Ocular Adverse Events after Coronavirus Disease 2019 mRNA Vaccination: Matched Cohort and Self-Controlled Case Series Studies Using a Large Database

The Global Epidemiology of Scleritis: A Systematic Review and Meta-analysis

PURPOSE

Scleritis, a severe inflammatory condition of the sclera, causes significant ocular pain and potential tissue damage. Often linked with systemic diseases, scleritis can be either infectious or noninfectious. Despite its clinical importance, the global incidence and detailed epidemiology of scleritis are poorly understood due to its heterogeneity and rarity. This systematic review and meta-analysis aim to elucidate the worldwide incidence and epidemiological trends of scleritis, examining variations across geographic regions, etiologies, and time periods.

DESIGN

Systematic Review and Meta-analysis.

CLINICAL RELEVANCE

Understanding scleritis epidemiology is crucial for enhancing diagnostic accuracy and treatment, especially concerning systemic illnesses commonly associated with this condition. Identifying epidemiological trends can inform healthcare policies and resource allocation, improving patient outcomes.

METHODS

We systematically reviewed literature across databases, including Embase, PubMed, Virtual Health Library, The Cochrane Library, and medRxiv. Population-based, cohort, case-control, cross-sectional, and claims database studies reporting the frequency, prevalence, or incidence of scleritis diagnosed through clinical or imaging techniques, were included. The screening was based on titles and abstracts, followed by a full-text review. We assessed the risk of bias using standardized tools and systematically extracted data for qualitative and quantitative synthesis. This review is registered with PROSPERO (CRD42022330948).

RESULTS

This review included 74 studies with 169,871 scleritis patients. The incidence was 2.67 per 100,000 in ophthalmological centers and 1.38 per 100,000 in broader population-based studies, both showing a decreasing trend over time. The patient population was predominantly female (67.24%), with an average age of 48.3 years. Epidemiological patterns were significantly influenced by etiology, geographic region, and publication period, with idiopathic cases being the most common. Scleritis was notably associated with systemic diseases such as rheumatoid arthritis, granulomatosis with polyangiitis, Sjögren's syndrome, sarcoidosis, and infectious agents like Mycobacterium tuberculosis and herpes virus.

CONCLUSION

This is the most extensive study on scleritis to date, providing comparative insights across geographic regions, age groups, and genders. Our meta-analysis highlights significant regional differences in scleritis incidence, reflecting variations in medical practice, access to care, and potential genetic and environmental factors. These findings underscore the need for further research to explore these patterns and their global health implications.

Association between immune checkpoint inhibitors and uveitis in patients with lung cancer, renal cell carcinoma, or malignant melanoma

OBJECTIVE

Immune checkpoint inhibitors (ICIs) reportedly have a potential risk of general ocular complications; however, whether ICIs have a risk of uveitis remains unclear. Therefore, we assessed whether ICI use has a higher risk of uveitis than chemotherapy alone.

METHODS

Using a large administrative claims database in Japan, we identified 26 474 patients with lung cancer, renal cell carcinoma, or malignant melanoma, who initiated ICI or chemotherapy between April 2014 and November 2022. The patients were divided into 2 groups: those receiving ICI with and without chemotherapy (ICI group: n = 8103) and those receiving chemotherapy alone (non-ICI group: n = 18 371). After propensity score-overlap weighting to adjust for background factors, we estimated the incidence of uveitis and performed Cox regression analyses. We also conducted subgroup analyses stratified by age (<75 and ≥75 years).

RESULTS

The overlap-weighted incidence of uveitis in the ICI group was higher than that in the non-ICI group (85.1 vs 55.9/10,000 person-years; number needed to harm: 343). The hazard ratio (HR) for uveitis in the ICI group was 1.49 (95% confidence interval, 1.11 to 2.01) in comparison with the non-ICI group. The age-stratified analysis showed that the ICI group had an increased risk among individuals aged <75 years (HR 1.65 [1.15 to 2.41]), while the risk did not differ among individuals aged ≥75 years (HR 1.35 [0.84 to 2.18]).

CONCLUSIONS

ICI use was associated with a higher risk of uveitis compared to non-ICI use, particularly among patients aged <75 years.

