Multiple Evanescent White Dot Syndrome After mRNA COVID-19 Vaccination

A 46-year-old woman noticed blurred vision in her right eye two weeks after receiving the fourth dose of a COVID-19 vaccine and visited a local eye clinic. Then, the patient was referred to our hospital to investigate the cause of decreased vision in the right eye. At the initial visit to our hospital, the best-corrected visual acuity (BCVA) in the right eye was 0.7 in decimal units and 1.5 in the left eye, respectively. Intraocular pressure was 17 mmHg in both eyes. Abnormal findings were observed only in the right eye; the left eye was completely normal. Therefore, all abnormal findings described below are related to the right eye. Anterior segment examination revealed inflammatory cells in the anterior chamber. The lenses in both eyes were almost clear, and the right eye showed vitreous cells and vitreous opacity. Fundus examination revealed multiple small white exudative spots. Optical coherence tomography (OCT) demonstrated disruption of the ellipsoid zone (EZ) and hyper-reflective lesions beneath the retina. Fluorescein angiography (FA) showed hyperfluorescence consistent with staining at the sites of exudative lesions, while indocyanine green angiography (ICGA) revealed corresponding hypofluorescent spots due to blocked fluorescence. Full-field electroretinography (ERG) showed reduced amplitudes of both a- and b-waves. Goldman perimetry identified a central scotoma in the right eye. Based on these findings, the patient was diagnosed with multiple evanescent white dot syndrome (MEWDS) in the right eye. Topical betamethasone sodium phosphate and fradiomycin sulfate were initiated six times a day for the right eye at the first visit. The day after the initial visit, the BCVA in the right eye rapidly declined to 0.01 in decimal units, prompting the initiation of oral prednisolone at 30 mg/day. Eight days later, a sub-Tenon's capsule injection of triamcinolone acetonide (20 mg/0.5 ml) was administered. The symptoms gradually improved thereafter, and the hyper-reflective subretinal lesions observed on OCT disappeared. Oral steroid therapy was tapered, and the visual acuity (VA) improved to 1.0 in decimal units four months later. A case of MEWDS occurring after COVID-19 vaccination showed favorable recovery with oral steroid therapy and sub-Tenon's injection.