Large-scale vaccination campaigns to prevent coronavirus disease 19 (COVID-19) started earlier in Europe and the USA compared to most of Asia, and therefore, early reports of new-onset or relapse of intraocular inflammatory disease after vaccination came from populations with low proportions of Asians. The data for these reports was gathered in the spring to summer of 2021 and revealed high rates of anterior uveitis (61.9% and 58.6% for 2 representative multicenter studies, the latter study included scleritis) [1, 2], a type of uveitis known to be common in Caucasians. In contrast, our experience with post-COVID-19 vaccination intraocular inflammation differed greatly to those early reports, prompting the current study.

Medical records were retrospectively reviewed of 10 consecutive patients (6 women and 4 men, mean age 44.6 years, all of Japanese ethnicity) presenting to the Kyorin Eye Center, Tokyo, between June and August of 2021 with new-onset or acutely worsening/relapsing intraocular inflammation within 1 month of vaccination with either BNT162b2 (Pfizer/BioNTech) or mRNA-1273 (Moderna), the only two COVID-19 vaccines offered to the general Japanese population to date. The present study was conducted in accordance with the tenets of the Declaration of Helsinki and was approved by the Kyorin University Hospital Research Ethics Committee.

Of 7 patients with new-onset disease, 4 were diagnosed with Vogt-Koyanagi-Harada (VKH) disease, and of 3 patients with worsening/relapsing disease, 1 had sympathetic ophthalmia that had been under long-standing good control on adalimumab and cyclosporine with excellent visual acuity in the sympathizing eye (Table 1). Only 1 patient (10%) had anterior uveitis. All patients received standard treatment for their condition and achieved usual clinical outcomes for their disease (Table 2).

A rapid survey was conducted by the Japanese Ocular Inflammation Society from February through December 2021, and results tabulated from 14 responding institutions revealed that of 35 patients with new-onset or recurrent uveitis presenting within 2 weeks of COVID-19 vaccination, only 6 (17.1%) had anterior uveitis, while an astonishing 17 (50%) had VKH disease [3]. A Japan nationwide retrospective multicenter study conducted prior to the COVID-19 pandemic of consecutive new patients presenting to uveitis specialty clinics over a 1-year period (not including scleritis) reported anterior uveitis as an anatomical type in 36% of patients and VKH disease and/or sympathetic ophthalmia in 8.2% [4]. While VKH disease and sympathetic ophthalmia share similar pathogenic mechanisms involving immune reaction against melanocyte-related antigens, it is unclear why these diseases would be preferentially triggered after COVID-19 vaccination. VKH or VKH-like disease has also been reported in association with intradermal vaccination for other infectious pathogens including hepatitis B virus and human papilloma virus [5]. We wonder whether the intradermal and/or intramuscular site (but still near the dermis) of vaccination may be playing a contributory role to triggering this particular vaccine-related adverse effect.