Ocular Adverse Events Following Coronavirus Disease 2019 Infection: A Self-controlled Case Series Study from the Entire Korean Population

Purpose

This study aimed to assess the risk of ocular adverse events, including retinal artery occlusion (RAO), retinal vein occlusion (RVO), noninfectious uveitis (NIU), noninfectious scleritis (NIS), optic neuritis (ON), ischemic optic neuropathy (ION), and ocular motor cranial nerve palsy (OMCNP), after coronavirus disease 2019 (COVID-19) infection.

Design

Population-based self-controlled case series (SCCS).

Participants

The study included patients from the entire Korean population of 52 million who experienced incident RAO, RVO, anterior NIU, nonanterior NIU, NIS, ON, ION, or OMCNP between January 1, 2021, and October 29, 2022.

Methods

This nationwide SCCS utilized data from the Korea National Health Insurance Service and the Korea Disease Control and Prevention Agency. The risk period after infection was defined as up to 24 weeks after COVID-19 infection. Conditional Poisson regression was used to calculate the relative incidence rate ratios (IRRs) for RAO, RVO, anterior NIU, nonanterior NIU, NIS, ON, ION, and OMCNP during the designated risk periods.

Main Outcome Measures

The IRRs for RAO, RVO, anterior NIU, nonanterior NIU, NIS, ON, ION, and OMCNP during the risk periods.

Results

The study included 9336, 103 362, 201 010, 25 428, 23 744, 3026, 69 933, and 16 335 cases of incident RAO, RVO, anterior NIU, nonanterior NIU, NIS, ON, ION, and OMCNP, respectively. The IRRs (95% confidence interval) during the early risk period (1-8 weeks) were 0.94 (0.83-1.07), 1.01 (0.97-1.04), 1.00 (0.98-1.03), 0.96 (0.90-1.03), 1.00 (0.94-1.07), 0.97 (0.81-1.17), 0.97 (0.93-1.01), and 1.02 (0.94-1.11), respectively. In the late risk period (9-24 weeks), the IRRs were 1.02 (0.92-1.12), 1.01 (0.98-1.04), 1.01 (0.99-1.03), 1.02 (0.97-1.08), 1.02 (0.97-1.08), 0.99 (0.85-1.15), 1.02 (0.99-1.06), and 0.97 (0.90-1.03), respectively. Stratified analyses showed that in patients with a history of cerebro-cardiovascular disease, the risk of RAO increased during the late risk period, with an IRR (95% confidence interval) of 1.19 (1.02-1.40).

Conclusions

The risk of incident RVO, anterior NIU, nonanterior NIU, NIS, ON, ION, or OMCNP did not increase after COVID-19 infection. The risk of incident RAO increased only in individuals with preexisting cardio-cerebrovascular disease.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Incidence and Association of Uveitis with COVID-19 Vaccination: A Systematic Review and Meta-Analysis

PURPOSE

In the wake of the COVID-19 pandemic, vaccines have been pivotal in curbing disease spread and severity. However, concerns over post-vaccination adverse events, including uveitis, an inflammatory ocular condition, have been noted. This systematic review and meta-analysis aimed to evaluate the incidence and association of uveitis following COVID-19 vaccination.

METHODS

A literature search was performed across several databases on October 21, 2023. Human studies examining the incidence of uveitis post-COVID-19 vaccination were included. The Newcastle-Ottawa Scale was used for quality appraisal of the included studies. Meta-analysis was performed to assess the overall incidence of uveitis and the relative risk of developing the condition post-vaccination. All statistical analyses were performed using R software version 4.3.

RESULTS

Six studies involving over 2 billion vaccine doses were included. The overall incidence of uveitis was 0.016% (95% CI: 0.010 to 0.026). No significant association was found between vaccination and the onset of uveitis (Relative Risk: 1.45 (95% CI: 0.82 to 2.57, p = 0.12) from four studies. The evidence quality was rated very low due to the limited number of studies and imprecision.

CONCLUSION

This analysis indicates a low incidence of uveitis following COVID-19 vaccination and no significant association with the vaccine. The findings are constrained by the small number of studies and low certainty of evidence, underscoring the need for further research. Comprehensive and longitudinal studies are necessary to confirm these findings and reinforce public confidence in COVID-19 vaccination programs.

