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Expedited Publication, Photo Essay

Corneal graft rejection after COVID-19 vaccination

Ravichandran, Swetha; Natarajan, Radhika

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Indian Journal of Ophthalmology: July 2021 - Volume 69 - Issue 7 - p 1953-1954
doi: 10.4103/ijo.IJO_1028_21
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A 62-year-old man presented with corneal graft rejection after COVID-19 vaccination. He had undergone penetrating keratoplasty for a childhood corneal scar in his right eye, 2 years ago. The aphakic and amblyopic eye had regained corrected vision of 6/36, N12 and was on topical steroid once a day.

He presented with congestion and diminution of vision of 5 days duration, having taken his first shot of COVID-19 vector vaccine (ChAdO × 1 nCoV-19 Corona Virus Vaccine Recombinant COVISHIELD™), 3 weeks prior. There were no loose sutures, neovascularization, iris synechiae, or any other stimulus for rejection. There was an advancing horizontal Khodadoust’s rejection line in the center of the endothelium with graft edema at its wake inferiorly [Fig. 1] and grade 2 anterior chamber reaction. The graft superior to the rejection line was clear [Fig. 2]. Treatment for corneal allograft rejection was started. This may be the first report of graft rejection after COVID-19 vector vaccination.

Figure 1
Figure 1:
It shows graft rejection with edema inferiorly and clear graft superiorly
Figure 2
Figure 2:
It shows an advancing Khodadoust’s endothelial rejection line


The immune privilege of the cornea is due to lack of blood and lymph vessels in the host bed and absence of major histocompatibility complex (MHC) class II antigen presenting cells, making the donor cornea invisible to the host immune system.[1]

Vaccination incites immune response that can induce Class II MHC complex antigens in all layers of the grafted cornea and could trigger allograft rejection like the influenza vaccine.[23] The recent rampant vaccination against COVID-19 has triggered a debate about similar such effect on endothelial or full thickness keratoplasty.[4] Now, it has become common practice to hike up topical steroids prior to any type of COVID-19 vaccination.[5]

Our case highlights the possibility of immune corneal graft rejection after COVID-19 vaccination which corneal surgeons should be aware of. It also raises the dilemma regarding the timing of the second dose of vaccination, in patients presenting with rejection.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

1. Wertheim MS, Keel M, Cook SD, Tole DM. Corneal transplant rejection following influenza vaccination Br J Ophthalmol. 2006;90:925
2. Steinemann TL, Koffler BH, Jennings CD. Corneal allograft rejection following immunization Am J Ophthalmol. 1988;106:575–8
3. Solomon A, Frucht-Pery J. Bilateral simultaneous corneal graft rejection after influenza vaccination Am J Ophthalmol. 1996;121:708–9
4. Phylactou M, Li JO, Larkin DFP. Characteristics of endothelial corneal transplant rejection following immunisation with SARS-CoV-2 messenger RNA vaccine Br J Ophthalmol. 2021 Apr 28 bjophthalmol-2021-319338 Epub 2021 Apr 28
5. Lockington D, Lee B, Jeng B, Larkin D, Hjortdal J. Survey of Corneal Surgeons'Attitudes Regarding Keratoplasty Rejection Risk Associated With Vaccinations, Cornea Epub. 2021 Jan 20

Corneal graft rejection; COVID-19 vaccination; Khodadoust’s line; vector vaccine

© 2021 Indian Journal of Ophthalmology | Published by Wolters Kluwer – Medknow