I feel like my last journal contribution was about COVID-19 ocular manifestations, here I go again…..!!

70 year old man – Diagnosed with Myasthenia Gravis aged 35 years

Required medication management until aged 45, then asymptomatic and weaned off meds

5 days post 1^st dose of Pfizer vaccine (2020) à recurrence of MG symptoms; general and ocular including diplopia and ptosis.

Back on medications and desperately regretting having had the vaccine. 

Referral from Neurologist:

“He has myasthenic syndrome that was diagnosed many years ago and unfortunately, it was under very good control prior to his COVID vaccination.  His fatigue and respiratory surveillance have recovered. However, he has had ongoing problems with diplopia.  The trial of increased steroids and azathioprine has not really improved things and I’m not convinced that any medication is going to be helpful here. I have suggested to him, because it is a fixed deficit, that he consider a pragmatic approach with a prism.  He is also experiencing some weakness in his hands, which I have arranged a nerve conductive study for him to investigate further causes.”

Orthoptic appointment:

3 years post vaccine and recurrence/exacerbation of MG.

Ptosis resolved

Diplopia persisting 1pd vertical prism required.

Bilateral pseudophake with multifocal implant so didn’t wear glasses.  Macular normal.

My investigation was simply to review the literature on MG exacerbation and to differentiate new-onset versus exacerbating the existing condition post COVID infection and/or vaccination.  Most documented evidence discussed MG developing general systemic symptoms rather than ocular manifestations.

Each highlight MG patients infected with SARS-CoV-2, commonly develop severe acute respiratory distress syndrome requiring intubation and have a higher mortality compared to the general population. With a neat summary of literature review of concurring findings that “COVID-19 infection can increase the risk of new-onset myasthenia gravis, myasthenic crisis, respiratory failure, and mortality rate due to cytokine storm in myasthenia gravis patients.”

I found no reported cases of fatality following COVID vaccination in MG patients.

Overall, literature discusses autoimmune and inflammatory diseases can be triggered by Covid-19 viral infection and/or COVID-19 vaccines, including MG new onset and recurrence or exacerbation.  Have a read for yourselves if it interests you or if have a similar patient, I’d be keen to hear of any outstanding ocular symptoms requiring treatment. 

Just another ocular manifestation to consider with our patients. Data is still being collected and published to give us better statistics.

My gentleman is one of the fortunate ones that at the date of me seeing him had never been infected with COVID-19.  And my sympathies for this gentleman and other patients that experience the recurrence or exacerbation of any condition that they had under control.

On the other hand, if his 1pd vertical prism is the only remaining effect from his pandemic experience, one may consider him very fortunate when we put it into perspective with those more impacted as well as those experiencing difficulties associated with long-COVID etc etc etc.

Reflective practice

COVID infection and vaccination are standard questions I include in my list when I ask in my history to patients regarding their onset of diplopia.