and Johnathan Etter M.D.
In 2009, H1N1 became widespread across the US and caused many severe complications. Some even died. Locally in Florida a pregnant woman went into a coma, lost her child but managed to survive, waking months later. With concerns of such health tragedies, many rushed to obtain the H1N1 vaccine. In a few more months this year, newer flu vaccines will be issued with recommendations for many to get them. While the adverse effects of these vaccines are relatively mild, they can have ophthalmic consequences, particularly those with corneal transplants. The following case demonstrates one such occurrence:
A 25 year old female with history of bilateral corneal transplants for keratoconus (OD in 2009, OS in 2004) received the live attenuated H1N1 vaccine intranasally. The following morning she awoke with bilateral corneal rejection OD more severe than OS. While the left eye responded well to topical steroid drops, the right remained edematous for over a month despite both sub-tenon’s injection of triamcinolone and oral prednisone. Eventually, the right eye cornea cleared and she was spared a repeat corneal transplant.
Corneal transplant rejection following vaccination has been described previously with influenza vaccine1,2,3, however in these cases the time from vaccination to rejection has ranged from two to eight weeks. The fast onset of corneal transplant rejection in this patient may likely be related to the close proximity of the inoculation site (nares) to the eye. However, this may also represent a more robust immune reaction to a relatively new and understood vaccine.
Where does this matter in refractive surgery? Increased immune response, and therefore inflammation, can be associated with regression, diffuse lamellar keratitis, transient light sensitivity, and, in severe cases, corneal melting. While there are no studies on vaccines and corneal refractive surgery, I would argue most refractive surgeons would not recommend it. Unfortunately, there are no clear guidelines on whether one should delay surgery and, if so, for how long. As our refractive, younger patients become more likely to obtain these vaccines, we should learn more in the future.
That said, H1N1 and other vaccines will become more readily available, and our patients will be more likely to obtain it, particularly without alerting their ophthalmologist. In discussing laser refractive surgery with our patients in these upcoming months, we must take care to warn our patients about receiving any vaccine prior to refractive surgery. If the vaccine is administered to the patient around the time of refractive surgery, we may want to consider a more frequent and prolonged course of topical steroid therapy.
REFERENCES
- Wertheim MS, Keel M, Cook SD, Tole DM. Corneal transplant rejection following influenza vaccination. Br J Ophthalmol 2006; 90(7):925.
- Solomon A, Fruct-Pery J. Bilateral simultaneous corneal graft rejections after influenza vaccination. Am J Ophthalmol 1996; 121: 708-9.
- Steinemann TL, Koffler BH, Jennings CD. Am J Ophthalmol. 1988; 106(5):575-8.