Sex: U
Vaccine: COVID19, COVID19, COVID19
Symptoms: Laboratory test, Optical coherence tomography, Scleritis, Ultrasound scan
Clinical narrative: POSTERIOR SCLERITIS; This solicited report received from a health care professional via NON-COMPANY STUDY. The patients' weight, height, and medical history were not reported. The patients' concurrent conditions included: covid-19 infection, and hypothyroidism.  SUBJECTS/METHODS: All patients with posterior scleritis referred to our service to rule out intraocular tumor between February 2021 and June 2022, who previously had COVID-19 vaccination and/or infection (n = 8). A retrospective detailed review of patients charts, and imaging was carried out. The patients received vaccination with covid-19 vaccine ad26.cov2. s (dose number in series-1) (suspension for injection, intramuscular, batch number was not reported) dose, start therapy date were not reported for covid-19 prophylaxis. Non-company suspect vaccine included: tozinameran (form of admin, route of admin, and batch number were not reported) dose, start therapy date were not reported for covid-19 prophylaxis and elasomeran (form of admin, route of admin, and batch number were not reported) dose, start therapy date were not reported for covid-19 prophylaxis. No concomitant medications were reported. On an unspecified date, following vaccination with covid-19 vaccine ad26.cov2. s, the patients experienced posterior scleritis  (dose number in series 1). Out of 8 patients, only one patient received Johnson and Johnson vaccine, 5 patients received Pfizer and 1 patient received Moderna. 3 patients got affected left eye and 5 patients got affected right eye. Systemic symptoms post-vaccine were reported as 3 patients had Flu-like symptoms, 1 patient had Inflammatory symptoms in other organs. There was growing evidence that COVID-19 infection causes dysregulation of the immune system and has been linked to several systemic autoimmune conditions, particularly vasculitis and inflammatory arthritis. Idiopathic inflammatory myopathies, systemic lupus erythematosus, and sarcoidosis have also all been linked to COVID-19 infection. Ocular manifestations of COVID-19 infection, particularly anterior segment complications, are relatively common.COVID19 vaccination has been linked to autoimmune ocular complications but data from population-based pharmacovigilance surveillance systems suggest that the prevalence of vaccination-associated ocular adverse events are rare. A meta-analysis of 2,347 confirmed COVID-19 infection cases showed that 11% of infected patients displayed ocular surface manifestations. Ocular pain (31%), discharge (19%), redness (11%), and follicular conjunctivitis (8%) were the main findings, and COVID-19 RNA was detected in 4% of ocular specimens from these patients. Posterior segment manifestations of infection, based on case reports alone, mainly relate to the pro-thrombotic state that can arise from COVID-19 infection and manifest with retinal vascular occlusion, acute macular neuroretinopathy, and paracentral acute middle maculopathy. Neuro-ophthalmic manifestations of COVID-19 infection include isolated cranial nerve palsies, Miller Fisher syndrome, nystagmus, and saccadic intrusions in association with either brainstem infarction or haemorrhagic acute necrotising encephalopathy. There are several case reports of episcleritis, anterior scleritis, and uveitis associated with COVID-19 infection, but no reported cases or series of posterior scleritis, as we document. Laboratory data (dates unspecified) included: Lab test revealed a super nasal choroidal effusion with "high water mark" and multiple hyper auto fluorescent choroidal folds, choroidal effusion infer nasally with a "high water mark" posteriorly suggesting partial resolution of fluid, Optical coherence tomography (vertical cut through fovea), intraretinal and shallow subretinal fluid with prominent choroidal folds were observed; and Ultrasonography Discrete scleral nodularity was identified in 4 (50%) subjects, with medium (n = 2, 25%) or high (n = 2, 25%) internal echogenicity, mean thickness of 2.4 mm (median 1.9 mm, range 1.93.3 mm), and dome-shaped (n = 4, 50%) with a base to maximum elevation ratio less than 7:1 and thickened choroidal detachment with episcleral Tenon's oedema (asterisk), suggestive of scleritis and at 4 weeks later, ultrasonography showed near-complete resolution of choroidal effusion and Tenon's oedema, confirmed the choroidal effusion at 2.6 mm in thickness and with minimal scleritis-related Tenon's oedema (occlumency). The main limitation of this study is our inability to prove a causal link between vaccination against COVID-19 and/or COVID-19 infection and posterior scleritis. It was, however, the most obvious variable relative to the scleritis. A previous study on etiology of choroidal pseudo melanoma identified posterior scleritis in a few cases [7]. Another limitation is that two of our patients were lost to follow-up, likely returning to their local ophthalmologist as we reassured them of the lack of melanoma. Loss to follow-up is anticipated, especially in this condition which can resolve spontaneously over time and can be managed locally. In summary, we documented 8 cases of COVID-19-related posterior scleritis simulating uveal melanoma that followed vaccination and/or infection by the virus. With conservative management, the inflammation tended to be self-limiting with resolution over 2 months and with minimal visual consequences. RESULTS: Previous COVID-19 vaccination was documented in 6 patients (75%) and previous COVID-19 infection and vaccination in 2 patients (25%). Demographic features included mean age of 59 years (median 68, range 586 years), race (n = 7, 87%), and male sex (n = 5, 63%). Mean visual acuity at presentation was 0.24 Log MAR (median 0.18, range 0.00.70). The main presenting symptom was blurred vision with pain (n = 5, 63%). Features that suggested scleritis and not uveal melanoma included pain (n = 6, 75%), anterior scleritis (n = 3, 38%), disc oedema (n = 1, 13%), choroidal detachment (n = 3, 38%), choroidal folds (n = 3, 38%), diffusely thickened scleral wall on ultrasonography (n = 2, 25%), Tenon's oedema (n = 5, 63%), and scleral nodule with medium/high internal reflectivity on ultrasonography (n = 4, 50%). Follow-up information at mean of 2 months (range 0.257 months) revealed visual acuity at date last seen was mean 0.30 log MAR (median 0.29, range 0.00.54). By 2 months, resolution of "tumor" was noted in 5/6 (83%) patients with follow-up.  The action taken with covid-19 vaccine ad26.cov2.s, tozinameran, and elasomeran was not applicable. The outcome of the posterior scleritis  was not reported. CONCLUSIONS: Posterior scleritis following COVID-19 vaccination and/or infection can masquerade as choroidal melanoma. At 2 months duration, partial or complete resolution of features with minimal visual consequence was noted. The reporter considered the causality between covid-19 vaccine ad26.cov2. s, and posterior scleritis as related. The reporter did not provide a causality assessment between tozinameran, and posterior scleritis, and between elasomeran, and posterior scleritis. Company causality between covid-19 vaccine ad26.cov2. s, and posterior scleritis was not related. This report was serious (Other Medically Important Condition).; Sender's Comments: V0 This report concerns a patient of unspecified age and gender who experienced a posterior scleritis, unspecified duration after receiving covid-19 vaccine ad26.cov2. There is a limited information regarding latency, clinical findings pertaining to this patient , medical history and associated risk factors. Based on the information available, a reasonable possibility to suggest a causal relationship between covid vaccine and the event posterior scleritis cannot be established. Hence, the causality is assessed not related at this time. Further details requested.