Transcript Bilateral Penetrating Keratoplasty Rejection After Administration of

Jonathan Etter, MD
Jeffrey Goldberg, MD
David Goldman, MD
The authors have no financial interests in the subject matter of this poster.
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Abstract: Bilateral penetrating keratoplasty rejection
following administration of H1N1 vaccine.
Purpose: To report a case of bilateral penetrating keratoplasty graft rejection
shortly after a patient was given the H1N1 vaccine.
Methods: A 25 year old women with keratoconus underwent penetrating
keratoplasty OS (2004) and OD (2009). Her vision was 20/25 OU following
surgery and both grafts were clear. In October, 2009 the patient received the liveattenuated H1N1 vaccine intranasally. The next morning she awoke with malaise,
swelling of her right eyelids and a visual decline OD. On presentation to the eye
clinic her vision was count fingers OD and 20/30 OS. The right eye demonstrated
a diffusely edematous graft with linear keratic precipitates and moderate
anterior chamber cell, while the graft OS displayed milder rejection signs. Both
eyes were treated with aggressive topical steroid.
Results: The patient’s graft OS improved with resolution of rejection stigmata, while
the right eye necessitated sub-tenons kenalog as well as oral prednisone. After
two months, the patient's graft OD finally cleared.
Conclusions: This demonstrates a case of bilateral graft rejection immediately
following administration of the H1N1 vaccine. It is possible that administration of
the vaccine initiated an immunologic response resulting in corneal graft rejection
in this patient.
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History of Present Illness
25 year old woman
with keratoconus
(status post PK ou)
awoke with
malaise, swollen
eyelids and blurry
vision bilaterally 48
hours after receiving
live attenuated H1N1
vaccine intranasally.
Representative photo of administration of
live-attenuated H1N1 Vaccine
(Image from www.pennlive.com)
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Prior Ocular History:
25 year old woman with keratoconus
2004
2005
PK OS
PK OD
2005 – 2009 Several rejection episodes
(All episodes responded to topical or
subtenons steroid)
Rejection episode OD that resulted in
Spring,
permanent scarring
2009
Summer,
Repeat PK OD
2009
Fall, 2009
VA OU 20/25
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Vision was count
fingers in her right
eye and 20/30
OS. Exam revealed
Diffuse corneal
edema, linear keratic
precipitates and
anterior chamber cell
OD (Figure 1), while
her left eye displayed
mild graft edema,
precipitates and
anterior chamber cell.
Figure 1: Slit lamp photo of right eye
during rejection episode.
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We treated her with aggressive
topical steroid which resolved
her rejection episode OS but
was not effective for her right
eye. In the following days we
administered sub-tenons
kenalog OD and started oral
prednisone. After those
measures and continuation of
topical steroid therapy her
rejection episode improved
after 2 months. (Figure 1)
Figure 1: Slit lamp photo of right eye
displays improvement of corneal
edema and haze after 2 months of
treatment.
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Prior reports of graft rejection
after vaccination
Steinemann TL, Koffler BH, Jennings CD.
Corneal allograft rejection following
immunization. Am J Ophthalmol. 106:5758, 1988.
Five episodes of graft rejection after
various vaccines (Influenza, Tetanus,
Hep B). Treated with topical and oral
steroid. 3/5 grafts cleared.
Solomon A, Frucht-Pery J. Bilateral
simultaneous corneal graft rejection
after influenza vaccination. Am J
Ophthalmol. 121:708-9, 1996.
Bilateral episode of graft rejection
after influenza vaccine. Treated with
topical, oral and subconjunctival
steroid. Both grafts cleared.
Wertheim MS, Keel M, Cook SD, Tole DM.
Corneal transplant rejection following
influenza vaccination. Br J Ophthalmol.
90:925,2006.
Three episodes of graft rejection
after Influenza vaccine. Treated with
topical steroid. All grafts cleared.
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
Corneal transplant rejection in conjunction with
the seasonal influenza vaccine has been reported
prior. (see previous slide) While we do not know
the exact mechanism by which the vaccination
process incites endothelial rejection, it does
make sense on a basic level that activation of the
cellular and humoral immune response may have
a local effect on the ocular surface.
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
Similar to other vaccines, that of H1N1 can be
administered in live-attenuated and inactivated
forms. The live-attenuated version is given
intranasally and consists of the live H1N1 virus
that has been altered so that it theoretically
generates an adequate immune response
without causing deleterious effects of the virus
itself. Inactivated vaccine contains virus that
has been killed. It is generally thought that liveattenuated vaccines generate a more robust
immune response and indeed our patient did
receive the live form.
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
It is quite possible however, that our patient would have
had a rejection episode after the inactivated vaccine as
well. Our patient had been prone to getting rejection
episodes in the past, so perhaps she was more
immunologically primed to have an event than others
would be. Given all of these complexities, it is difficult to
make any hard and fast recommendations based upon
this single event. However, it may be important to
consider the possibility of transplant rejection in patients
deciding whether or not to get vaccinated. If those
patients do decide to get vaccinated, it may also be
prudent to monitor them very closely for rejection in the
post-vaccination period or increase their anti-rejection
medications around the time of vaccination.
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