key: cord-1034867-681f5hbf authors: Drüke, Daniela; Pleyer, Uwe; Hoerauf, Hans; Feltgen, Nicolas; Bemme, Sebastian title: Acute macular neuroretinopathy (AMN) following COVID-19 vaccination date: 2021-09-23 journal: Am J Ophthalmol Case Rep DOI: 10.1016/j.ajoc.2021.101207 sha: ea3131984cd2f6829ca4d171b18e483e68b0f89a doc_id: 1034867 cord_uid: 681f5hbf PURPOSE: To describe a case of acute macular neuroretinopathy (AMN) in a 23-year-old Caucasian female after a COVID-19 vaccination (Vaxzevira). OBSERVATIONS: Our patient perceived visual symptoms in both eyes one day after COVID-19 vaccination. Hyporeflective petalloid shaped perifoveal lesions appeared in infrared reflectance (IR) imaging, and Spectral domain-optical coherence tomography (SD-OCT) revealed structural alterations of outer retinal layers that resulted in persistent disruption of the ellipsoid zone (EZ) and the interdigitation zone (IZ). CONCLUSIONS AND IMPORTANCE: We report a novel association between AMN and COVID-19 vaccination. In addition to a febrile infection and oral contraception, previous vaccination should also be considered a potential risk factor for AMN. COVID-19 is a global pandemic that has affected over 120 million people around the world (1), and viral mutants are potentially causing incidence levels to rise even faster. Twelve vaccines have so far been approved by national regulatory authorities (2), and more than 500 million COVID-19 vaccination doses have been administered worldwide (3) . COVID-19 Vaccine Vaxzevria© (previously COVID-19 Vaccine AstraZeneca, AZD1222) is based on an adenovirus vector encoding the SARS-CoV-2 S glycoprotein. (4) According to the product information, common adverse reactions to COVID-19 Vaccine Vaxzevria include pain at the injection site, headache, myalgia, fatigue, malaise, fever, chills, arthralgia and nausea. A 23-year-old Caucasian female presented with a one-day history of dark paracentral spots in both eyes. One day before symptom onset, she had received a COVID-19 vaccine (Vaxzevria©, AstraZeneca). She also reported a headache and cervical pain on the first day after vaccination, fever was denied. Her medical history was significant for juvenile idiopathic arthritis (JIA) and associated recurrent iritis. Systemic treatment consisted of methotrexate 10 mg weekly and sulfasalazine 2000 mg daily, and she had been applying topical steroids once a day into her right eye since having presented with an anterior chamber inflammation six weeks earlier. She had reported joint swelling in her left knee, for which she had been injected with an intraarticular steroid three weeks before her vaccination. Except for oral contraception, she was taking no other medications. On examination, visual acuity was 20/20 in both eyes without correction. Amsler grid and microperimetry showed paracentral scotoma ( Fig. 1 A and 3A ). Except for a superficial punctate keratitis, each eye's anterior segment exam was unremarkable. Fundus examination revealed a normal optic disc, and juvenile reflexes of the macula in both eyes. Fundus photography indicated a subtle brownish rimmed lesion parafoveal in the right eye and a bigger blurred lesion nasal to the macula in the left eye ( Fig. 1 B) . We diagnosed AMN and started 40 mg prednisolone daily for one week followed by a dose of 20 mg for another week. After initial improvement, the patient reported consistent scotomas over the subsequent weeks. Within a period of 15 weeks, however, structural alterations of the outer retina appeared regressive on SD-OCT ( Fig. 3 B-E) accompanied by decreasing scotomas on microperimetry (Fig. 3 A, F) . Furthermore, AMN has already been described as a potential adverse effect after immunization. Until now, two cases of AMN have been reported following influenza vaccination (21, 22) . The underlying pathomechanism remains unsolved. There is no evidence for a direct link between Vaxzevria vaccination and reduced blood flow or increased thrombus formation within the inner choroidal vasculature. The prednisolone treatment in our patient might have contributed to the initial improvement of the scotomas since it has recently been described to improve capillary and choroidal blood void in AMN. complications, yet. In our patient, we are assuming an immune-mediated reaction that has been described after influenza vaccination. To our knowledge, this is the first report of AMN following a COVID-19 vaccination. AMN Funding: None. Conflicts of interest: The authors declare that there is no conflict of interest. Authorship: All authors attest that they meet the current ICMJE criteria for Authorship. 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