Ocular MG Signs Emerge After COVID-19 Vaccine But Cause Unclear

Lindsey Shapiro, PhD avatar

by Lindsey Shapiro, PhD |

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A man developed signs of myasthenia gravis (MG) with eye symptoms about a month after receiving the first shot of Oxford-AstraZeneca’s COVID-19 vaccine, a case study reports.

“This case report implies that COVID-19 vaccination may cause myasthenia gravis with ocular symptoms,” the researchers wrote. “But we should also consider the possibility that the onset of myasthenia gravis symptoms with vaccination could be coincidental.”

The report, “Myasthenia gravis with ocular symptoms following a ChAdOx1 nCoV-19 vaccination: A case report,” was published in the American Journal of Ophthalmology Case Reports.

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The muscles that control eye and eyelid movements are typically among the first affected in MG, leading to ocular symptoms like paralysis of eye movements, double vision, or eyelid droopiness in about 85% of MG patients. In some patients, MG symptoms are limited to the eyes, a condition known as ocular MG.

Some cases of eye-related symptoms have been reported after COVID-19 vaccination. Further, a few rare reports of ocular MG, MG, and MG crises emerging after vaccination exist, although a causal link between COVID-19 vaccination, eye symptoms, and MG has not been established.

Here, researchers reported the case of a 35-year-old man referred to their clinic in South Korea with symptoms of double vision in both eyes that had started three weeks earlier — about a week after receiving the first dose of Oxford-AstraZeneca’s COVID-19 vaccine. He had no other significant medical, surgical, or social history.

The patient said that on the evening after vaccination, he experienced a headache, dizziness, numbness in his arms and legs, and diarrhea, with nausea emerging four days later. All of these symptoms spontaneously resolved. However, a week later, he started experiencing double vision with no other symptoms.

Eye exams conducted in the clinic revealed the man had normal visual acuity and eye pressure. His left eye was slightly deviated upwards (hypertropia) and had alterations to its movement, whereas the right eye appeared to be normal.

Additional tests showed normal pupil reactivity to light, a healthy optic nerve — the nerve sending signals between the brain and eyes — and normal function of the retina, a region at the back of the eye that contains specialized light-sensitive cells that play a key role in vision.

When a pack of ice was placed for two minutes over the patient’s eyes, his double vision temporarily eased.

A battery of other tests showed that his arm and leg muscle strength was normal, as was his nerve function. While most laboratory findings were normal, a blood test revealed the presence of self-reactive antibodies, or autoantibodies.

Specifically, the man had elevated levels of antibodies targeting the acetylcholine receptor — a protein important for nerve-muscle communication that is commonly targeted in MG. His antibody levels were at 1.6 nanomoles per liter (nmol/L) — above the normal range of 0–0.5 nmol/L. Based on these findings, the man was diagnosed with MG with ocular symptoms.

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Autoimmune reactions have been reported as a very rare occurrence after vaccination, raising the possibility that COVID-19 vaccination might have spurred the onset of MG, an autoimmune disorder, in this patient. But causation cannot be inferred based on this case report, as there is the possibility that MG emergence after vaccination was a coincidence, the team noted.

“We cannot rule out that a pre-existing subclinical myasthenia gravis … unmasked by a viral-like illness following vaccination even if the patient had had no symptoms,” the researchers wrote.

“The underlying mechanism of the disease following vaccination requires further investigation,” they added.