effects side ocular induced-Drug • 7 Part

Conditional/Unclassified

1. Episcleritis

2. Scleritis

3. Orbital myositis

4. Uveitis

Clinical significance

Earlier influenza vaccines were from swine but these have discontinued due to an increased incidence of neurological complications, including optic neuritis, optic atrophy and blindness (Cangemi and Bergen 1980; Macoul 1982). Poser (1982) reported isolated trochlear and 59 facial nerve paresis also using swine vaccine. Manufacturers use various virus strains, which may produce different ocular effects. The best-studied adverse ocular side effect is an influenza-vaccine-induced oculo-respiratory syndrome, which consists of cough, wheeze, chest tightness, difficulty breathing and/or sore throat. The ocular manifestation is bilateral conjunctivitis, which can occur within hours of inoculation. This may or may not include facial edema. Fredette et al (2003) noted photophobia, blurred vision, lid edema, ocular pain and conjunctival concentrates as part of the syndrome. Onset varies between 2 and 24 hours after exposure and resolves within 48 hours. Up to 16% of women between the ages of 50 and 59 had this syndrome, making them the highest risk group (Skowronski et al 2002a). DeSerres et al (2003a) has shown that an earlier onset of this syndrome (less than 2 hours) is more likely in younger patients who have more coughs and sore throats, and a later onset (after 2 hours) is more likely in the older population, who have more ocular symptoms. The frequency of this syndrome substantially decreased with each annual injection over a 4-year follow-up ­series (DeSerres et al 2005). While the above data are mainly from a specific manufacturer, this vaccine was minimally retrogenic, therefore this syndrome can be associated with influenza vaccines in general (DeSerres et al 2003b; Scheifele et al 2003).

Hull and Bates (1997) reported a case of bilateral optic neuritis­ developing within 2 weeks of being vaccinated by the newer influenza vaccination. This happened on two separate occasions,­ 1 year apart. Ray and Dreizin (1996) reported a similar­ case without rechallenge data. There have been various reports of unilateral and bilateral optic neuritis after vaccination with good recovery, with or without treatment. Kawasaki et al (1998) reported bilateral ischemic optic neuropathy with two cases of permanent visual loss. The authors speculated that an immune complex-mediated vasculopathy following vaccination can cause anterior ischemic optic neuropathy. Knopf (1991) reported­ a case of complicated cataract surgery with secondary uveitis that had complete recovery. Four months later, following a flu vaccination, the patient had a recurrence of her uveitis with decreased vision and cystoid macular edema. When a rare case of extraocular muscle abnormalities or uveitis occurs, this is usually­ within 2 to 14 days following inoculation. These may last from a few days to a few weeks.

Patients with corneal grafts who are vaccinated are probably at higher risk for a graft rejection. Most patients who react usually only have mild graft reactions, which can be controlled with topical ocular steroids. However, severe reactions requiring re-grafts have occurred. Steinemann et al (1988), Solomon and Frucht-Pery (1996), Wertheim et al (2006) and the National Registry have a total of eight cases of graft rejection. Thurairajan et al (1997) reported a case of bilateral orbital myositis and posterior scleritis following influenza vaccination. The authors found no other cause for this and felt these ocular side effects, including an associated acute symmetrical polyarthropathy, were due to the vaccine. Mutsch et al (2004) reported 46 cases of Bell’s palsy with

an influenza vaccine that was only used in Switzerland. There are cases of episcleritis after inoculation in the National Registry.

References And Further Reading

Cangemi FE, Bergen RL. Optic atrophy following swine flu vaccination. Am Ophthalmol 12: 857, 1980.

De Serres G, Boulianne N, Duval B, et al. Oculo-respiratory syndrome following influenza vaccination: evidence for occurrence with more than one influenza vaccine. Vaccine 21: 2346–2353, 2003.

De Serres G, Grenier JL, Toth E, et al. The clinical spectrum of the oculo-respi- ratory syndrome after influenza vaccination. Vaccine 21: 9726–3732, 2003.

De Serres G, Toth E, Menard S, et al. Oculo-respiratory syndrome after influenza vaccination: trends over four influenza seasons. Vaccine 23: 3732–9726, 2005.

Fredette MJ, De Serres G, Malenfant M. Ophthalmological and biological features of the oculorespiratory syndrome after influenza vaccination. Clin Infect Dis 37: 1136–1138, 2003.

Hull TP, Bates JH. Optic neuritis after influenza vaccination. Am J Ophthalmol 124(5): 703–704, 1997.

