Optometry: Open Access
Open Access

In Dec 2019, the planet Health Organization proclaimed that a unique coronavirus, SARS-CoV-2, was to blame for outbreak of coronavirus disease-19 (COVID-19) [1]. Over four million individuals worldwide have died owing to this current irruption. Presently accessible vaccines have shown wonderful and promising leads to preventing symptomatic COVID-19. However, immunogen facet effects could occur, though this risk is low. There is also unsupported complications following industrial unharness as a result of solely a restricted range of individuals participated within the clinical trials [2]. Available SARS-CoV-2 immunogens embody the ChAdOx1 nCoV- 19 vaccine (AZD1222) that was developed at Oxford University. This consists of a replication-deficient chimp adenoviral vector ChAdOx1. This immunogen contains the SARS-CoV-2 spike macromolecule (nCoV-19) cistron, and has shown wonderful efficaciousness and safety profiles [3].

The “COVID-19 immunogen AstraZeneca analysis print” lists all uk spontaneous reports of suspected adverse drug reactions to the ChAdOx1 nCoV-19 immunogen that had been received between April 01, 2021, and Gregorian calendar month thirty, 2021 [4]. Varied ophthalmic reactions involving the palpebra, anterior phase, retina, cranial nerve, and extraocular muscles were reported during this document, as well as 2 cases of ocular myasthenia, similarly as twelve cases of myasthenia and 3 cases of myasthenia crises. However, the list doesn't imply a causative link between the immunogen and these listed diseases. Until now, solely a number of cases of myasthenia following nCoV-19 vaccination are revealed [5].

In our case report, we tend to describe very well the clinical presentation of a 35-year-old man United Nations agency developed myasthenia with ocular symptoms following a ChAdOx1 nCoV-19 immunogen injection [6].

Case Report

This 35-year-old, healthy man was stated our clinic owing to binocular diplopia that had started regarding 3 weeks earlier. There was no important past anamnesis, like DM, cardiovascular disease, lipaemia, vessel disorder, or disease. There was no important surgical history or social history [7]. He denied any trauma history. The sole medication he had received recently was the primary dose of the AstraZeneca animal virus vectored immunogen ChAdOx1 nCoV- 19 one month earlier. On the evening of vaccination, he developed headache, dizziness, symptom in each higher and lower extremity, and symptom. He developed nausea four days following the vaccination, and everyone these symptoms then impromptu resolved. One week once the vaccination, the patient developed associate acute-onset of vertical binocular visual defect. On review of the case, there have been no alternative symptoms.

On ocular examination, his sight was 20/20 and pressure was traditional in each eyes. We tend to measured associate eight prism diopters (PDs) left hypertropia. The extraocular motility check showed full ductions of his right eye. However we tend to discovered a seventy fifth infraduction within the left eye. His visual defect quickly improved following ice packing for two min. each pupils reacted unremarkably to direct lightweight, and that we discovered no incapacity in corticipetal aperture reactions [8]. The anterior phase examination showed traditional findings, and therefore the anatomical structure examination unconcealed a healthy-appearing cranial nerve. Retinas in each eye were while not important torsion. His higher and lower extremity strength on each side was traditional, as were his deep connective tissue reflexes.

Our review of a pre- and post-contrast high-resolution nerves resonance 3-D imaging employing a 3-T system unconcealed no abnormality within the nerves III, IV, or VI pathways, and that we found no abnormality on resonance roentgenography [9].

Laboratory tests, as well as white vegetative cell count, Hb level, corpuscle deposit, C-reactive protein, and electrolytes were all traditional [10]. Medical science investigations unconcealed a positive antinuclear protein result, whereas the patient's antineutrophil protoplasm protein showed a negative result. The anticardiolipin protein, ganglioside protein, and thyroid protein were all noted to possess been among traditional vary. Neurotransmitter receptor antibodies were noted as one.60 nmol/L, which was on top of the traditional limit. Supported the on top of results, the patient was diagnosed with myasthenia with ocular symptoms. No thymus abnormality was discovered on chest CAT [11].

Discussion

Myasthenia gravis is associate disease caused by autoantibodies to the neurotransmitter receptors at the myoneural junction. The supply of neurotransmitter receptors at the postsynaptic myoneural junction decreases owing to protein destruction and therefore the inflammatory response in myasthenia patients. Most patients with myasthenia ordinarily have associate initial presentation of ocular manifestations, like pupil-sparing prolapses and/or visual defect [12]. A myasthenia disease of the myoneural junction identification is often confirmed by seropositivity of neurotransmitter receptor antibodies or of antibodies to alternative neuromuscular junction proteins, as well as antimuscle specific amino acid enzyme (Figure 1). Finding elevated neurotransmitter receptor protein levels is extremely specific for myasthenia, though solely 85%–90% of patients with generalized myasthenia and five hundredth of ocular myasthenia patients have detectable antibodies.

Figure 1: The Hess-Weiss test at presentation. Abbreviations: OS, oculus sinister, left eye; OD, oculus dexter, right eye.

The key infective mechanism of disease like myasthenia is assumed to be molecular mimicry by that microorganism or microorganism agents trigger associate immune reaction against car antigens. Within the development of myasthenia, associate antibodies created by associate inflammatory reaction to an external agent will cross react with the neurotransmitter receptors owing to molecular likeness [13].

This ends up in injury. The assembly of autoantibodies for myasthenia may be a B cell-dependent method and plays a very important role within the loss of self-tolerance and dysregulation.