COVID-19 Vaccination and Ocular Adverse Events: A Self-Controlled Case Series Study From the Entire South Korean Population

PURPOSE

This study aimed to assess the risk of ocular adverse events, including retinal artery occlusion (RAO), retinal vein occlusion (RVO), noninfectious uveitis (NIU), noninfectious scleritis (NIS), optic neuritis (ON), ischemic optic neuropathy (ION), and ocular motor cranial nerve palsy (OMCNP), following Coronavirus Disease 2019 (COVID-19) vaccination.

DESIGN

Population-based self-controlled case series METHODS: This study utilized nationwide claims and vaccination data provided by the Korea National Health Insurance Service and Korea Disease Control and Prevention Agency. From the entire South Korean population of 52 million individuals, patients with incident RAO, RVO, anterior NIU, nonanterior NIU, NIS, ON, ION, or OMCNP between January 2021 and March 2022 were included. The postvaccination risk period was defined as up to 56 days after COVID-19 vaccination. The relative incidence rate ratios (IRRs) for RAO, RVO, anterior NIU, nonanterior NIU, NIS, ON, ION, and OMCNP during the risk periods were measured using conditional Poisson regression.

RESULTS

The study included 6,590, 70,120, 137,958, 17,921, 15,492, 2,039, 49,089, and 11,312 cases of incident RAO, RVO, anterior NIU, nonanterior NIU, NIS, ON, ION, and OMCNP, respectively. The IRRs (95% confidence interval) during the early risk period (0-28 days) were 0.95 (0.88-1.01), 0.96 (0.94-0.98), 0.93 (0.91-0.94), 0.93 (0.89-0.96), 0.96 (0.92-1.01), 1.04 (0.92-1.18), 0.98 (0.95-1.00), and 0.91 (0.86-0.96), respectively. In the late risk period (29-56 days), the IRRs were 0.96 (0.89-1.03), 0.93 (0.91-0.96), 0.96 (0.95-0.98), 1.00 (0.95-1.04), 0.96 (0.91-1.01), 1.00 (0.87-1.15), 1.01 (0.98-1.04), and 0.95 (0.90-1.01), respectively.

CONCLUSION

COVID-19 vaccination did not increase the risk of incident RAO, RVO, anterior NIU, nonanterior NIU, NIS, ON, ION, or OMCNP during the postvaccination period.

Incident Ocular Inflammation After COVID-19 Infection in a US Veteran Population

PURPOSE

To investigate whether COVID-19 infection is a risk factor for incident ocular inflammatory disease.

DESIGN

Retrospective case-crossover study.

METHODS

The US Veterans Health Administration Corporate Data Warehouse was used to identify patients with positive COVID-19 testing and incident ocular inflammatory disease between March 2020 and May 2022. The timing of incident ocular inflammation and COVID-19 testing was assessed for each participant to determine whether positive COVID-19 testing occurred 0-60 days prior to incident ocular inflammation diagnosis (risk period) or 15-75 days after incident ocular inflammation diagnosis (control period). The main outcome measure was the odds of positive COVID-19 testing in the risk period versus control period.

RESULTS

Of the 1006 patients with incident ocular inflammation and a positive COVID-19 test in the study period, the age mean ± standard deviation was 62.6 ± 9.8 years and 840 (83%) were male. The odds of COVID-19 exposure was higher in the risk than control period (odds ratio [OR], 1.56; 95% confidence interval [CI], 1.04-2.36; P = 0.03). Ocular inflammation was more likely to be bilateral in the risk period (OR, 3.97; 95% CI, 1.01-23.01; P = 0.03). Other ocular features and demographic characteristics were similar in the risk and control periods. Most cases of ocular inflammation were quiescent at the most recent eye examination.

CONCLUSIONS

Incident ocular inflammation is associated with COVID-19 infection, but the increased risk is small, and the ocular inflammation is typically acute.

Risk of falls or fall-related injuries associated with potentially inappropriate medication use among older adults with dementia

BACKGROUND

Potentially inappropriate medications (PIMs) are prevalent in older adults with dementia and subsequent falls or fall-related injuries. The present study determined the risk of falls or fall-related injuries associated with PIM use in older adults with dementia.