Kawasaki A, Purvin VA, Tang R. Bilateral anterior ischemic optic neuropathy following influenza vaccination. J Neuro-Ophthalmol 18(1): 56–59, 1998.

Knopf HL. Recurrent uveitis after influenza vaccination. Ann Ophthalmol 23(6): 213–214, 1991.

Ghosh C. Periorbital and orbital cellulites after H. influenza b vaccination. Ophthalmology 108: 1514–1515, 2001.

Macoul KL. Bilateral optic nerve atrophy and blindness following swine influenza vaccination. Ann Ophthalmol 14: 398, 1982.

Mutsch M, Zhou W, Rhodes P, et al. Use of the inactivated intranasal influenza vaccine and the risk of Bells’ palsy in Switzerland. N Engl J Med 350: 896–903, 2004.

Poser CM. Neurological complications of swine influenza vaccination. Acta Neurol Scand 66: 413–431, 1982.

Ray CL, Dreizin IJ. Bilateral optic neuropathy associated with influenza vaccination. J Neuro-Ophthalmol 16(3): 182–184, 1996.

Scheifele DW, Duval B, Russell ML, et al. Ocular and respiratory symptoms attributable to inactivated split influenza vaccine: evidence from a controlled trial involving adults. Clin Infect Dis 36: 850–857, 2003.

Skowronski DM, Bjornson G, Husain E, et al. Oculo-respiratory syndrome after influenza immunization in children. Pediatr Infect Dis J 24: 63–69, 2005.

Skowronski DM, De Serres G, Hebert J, et al. Skin testing to evaluate oculo-respiratory syndrome (ORS) associated with influenza vaccination during the 2000–2001 season. Vaccine 20: 2713–2719, 2002.

Skowronski DM, Lu H, Warrington R, et al. Does antigen-specific cytokine response correlate with the experience of oculorespiratory syndrome after influenza vaccine? J Infect Dis 187: 495–499, 2003a.

Skowronski DM, Strauss B, De Serres G, et al. Oculo-respiratory syndrome: a new influenza vaccine-associated adverse event? Clin Infect Dis 36: 705–713, 2003b.

Skowronski DM, Strauss B, Kendall P, et al. Low risk of recurrence of oculorespiratory syndrome folloing influenza revaccination. CMAJ 167: 853–858, 2002.

Solomon A, Frucht-Pery J. Bilateral simultaneous corneal graft rejection after influenza vaccination. Am J Ophthalmol 121(6): 708–709, 1996.

Steinemann TL, Koffler BH, Jennings CD. Corneal allograft rejection following immunization. Am J Ophthalmol 106: 575–578, 1988.

Thurairajan G, Hope-Ross MW, Situnayake RD, et al. Polyarthropathy, orbital myositis and posterior scleritis: an unusual adverse reaction to influenza vaccine. Br J Rheum 36: 120–123, 1997.

Wetheim MS, Keel M, Cook SD, et al. Corneal transplant rejection following influenza vaccination. Br J Ophthalmol 90: 925–926, 2006.

Generic names: 1. Measles, mumps and rubella virus vaccine live; 2. measles virus vaccine live; 3. mumps virus vaccine live; 4. rubella and mumps virus vaccine live; 5. rubella virus vaccine live.

Proprietary names: 1. MMR II; 2. Attunvax; 3. Mumpsvax; 4. Biavax II; 5. Meruvax II.

Primary use

These vaccines are used to provide active immunity to measles, mumps and rubella.

agents miscellaneous and antagonist metal Heavy • 12 Section

effects side ocular induced-Drug • 7 Part

4. Photophobia

5. Scotomas – centrocecal

6. Decreased vision

Conditional/Unclassified

1. Neuroretinitis

a.Optic disc edema

b.Macular edema

c.Hard exudates

Clinical significance

Neurological adverse reactions were much more common with the earlier preparations of rabies vaccine made from infected rabbit brain tissue than from later-generation vaccines. There are reports of optic neuritis (Cormack and Anderson 1934; Srisupan and Konyama 1971; Chayakul et al 1975; Francois and Van Lantschoot 1976; Van de Geijn et al 1994; Dadeya et al 2004). Optic neuritis usually occurs from a few weeks to 3 months post vaccination and is often part of acute disseminated encephalomyelitis (Brain 1962). There are cases (Consul et al 1968; Stratton et al 1994) where the optic neuritis was the only neurological finding. Mostly, patients can recover to good vision, but some permanent damage to the retinal fibers may occur (Consul et al 1968). While neurological complications due to rabies vaccinations are rare, encephalitis, myelitis and encephalomyelitis are well documented. This includes varying degrees of paralysis, including the oculomotor nerves (Walsh 1957). Chayakul et al (1975), along with cases in the National Registry, reported various paresis and paralysis of the ocular motor nerves. This is usually associated with a vaccine-induced encephalomyelitis.

