the multiple evanescent white dot syndrome, disease recurrence, photopsia, blurred vision, periphlebitis and symptom recurrence were recovered/resolved.   The reporter considered the multiple evanescent white dot syndrome, photopsia, blurred vision and periphlebitis to be related to HPV vaccine. It was unknown if the reporter considered the disease recurrence and symptom recurrence to be related to HPV vaccine. The reporter considered the multiple evanescent white dot syndrome, disease recurrence, photopsia and symptom recurrence to be related to HPV vaccine.     Additional Information: GSK Receipt Date:   13 Jan 2023 Author Comment:  Co-suspect medication included Meningococcal conjugate vaccine. A 17-year-old female presented with a one-week history of photopsia and blurred vision in her left eye (OS). Her past medical history was remarkable for her having received the human papillomavirus (HPV) and meningococcal (conjugate) vaccines simultaneously 16 days before the onset of her symptoms. Her review of systems, as well as past social and family history, were otherwise unremarkable. Upon a comprehensive ophthalmic evaluation, her best-corrected visual acuity (BCVA) was 20/20 in the right eye (OD) and 20/100 OS with a manifest refraction of plano -0.75 x 105 OD and -1.50 -0.50 x 80 OS. The intraocular pressure was 19 mmHg in both eyes (OU). The pupils were round and reactive to light, and there was no afferent pupillary defect (APD). Color vision OU, as assessed by the Ishihara color plate test, revealed no defect. Extraocular movements were within normal limits. A slit-lamp examination was within normal limits, bilaterally, with no evidence of keratic precipitates, signs of inflammation in anterior chambers, or vitreous cells in either eye. The patient's right fundus was unremarkable; however, the left fundus revealed multiple white dots in the macula and nasal periphery. The fundus autofluorescence (FAF) was within normal limits in the OD; however, in the OS, it was marked by hyperfluorescent spots in the macula and nasal periphery in a similar pattern as what was observed in the fundus examination. The intravenous fluorescein angiogram (FA) showed normal findings in the OD; in the OS, it revealed hyperfluorescent spots and mild periphlebitis in the nasal midperiphery. The patient's indocyanine green angiography was unremarkable within normal limits in the OD; in the OS, it was remarkable for spots around the macula and nasal midperiphery. A spectral-domain optical coherence tomography (OCT) of the OD was within normal limits; however, the OS revealed numerous focal hyporeflective lesions at the inner segment/outer segment (IS/OS) junction, which correlated with the macular lesions. Provided with the clinical and ancillary testing results, an assessment of MEWDS was made, and a workup was ordered to rule out secondary etiologies, such as syphilis and sarcoidosis. All the tests, including fluorescent treponemal antibody absorption, rapid plasma reagin, and a chest x-ray, were negative. The patient was placed under close observation without any topical or systemic therapy. One month following her initial diagnosis, the patient's symptoms had resolved. The patient's BCVA remained 20/20 OD and improved to 20/20 OS. A fundus examination revealed multiple relatively ill-defined brown-colored subretinal lesions in the nasal midperiphery corresponding to the location where the MEWDS lesions were present. The FAF and FA hyperfluorescent spots in the macula and nasal periphery had resolved. The corresponding OCT images of the OS showed that the numerous focal hyporeflective lesions previously found at the IS/OS junction had been resolved. The patient received the second dose of the HPV vaccine series two days after her follow-up. She later developed COVID-19 (six weeks after her initial presentation). Her symptoms were mild, including anosmia and nasal congestion; nevertheless, she evidenced no ocular symptoms during the course of the infection. Three months following her initial visit, a color fundus photograph, and FAF revealed that the lesions had resolved; she presented no further complaints at this time. Four months after the initial presentation, the patient received her first dose of the BNT162b2 COVID-19 vaccine, which was followed by the second dose a month later. Eight months following her initial presentation, the patient presented with flashes in OD. Upon ophthalmic examination, her BCVA was 20/20 OU, no APD was present, and the slit-lamp examination was within normal limits. A right fundus examination revealed multiple white spots nasal to the disk. The FAF and FA revealed hyperfluorescent lesions nasal to the disk and surrounding the peripapillary region corresponding to the fundus findings. The ICG revealed numerous hypocyanescent spots nasal to the disk and corresponding to the previously described lesions. The patient was diagnosed as experiencing a recurrence of MEWDS in the OD and scheduled for regular follow-up until the condition resolved. One month following the initial presentation of the symptoms in the OD, the patient presented with a recurrence of flashes. The patient's BCVA remained 20/20 OU. A fundus examination revealed white lesions suggestive of active MEWDS temporal to the macula and brown-colored spots nasal to the disk, suggestive of recovering MEWDS nasally. The following month, the patient's BCVA remained 20/20 OU. The fundus of the OD was remarkable for brown-colored spots of recovering MEWDS in the temporal region. An FA was performed and found to be within normal limits. The patient's symptoms resolved, and she received the third dose of the BNT162b2 COVID-19 vaccine 11 months after her initial presentation. On her last follow-up visit, 13 months after presentation, she had a visual acuity of 20/20 OU, and her fundus examination was unremarkable, including the resolution of the multiple relatively ill-defined brown-colored subretinal lesions.  Additional Supportive Information:  "The human papilloma, meningococcal, hepatitis A, hepatitis B, COVID-19, influenza, and yellow fever vaccines have been associated with a handful of MEWDS cases. The patient's encounter with a wide array of antigens incorporated into the meningococcal vaccine, the HPV vaccine, and the three doses of BNT162b2 COVID-19 vaccine, as well as her acquiring of the COVID-19 viral infection, formulated a powerful immune challenge.  Vaccines might serve as immunological triggers of MEWDS, which further supports the post-infectious or immune-mimicry etiology of this disease. Recurrent MEWDS might occur when an individual was exposed to a powerful immune challenge, such as receiving a wide array of vaccinations in a short period of time".  This article is not available for regulatory reporting due to copyright restriction