Reports on reaction reactions following vaccination would most likely represent but zero.01% of all vaccinations performed worldwide, though underreporting could bias these calculations. As infectious agents could induce pathology, we will assume that vaccinations might also trigger pathology during a similar method. Thus, vaccination should be considered as part of the mosaic of autoimmunity, in which abrogation of one autoimmune disease may concomitantly induce another autoimmune disease (Figure 2). But we should also consider the possibility that the onset of myasthenia gravis symptoms with vaccination could be coincidental. We cannot rule out that a pre-existing subclinical myasthenia gravis might by unmasked by a viral-like illness following vaccination even if the patient had had no symptoms [14].

Figure 2: The Hess-Weiss test after ciprofloxacin cessation. Abbreviations: OS, oculus sinister, left eye; OD, oculus dexter, right eye.

Myasthenia gravis following vaccination is rare, and only a few reports of myasthenia gravis following human papillomavirus or hepatitis B vaccinations have been previously published. Also, a few cases of myasthenia gravis following nCoV-19 vaccination have recently been published. One case developed myasthenia gravis after the ChAdOx1 nCoV-19 vaccine administration, as in this case, and some cases developed myasthenia gravis after administration of other types of vaccines [15]. Among them, there were four case reports of generalized myasthenia gravis, occurring after the second dose of BNT162b2 and after the second dose of Moderna nCoV-19 vaccination, and one case report of myasthenia gravis with ocular symptoms only. In one case report, a patient who had only ocular symptoms exhibited left-sided ptosis eight days after receiving his first dose of ChAdOx1 nCoV-19 vaccination. His low-frequency repetitive nerve stimulation showed decreased amplitude, and a serum anti-AChR antibody titer was 1.9 nmol/L at 20 days post-vaccination.

Conclusion

This case report implies that COVID-19 vaccination may cause myasthenia gravis with ocular symptoms. The underlying mechanism of the disease following vaccination requires further investigation.

References

1. Voysey M, Clemens SAC, Madhi SA (2021) Safety and efficacy of the ChAdOx1 nCoV-19 vaccine (AZD1222) against SARS-CoV-2: an interim analysis of four randomised controlled trials in Brazil, South Africa, and the UK. Lancet 397:99–111.

Indexed at, Google Scholar, Crossref

2. Baden LR, El Sahly HM, Essink B (2021) Efficacy and safety of the mRNA-1273 SARS-CoV-2 vaccine. N Engl J Med 384:403–416.

Indexed at, Google Scholar, Crossref

3. Polack P, Thomas SJ, Kitchin N (2020) Safety and efficacy of the BNT162b2 mRNA covid-19 vaccine. N Engl J Med 383:2603–2615.

Indexed at, Google Scholar, Crossref

4. Soiza RL, Scicluna C, Thomson EC (2021) Efficacy and safety of COVID-19 vaccines in older people. Age Ageing. 50:279–283.

Indexed at, Google Scholar, Crossref

5. Wong RLM, Ting DSW, Wan KH (2020) COVID-19: ocular manifestations and the APAO prevention guidelines for ophthalmic practices. Asia Pac J Ophthalmol 9:281–284.

Indexed at, Google Scholar, Crossref

6. Dinkin M, Gao V, Kahan J (2020) COVID-19 presenting with ophthalmoparesis from cranial nerve palsy. Neurology 95:221–223.

Indexed at, Google Scholar, Crossref              

7. Gutierrez-Ortiz C, Mendez-Guerrero A, Rodrigo-Rey S (2020) Miller Fisher syndrome and polyneuritis cranialis in COVID-19. Neurology. 95:601–605.

Indexed at, Google Scholar, Crossref

8. Shimabukuro TT, Cole M, Su JR (2021) Reports of anaphylaxis After receipt of mRNA COVID-19 vaccines in the US-December 14, 2020-January 18, 2021. JAMA 32:1101–1102.

Indexed at, Google Scholar, Crossref

9. Abu-Hammad O, Alduraidi H, Abu-Hammad S (2020) Side effects reported by Jordanian healthcare workers who received COVID-19 vaccines. Vaccines.9: 65-68.

Indexed at, Google Scholar, Crossref

10. Kounis NG, Koniari I, de Gregorio C (2020) Allergic reactions to current available COVID-19 vaccinations: pathophysiology, causality, and therapeutic considerations. Vaccines. 9: 56-61.

Indexed at, Google Scholar, Crossref

11. Menni C, Klaser K, May A (2021) Vaccine side-effects and SARS-CoV-2 infection after vaccination in users of the COVID Symptom Study app in the UK: a prospective observational study. Lancet Infect Dis. 21:939–949.

Indexed at, Google Scholar, Crossref

12. Ostergaard SD, Schmidt M, Horvath-Puho E, Thomsen RW, Sorensen HT (2020)  Thromboembolism and the Oxford-AstraZeneca COVID-19 vaccine: side-effect or coincidence? Lancet. 397:1441–1443.

Indexed at, Google Scholar, Crossref

13. Cheng JY, Margo CE (2021) Ocular adverse events following vaccination: overview and update. Surv Ophthalmol 45: 134-138.

Indexed at, Google Scholar, Crossref

14. Lee MA, Lee C, Park JH, Lee JH (2021) Early-onset myasthenia gravis following COVID-19 vaccination. J Kor Med Sci 37:50-55.

Indexed at, Google Scholar, Crossref

15. Tagliaferri AR, Narvaneni S, Azzam MH, Grist W (2021) A case of COVID-19 vaccine causing a myasthenia gravis crisis. Cureus13: 76-79.

Indexed at, Google Scholar, Crossref