Saxena et al (2005) reported bilateral neuroretinitis using chick embryo cell anti-rabies vaccine. The neuroretinitis was an acute swelling of both the optic discs associated with hard exudates and macular edema.

References And Further Reading

Brain WR. Diseases of the Nervous System, 6th edn, Oxford University Press, New York, 1962.

Chayakul V, Ishikawa S, Chotibut S, et al. Convergence insufficiency and optic neuritis due to antirabies inoculation – a case study. Jpn J Ophthalmol 19: 307–314, 1975.

Consul BN, Purohit GK, Chhabra HN. Antirabic vaccine optic neuritis. Indian J Med Sci 22: 630–632, 1968.

Cormack HS, Anderson LAP. Bilateral papillitis following antirabic inoculation: recovery. Br J Ophthalmol 18: 167, 1934.

Cremieux G, Dor JF, Mongin M. Paralysies faciales peripheriques et polyradiculoneurites post-vaccino-rabiques. Acta Neurol Belge 78: 279, 1978.

Dadeya S, Guliani BP, Gupta VS, et al. Retrobulbar neuritis following rabies vaccination. Trop Doct 34: 174–175, 2004.

Francois J, Van Lantschoot G. Optic neuritis and atrophy due to drugs. T Geneesk 32: 151, 1976.

Gupta V, Bandyopadhyay S, Bapuraj JR, et al. Bilateral optic neuritis complicating rabies vaccination. Retina 24: 179–181, 2004.

Saxena R, Sethi HS, Rai HK, et al. Bilateral neuro-retinitis following chick embryo cell anti-rabies vaccination: a case report. BMC Ophthalmol 5: 20, 2005.

Srisupan V, Konyama K. Bilateral retrobulbar optic neuritis following anti­ rabies vaccination. Siriraj Hosp Gaz 23: 403, 1971.

Stratton KR, Howe CJ, Johnston RB Jr. Adverse Events Associated with Childhood Vaccines: Evidence Bearing on Causality, Vaccine Safety Committee, Division of Health Promotion and Disease Prevention Institute of Medicine (eds), Washington, DC, National Academy Press, 1994.

Van de Geijn E, Tukkie E, Van Philips L, Punt H. Bilateral optic neuritis with branch retinal artery occlusion associated with vaccination. Doc Ophthalmol 86: 403–408, 1994.

Van der Meyden CH, Van den Ende J, Uys M. Neurological complications of rabies vaccines. S Afr Med J 53: 478, 1978.

Walsh FB. Clinical Neuro-ophthalmology, 2nd edn, Wiliams and Wilkins, Baltimore, p 477, 1957.

Generic name: Smallpox (Vaccinia) vaccine.

Proprietary name: Dryvax.

Primary use

Used as a vaccination against the vaccinia virus.

Ocular side effects

Systemic administration – autoinoculation from vaccination site

Certain

1. Eyelids and conjunctiva

a.Blepharoconjunctivitis

b.Vesicles

c.Pustules

d.Profound edema

e.Periorbital erythema (Fig. 7.12e)

f.Prearicular and submandiublar lymphadenopathy

g.Scarring

h.Madrosis

i.Conjunctivitis

i.Papillary reaction

ii.Serous and mucopurulent discharge

iii.Ulceration

iv.Symblepharon

j.Punctal stenosis

2. Cornea

a.Superficial punctate keratitis

b.Interstitial and stromal keratitis

c.Disciform keratitis

d.Necrosis

e.Perforation

f.Subepithelial opacities

g.Ring infiltrates

3. Iritis

4. Photophobia

Conditional/Unclassified

1. Retina

a.Cotton wool spots

b.Branch arteriolar occlusions

c.Vasculitis

Fig. 7.12e  Periorbital edema and erythema after smallpox immunization. Photo courtesy of Pepose JS, et al. Ocular complications of smallpox vaccination. Am J Ophthalmol 136: 343—352, 2003.

agents miscellaneous and antagonist metal Heavy • 12 Section