METHODS

The National Health Insurance Service-Elderly Cohort Database 2.0 (NHIS-ECDB 2.0) was used for this self-controlled case series (SCCS) study. This study included 1430 participants who went through exposure and non-exposure periods of PIM application among patients with dementia and experienced outcome events of falls or fall-related injuries between January 2016 and December 2019. The incidence of falls or fall-related injuries during the exposure and post-exposure periods was compared with that during the non-exposure period. Beers Criteria were used to define PIMs in patients with dementia. Negative binomial regression was conducted. The incidence rate ratio (IRR) was used to determine the risk of falls or fall-related injuries.

RESULTS

During the exposure periods in which falls or fall-related injuries occurred, the mean number of PIMs among patients with dementia was 3.76 (SD = 2.99), and the most commonly used PIMs among patients with dementia were first-generation antihistamines (n = 283; 59.1%). Compared to the non-exposure period, the adjusted IRR during the exposure period was 1.57 (95% CI = 1.39-1.76). The risk of falls or fall-related injuries was increased when PIM use in patients with dementia was initiated (1-14 days: IRR = 2.76, 95% CI = 2.31-3.28; 15-28 days: IRR = 1.95, 95% CI = 1.48-2.56; ≥ 29 days: IRR = 1.17, 95% CI = 1.01-1.35). Especially, an increased risk of falls or fall-related injuries was associated with greater PIM use among patients with dementia.

CONCLUSION

Among older adults with dementia, PIMs significantly increase the risk of falls and fall-related injuries. Therefore, strategies should be developed to manage PIM prescriptions in patients with dementia to prevent falls.

Uveitis Risk After the First Dose of COVID-19 Vaccination Based on Uveitis History: Matched Cohort and Crossover Case Series Study

PURPOSE

To investigate the risk of noninfectious uveitis following the first dose of coronavirus disease 2019 (COVID-19) vaccination based on the uveitis history.

DESIGN

Retrospective matched cohort and crossover case series study.

METHODS

A random sample of 7 917 457 individuals who received COVID-19 vaccine between January 2021 and March 2022 in Korea, and had no recorded history of COVID-19 were categorized into the control and uveitis groups based on their uveitis history. After performing 3:1 propensity score matching, we assessed the cumulative incidence and risk of noninfectious uveitis in the 180 days after COVID-19 vaccination. Additionally, we performed a crossover case series analysis to compare the pre- and postvaccination incidence rate ratios (IRRs) of uveitis in individuals with and without a history of uveitis.

RESULTS

In the matched cohort analysis, uveitis group had a significantly higher cumulative incidence of uveitis (15.4%) than control group (0.10%). The uveitis group exhibited increased risks of all uveitis types, anterior, and nonanterior uveitis in the first 60 days (hazard ratio [HR]: 169, 158, and 253, respectively) and in days 61 to 180 (HR: 166, 164, and 143, respectively) after vaccination. In the crossover case series analysis, uveitis occurred with relatively equal frequency in 20-day intervals during the 180 days before and after vaccination, regardless of uveitis history. For uveitis group, the adjusted IRRs for early and late postvaccination events were 0.92 (95% CI, 0.88-0.96) and 0.83 (95% CI, 0.80-0.85), respectively.

CONCLUSIONS

COVID-19 vaccination did not increase the risk of uveitis, regardless of uveitis history.

Ischemic and Inflammatory Ocular Adverse Events Following Different Types of Vaccination for COVID-19 and Their Incidence Analysis

PURPOSE

To evaluate the ocular adverse event (OAE) and the incidence rate that can occur after the COVID-19 vaccination.

METHODS

Patients who visited with an ophthalmologic diagnosis within a month of COVID-19 vaccination were retrospectively analyzed. OAEs were categorized as ischemia and inflammation by their presumed pathogenesis and were compared by types of vaccine: messenger RNA (mRNA) and viral vector vaccine. The crude incidence rate was calculated using data from the Korea Disease Control and Prevention Agency.

RESULTS

Twenty-four patients with OAEs after COVID-19 vaccination were reviewed: 10 patients after mRNA and 14 after viral vector vaccine. Retinal vein occlusion (nine patients) and paralytic strabismus (four patients) were the leading diagnoses. Ischemic OAE was likely to occur after viral vector vaccines, while inflammatory OAE was closely related to mRNA vaccine (p = 0.017). The overall incidence rate of OAE was 5.8 cases per million doses: 11.5 per million doses in viral vector vaccine and 3.4 per million doses in mRNA vaccine.

