![]() Examination revealed a pattern of strabismus fitting that of a right 4th cranial nerve palsy. We recently encountered a 46-year-old male patient who developed torsional, binocular diplopia 3 days after the second dose of Oxford–AstraZeneca ChAdOx1 nCoV-19 (AZD1222). Presumed inflammatory cranial neuropathies in general are common among patients after vaccines. We cannot know if the patient had optic neuritis or optic disc edema that was present for longer than his symptoms without an examination. Transient visual obscurations associated with optic disc edema (even that secondary to increased intracranial pressure, i.e., papilledema) are another consideration, but these events tend to manifest on the order of seconds and are elicited by transient increases in intrathoracic/central venous pressure. Regarding the case presented by Santovito and Pinna, the likelihood the patient had an optic neuropathy is low given the brief duration (hours) of symptoms. Visual prognosis is generally favorable, but ideal management remains elusive. The mechanism underlying optic neuritis in the setting of vaccination is not well understood previous studies have suggested molecular mimicry between myelin basic protein and viral proteins, epitope spreading, bystander activation, and superantigen activation as potential mechanisms. In a review of adverse ocular events from 2010 to 2020, optic neuritis was found to be the most common event associated with nine different vaccines with a mean onset of 10.8 days (range: 1 day–1 month) post-injection. ![]() Optic neuritis may manifest with reduction of visual acuity and darkening of the visual field, accompanied by pain exacerbated with ocular movement. In the current case, the onset, course, and duration of the reported symptoms narrow the field of etiological possibilities to the inflammatory and vascular categories. However, these ophthalmologic and neuro-ophthalmologic manifestations are non-specific, so definitive attribution to a particular exposure is generally difficult. ![]() Several case reports have reported on cranial nerve palsies, particularly oculomotor (third cranial) nerve and abducens (sixth cranial) nerve palsies presenting with diplopia and/or ophthalmoplegia. Regarding neuro-ophthalmologic manifestations, optic neuritis has been reported in several reports at various stages of COVID-19 infection. In one study, COVID-19 infection resulted in ocular manifestations in 1.4% of patients a review of the literature indicates that these manifestations most frequently result in reactive inflammation of the eyelids, follicular conjunctivitis, eye redness, foreign body sensation, and eye discharge. The neurologic and ophthalmic manifestations of SARS-CoV-2 (COVID-19) are well established. However, little insight can be gained without a corroborative neuro-ophthalmic examination within the window that the patient exhibited symptoms. The timeline of events beginning after the vaccination supports that the exposure caused the patient’s symptoms. We read with interest the article “Acute reduction of visual acuity and visual field after Pfizer-BioNTech COVID-19 vaccine 2nd dose” by Santovito and Pinna. ![]()
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