Sex: M
Vaccine: COVID19
Symptoms: Angiogram, Fluorescence angiogram, Fundoscopy, Fundus autofluorescence, Investigation
Clinical narrative: acute posterior multifocal placoid pigment epitheliopathy; This is a literature report.  This case is unique for its unilateral presentation that occurred 2 weeks  after administration of the first dose of the Pfizer-BioNTech vaccine against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in a healthy adolescent boy without a history of the novel coronavirus disease (COVID-19) infection that was discovered in December 2019. A 17-year-old healthy boy presented to a clinic for a second opinion of his ocular condition. He was initially seen at the emergency department 2 weeks before presentation for an acute visual disturbance in the right eye that was described as 'blind spots' in his vision. He was examined by an attending optometrist who diagnosed the patient with right acute posterior multifocal pigment epitheliopathy. He presented to our clinic 6 days later for a second opinion. On examination, his uncorrected Snellen visual acuity was 20/20 in the right and left eyes. Extraocular motilities were full and smooth in both eyes. Pupils were equal and briskly reactive to light without an afferent pupillary defect in both eyes. Confrontation visual fields were full in both eyes. Slit-lamp examination showed a normal result in both eyes. Goldmann applanation tonometry was 18 mmHg in the right eye and 17 mmHg in the left eye. A dilated fundus examination revealed clear vitreous in both eyes. Both optic nerves were well perfused with distinct margins. Cup-to-disc ratio was 0.35 in both eyes, and the retinal vasculature was normal caliber in both eyes. There were multiple flat, creamywhite placoid subretinal lesions within the posterior pole and temporal midperipheral retina of the right eye, which are demonstrated. The retinal fundus of the left eye was unremarkable. Fundus autofluorescence and optical coherence tomography angiography confirmed a diagnosis of acute posteriormultifocal placoid pigment epitheliopathy in the right eye. Fundus autofluorescence of the right eye demonstratedmultiple hypoautofluorescent placoid lesions in the posterior pole and midperiphery with hyperautofluorescent borders, which is consistent with the acute phase of the disease because of the proposed masking of the underlying retinal pigment epithelium by swollen retinal cells. Fundus  utofluorescence of the left eye was unremarkable. Optical coherence tomography angiography of the right eye demonstrated hypoperfusion of the choriocapillaris in a placoid pattern that was more extensive than the clinically observed creamy-white lesions. Optical coherence tomography angiography of the left eye showed a normal result. Optical coherence tomography of the right eye demonstrated focal areas of disruption of the ellipsoid layer, outer retina, and retinal pigment epithelium, whereas optical coherence tomography of  the left eye was unremarkable. The patient was seen by an ophthalmologist 2 days later for fluorescein angiography, which further confirmed a diagnosis of unilateral acute posterior multifocal placoid pigment epitheliopathy in the right eye by demonstrating early hypofluorescence and late staining of the placoid lesions in the right eye. Fluorescein angiography of the left eye was unremarkable. The patient was observed without any intervention until he developed a mild anterior vitritis in the right eye 42 days after initial presentation. A laboratory evaluation was ordered for the patient, which included the following panel: Toxoplasma gondii immunoglobulins G and M, syphilis antibody screen immunoassay, erythrocyte sedimentation rate, C-reactive protein, human leukocyte antigen B27, antinuclear antibody, antineutrophil cytoplasmic antibody, angiotensin-converting enzyme, Borrelia burgdorferi antibody, herpes simplex virus 1 and 2 polymerase chain reaction, ?-interferon, and Epstein-Barr virus antibody panel. The laboratory evaluation revealed negative results for a systemic infectious and autoimmune etiology, and the patient was subsequently started on a course of oral prednisone that was tapered for 5 weeks. Four months after initial symptom onset, the placoid lesions were replaced by pigmented scars, and the anterior vitritis was completely resolved. During this time, the left eye remained unaffected. The patient's Snellen visual acuity remained at 20/20 in the right and left eyes. The complete timeline of the patient's ocular events is outlined. The Pfizer-BioNTech mRNA vaccine uses a lipid nanoparticle-encapsulated mRNA that encodes a stabilized prefusion form of the SARS-CoV-2 glycoprotein trimer. The vaccine produces high levels of neutralizing antibodies that target the spike proteins in the virus. The advantage of anmRNA vaccine is that it is noninfectious, does not integrate into the host genome, and does not induce vector-specific responses. However, it may result in potential ocular inflammatory events due to aberrant activation of the innate and acquired immune systems due to similarities between the SARS-CoV-2 spike glycoprotein and human proteins. Stimulation of a strong T-cell response by the vaccine can thus induce autoimmune manifestations because of a close resemblance between vaccine peptide fragments and uveal self-peptides. It has been postulated that neutralizing antibodies against SARS-CoV-2 spike proteins and activated T-helper-1 cells can cross-react with proteins and antigens in large arteries, outer retinal layers, and retinal pigment epithelial cells. Another potential cause of retinal inflammatory reactions is inflammatory damage caused by vaccine adjuvants that are found in mRNA vaccines whose role is to potentiate immunogenic activity. Various ocular sequelae after COVID-19 mRNA vaccination have been reported in the literature, including acute anterior uveitis, multifocal choroiditis, acute zonal occult outer retinopathy, reactivation of Vogt-Kayanagi-Harada disease, multiple evanescent white dot syndrome, and acute macular neuroretinopathy. This case underscores the potential for SARS-CoV-2 vaccine-related ocular sequelae because this is the first reported case of acute posterior multifocal placoid pigment epitheliopathy after an mRNA vaccine, to the authors' knowledge.  No follow-up attempts are needed. No further information is expected.; Sender's Comments: Based on the available information, a possible contributory role of the suspect product cannot be completely excluded for reported Acute posterior multifocal placoid pigment epitheliopathy' due to a plausible temporal association.The impact of this report on the benefit-risk profile of the Pfizer product and on the conduct of the study is evaluated as part of Pfizer procedures for safety evaluation, including the review and analysis of aggregate data for adverse events. Any safety concern identified as part of this review, as well as any appropriate action in response, will be promptly notified to regulatory authorities, Ethics Committees, and Investigators, as appropriate.