CONCLUSIONS

OAEs can be observed shortly after the COVID-19 vaccination, and their category was different based on the types of vaccine. The information and incidence of OAE based on the type of vaccine can help monitor patients who were administered the COVID-19 vaccine.

Management of Scleritis in Older Adults

Scleritis, an inflammatory disease of the eye affecting scleral tissue, presents unique challenges in the older adult population. Unlike their younger counterparts, older individuals manifest a distinct spectrum of the disease with different underlying etiologies, co-morbidities, altered immune function, and an increased risk of systemic side effects from medication choices. Addressing these complexities necessitates a comprehensive and multidisciplinary approach. Treatment of choice will depend on any underlying cause but generally involves non-steroidal anti-inflammatory drugs, systemic or local corticosteroids, and potentially disease-modifying anti-rheumatic drugs. Utilization of these therapeutic agents in older adults warrants careful consideration because of their potential side-effect profiles. This article critically examines the specific concerns for the use of these drugs in older patients and reviews the existing literature on their use in this specific cohort.

Risk of Noninfectious Uveitis after Coronavirus Disease 2019 Vaccination in a United States Claims Database

PURPOSE

To assess noninfectious uveitis (NIU) risk after coronavirus disease 2019 (COVID-19) vaccination in patients without a history of uveitis.

DESIGN

A retrospective matched cohort study and self-controlled case series (SCCS) analysis using a longitudinal data asset with claims data from the OptumLabs Data Warehouse from December 11, 2020, through November 30, 2021.

PARTICIPANTS

The matched cohort analysis included patients continuously enrolled for 730 days before December 11, 2020, who received a COVID-19 vaccination during the study period. This COVID-19-vaccinated group was matched to a COVID-19-unvaccinated historical cohort enrolled in 2018 and 2019. The SCCS design included individuals from the vaccinated cohort who experienced an NIU event during the study period. Enrollees with a history of uveitis were excluded.

METHODS

Hazard ratios (HRs) were calculated using Cox proportional hazards models in the matched cohort design. Incidence rate ratios (IRRs) comparing NIU incidence in exposed risk periods after vaccination and unexposed control periods within individuals were calculated using conditional Poisson regression models in the SCCS design. Models were adjusted for age, recent receipt of non-COVID-19 vaccinations, corticosteroid or immunosuppressive use, and smoking history. Subgroup analyses were conducted by vaccination type and age group.

MAIN OUTCOME MEASURES

Rates of NIU identified with International Classification of Diseases, Tenth Revision, codes.

RESULTS

The matched cohort analysis included 4 611 378 patients, with 2 305 689 per cohort. The adjusted HR comparing NIU incidence in the COVID-19-vaccinated and unvaccinated cohort was 0.91 (95% confidence interval [CI], 0.75-1.10; P = 0.33). The SCCS analysis included 686 patients. The IRR comparing NIU risk after vaccination with risk during control intervals was 1.05 (95% CI, 0.89-1.23; P = 0.57). An increased risk was found in the subgroup aged 5 to 44 years (IRR, 1.40; 95% CI, 1.04-1.87; P = 0.024).

CONCLUSIONS

The matched cohort and SCCS analyses did not detect increased NIU risk after COVID-19 vaccination overall in individuals without history of uveitis, providing reassurance about the vaccine's safety. The finding of increased risk in the youngest subgroup suggests heightened immune responses in younger individuals, warranting further investigation.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Neuro-Ophthalmic Adverse Events of COVID-19 Infection and Vaccines: A Nationwide Cohort Study

Purpose

To evaluate the association of COVID-19 infection and vaccination with neuro-ophthalmic adverse events.

Methods

In this nationwide population-based retrospective cohort study, 8,498,353 patients were classified into three groups: control, COVID-19 infection, and COVID-19 vaccination. We conducted separate analyses for the early phase (within 60 days) and late phases (61-180 days) to estimate the incidence rates and hazard ratio (HR) for each neuro-ophthalmic adverse event. The adverse events included in this analysis were optic neuritis, papilledema, ischemic optic neuropathy, third nerve palsy, fourth nerve palsy, sixth nerve palsy, facial palsy, nystagmus, ptosis, blepharospasm, anomalies of pupillary function, and Guillain-Barré syndrome/Miller Fisher syndrome (GBS/MFS).

