Sex: F
Vaccine: FLUX
Symptoms: Ocular vasculitis, Optical coherence tomography abnormal, Papilloedema, Retinal ischaemia, Retinal pigment epitheliopathy
Clinical narrative: Recurrent acute posterior multifocal placoid pigment epitheliopathy (APMPPE) in the contralateral eye; This literature case was received on 22-Jan-2024 and concerned an adult female patient of unreported age.  The purpose of this study was to report a rare case of delayed contralateral acute posterior multifocal placoid pigment epitheliopathy (APMPPE) of the right eye, in which unilateral lesion resolution was followed by contralateral eye involvement 31 months later. This was the longest documented interval between unilateral presentation of APMPPE and the development of contralateral eye involvement.  The patient's historical conditions included APMPPE and viral gastrointestinal (GI) illness. The patient's historical drug included prednisone, used for APMPPE of the right eye. The patient's concomitant medications were not reported.  On an unspecified date, the patient was vaccinated with influenza vaccine (brand not specified; dose, anatomical location, route of administration and indication: not reported). The batch number was not reported.  On an unspecified date, one month after receiving influenza vaccine, the patient experienced similar symptoms of new onset blurry vision in the left eye. The patient denied any photopsias or other ocular or neurologic symptoms. Best-corrected visual acuity (BCVA) was 20/20-1 oculus dexter (OD) and 20/20-1 oculus sinister (OS). Examination revealed a quiet anterior chamber (AC) in both eyes and a normal dilated fundus examination (DFE) in the right eye but was significant for mild disc edema and multiple creamy, yellow-white placoid lesions temporal to the fovea of the left eye. Optical coherence tomography (OCT) showed outer retinal hyper-reflectivity and attenuation of the ellipsoid zone temporal to the fovea. Fluorescein angiography (FA) revealed early hypofluorescence of the lesions in the left eye. OD was within normal limits on exam and multimodal imaging. Given the patient's history and clinical findings, the diagnosis of recurrent APMPPE in the contralateral eye was made. Repeat syphilis testing returned negative. The patient was once again started on oral prednisone with significant improvement in symptoms. Follow-up examination demonstrated improvement in vision and resolution of left optic nerve edema and placoid lesions in the macula. The patient deferred repeat magnetic resonance imaging (MRI)/magnetic resonance angiogram (MRA) testing for evaluation for central nervous system (CNS) vasculitis.  On an unspecified date, the patient recovered from the event. As reported, there was a complete resolution.  The reporter did not provide a causality assessment.   In conclusion, APMPPE, an inflammatory vasculitis of the choroid, led to hypoperfusion and ischemic injury of the retinal pigment epithelium (RPE) with subsequent lesion formation. APMPPE might be preceded by a viral prodrome or vaccination, both of which were seen in this case. Choroidal inflammation seen in APMPPE was therefore thought to stem from immune-mediated processes. Unilateral cases often had fellow eye involvement within days to a few weeks. Single eye involvement with delayed contralateral presentation, as seen in our patient, was rare. This case demonstrated that lesion resolution in one eye can be followed by contralateral eye involvement up to 31 months later, highlighting the importance of routine ophthalmic monitoring for patients with unilateral APMPPE.  The event was considered to be medically significant by a Physician within Department.   Company comment: The purpose of this study was to report a rare case of delayed contralateral acute posterior multifocal placoid pigment epitheliopathy (APMPPE) of the right eye, in which unilateral lesion resolution was followed by contralateral eye involvement 31 months later. This was the longest documented interval between unilateral presentation of APMPPE and the development of contralateral eye involvement. An adult patient was vaccinated with the suspect product influenza vaccine. The patient experienced blurry vision in the left eye. Examination revealed a quiet anterior chamber (AC) in both eyes and a normal dilated fundus examination (DFE) in the right eye but was significant for mild disc edema and multiple creamy, yellow-white placoid lesions temporal to the fovea of the left eye. Optical coherence tomography (OCT) showed outer retinal hyper-reflectivity and attenuation of the ellipsoid zone temporal to the fovea. Fluorescein angiography (FA) revealed early hypofluorescence of the lesions in the left eye. Given the patient's history and clinical findings, the diagnosis of recurrent acute posterior multifocal placoid pigment epitheliopathy in the contralateral eye was made. The patient's significant historical conditions included acute posterior multifocal placoid pigment epitheliopathy of the right eye. Based on underlying medical history and implausible temporal relationship, causal role of the suspect vaccine is assessed as not related.; Sender's Comments: The purpose of this study was to report a rare case of delayed contralateral acute posterior multifocal placoid pigment epitheliopathy (APMPPE) of the right eye, in which unilateral lesion resolution was followed by contralateral eye involvement 31 months later. This was the longest documented interval between unilateral presentation of APMPPE and the development of contralateral eye involvement. An adult patient was vaccinated with the suspect product influenza vaccine. The patient experienced blurry vision in the left eye. Examination revealed a quiet anterior chamber (AC) in both eyes and a normal dilated fundus examination (DFE) in the right eye but was significant for mild disc edema and multiple creamy, yellow-white placoid lesions temporal to the fovea of the left eye. Optical coherence tomography (OCT) showed outer retinal hyper-reflectivity and attenuation of the ellipsoid zone temporal to the fovea. Fluorescein angiography (FA) revealed early hypofluorescence of the lesions in the left eye. Given the patient's history and clinical findings, the diagnosis of recurrent acute posterior multifocal placoid pigment epitheliopathy in the contralateral eye was made. The patient's significant historical conditions included acute posterior multifocal placoid pigment epitheliopathy of the right eye. Based on underlying medical history and implausible temporal relationship, causal role of the suspect vaccine is assessed as not related.