Corneal Surgery and H1N1 Flu

By David A. Goldman, MD¹ and Jonathan Etter, MD²

1. Assistant Professor of Clinical Ophthalmology, Bascom Palmer Eye Institute
2. Lecturer, Bascom Palmer Eye Institute

Because concerns of H1N1 have become widespread across the U.S., many have rushed to obtain the H1N1 vaccine. While the adverse effects of this vaccine are relatively mild, they can have ophthalmic consequences. The following case demonstrates one such occurrence:

A 25-year old female with history of bilateral corneal transplants for keratoconus (OD in 2009, OS in 2004) received the live attenuated H1N1 vaccine intra-nasally. The following morning she awoke with bilateral corneal rejection OD more severe than OS. While the left eye has responded well to topical steroid drops, the right remains edematous despite both sub-tenon’s injection of triamcinolone and oral prednisone.

Corneal transplant rejection following vaccination has been described previously with the influenza vaccine [1-3]. However, in these cases the time from vaccination to rejection has ranged from two to eight weeks. The fast onset of corneal transplant rejection in this patient may likely be related to the close proximity of the inoculation site (nares) to the eye. However, this may also represent a more robust immune reaction to a relatively new and understood vaccine.

Where does this matter in refractive surgery? Increased immune response, and therefore inflammation, can be associated with regression, diffuse lamellar keratitis, transient light sensitivity, and, in severe cases, corneal melting.

As the H1N1 vaccine becomes more available, our patients will be more likely to obtain it, particularly without alerting their ophthalmologist. In discussing laser refractive surgery with our patients in these upcoming months, we must take care to warn our patients about receiving the H1N1 vaccine prior to refractive surgery. If the vaccine is administered to the patient around the time of refractive surgery, we may want to consider a more frequent and prolonged course of topical steroid therapy.

References

1. Wertheim MS, Keel M, Cook SD, Tole DM. Corneal transplant rejection following influenza vaccination. Br J Ophthalmol 2006; 90(7):925.


2. Solomon A, Fruct-Pery J. Bilateral simultaneous corneal graft rejections after influenza vaccination. Am J Ophthalmol 1996; 121: 708-9.


3. Steinemann TL, Koffler BH, Jennings CD. Am J Ophthalmol. 1988; 106(5):575-8.
   

Correspondence:
David Goldman, MD
Bascom Palmer Eye Institute
7101 Fairway Dr
Palm Beach Gardens, FL 33418
DGoldman@med.miami.edu

W: 561-515-1543
F: 561-355-8600