Results

Neuro-ophthalmic adverse events other than ptosis and GBS/MFS exhibited no significant increase after COVID-19, and their incidence was extremely low. The incidence rate of ptosis in both phases was significantly higher in patients administered COVID-19 vaccination (HR = 1.65 in the early phase and HR = 2.02 in the late phase) than in the control group. Additionally, BNT162b2 conferred a lower ptosis risk than ChAdOx1. GBS/MFS had a significantly higher incidence rate in the early phase (HR = 5.97) in patients with COVID-19 infection than in the control group.

Conclusions

Ptosis was associated with COVID-19 vaccination, particularly with the ChAdOx1 vaccine, while GBS/MFS was associated with COVID-19 infection. In contrast, no association was found between other neuro-ophthalmic adverse events and COVID-19 infection or vaccination. These results may provide helpful insights for diagnosing and treating the neuro-ophthalmological adverse events after COVID-19.

The risk assessment of uveitis after COVID-19 diagnosis: A multicenter population-based study

Reports on uveitis after COVID-19 have been limited. Our objective was to examine the risk of uveitis among COVID-19 patients. This was a retrospective cohort study based on the TriNetX platform. The exposure group was patients with positive laboratory test result for SARS-CoV-2 and the comparison group was those tested negative for COVID-19 throughout the study period. The endpoint is the new diagnoses of uveitis. This study composed of 2 105 424 patients diagnosed with COVID-19 (55.4% female; 62.5% white; mean age at index 40.7 years) and 2 105 424 patients (55.4% female; 62.4% white; mean age at index 40.7 years) who never had COVID-19. There was significantly increased risk of new diagnosis of uveitis since the first month after diagnosis of COVID-19 compared with matched controls (HR: 1.18, 95% CI: 1.03-1.34) up to 24 months (HR: 1.16, 95% CI: 1.09-1.22). Our findings strengthen those previously raised by case series with a larger and multicenter study. We found that uveitis was significantly associated with COVID-19 infection. Our findings reiterate the need for careful investigation as well as increased awareness from ophthalmologists in considering the possibility of COVID-19 in vulnerable patients with new presentation of uveitis.

Retinal Vein Occlusion after COVID-19 Vaccination-A Review

Background Retinal vein occlusion (RVO) occurring after COVID-19 vaccination has been reported worldwide. Such a sight-threatening condition occurring after COVID-19 vaccination is a menace to ophthalmic health. This article reviews current evidence related to post-COVID-19 vaccination RVO. Method A total of 29 relevant articles identified on PubMed in January 2023 were selected for review. Observation All cases presented to ophthalmologists with visual loss shortly after COVID-19 vaccination. Mean and median age were both 58. No sex predominance was observed. RVO was diagnosed from findings on dilated fundal examination and ophthalmic imaging. AstraZeneca and BNT vaccines accounted for most cases. Vascular risk factors, e.g., diabetes mellitus and hypertension, were common. Most laboratory tests requested came back unremarkable. Most patients responded well to standard treatment, except those with ophthalmic comorbidities. Visual prognosis was excellent on short-term follow-up. Discussion The causality between RVO and COVID-19 vaccination is undeterminable because of the nature of articles, heterogenous reporting styles, contradicting laboratory findings and co-existing vascular risk factors. Vaccine-induced immune thrombotic thrombocytopenia, retinal vasculitis and homocysteinaemia were proposed to explain post-vaccination RVO. Large-scale studies have demonstrated that the incidence of RVO following COVID vaccination is very low. Nevertheless, the effects of boosters on retinal vasculature and ophthalmic health are still unclear. Conclusions The benefits of COVID-19 vaccination are believed to outweigh its ophthalmic risks. To ensure safe vaccination, the prior optimisation of comorbidities and post-vaccination monitoring are important. COVID-19 vaccines (including boosters) should be offered with reasonable confidence. Further studies are warranted to elucidate the ophthalmic impact of vaccines.