The wait is over. In many states across the country, individuals other than front-line healthcare workers are now eligible to receive the COVID-19 vaccine.
Here at the University of Iowa, we’ve been inundated with phone calls from our corneal transplant patients, who have been asking what’s probably on your mind, too: “Will the COVID vaccine endanger my corneal transplant?” and “Should I change my steroid eye drop regimen when I get vaccinated?”
Here’s the short answer:
For the vast majority of DSAEK and DMEK corneal transplant recipients, the COVID vaccine presents minimal if any risk of rejection, which, even if it occurs, will almost certainly not result in you needing to replace your transplant, especially if it’s caught early. If you’re well beyond the immediate postoperative period and you’re on a low-frequency steroid eye drop regimen (e.g. once daily or once every other day, whatever your flavor of steroid), and if you have no history of steroid-induced high eye pressure or glaucoma, and you either have the rejection-heebie-jeebies, and/or you’d rather not take any chances because tempting fate just doesn’t seem like a good idea during a once-in-a-century-global-pandemic, then…
To “play it safe,” increase your steroid eye drop frequency to four times a day starting 1 week before your first COVID vaccination, continue it four times a day until 1 week after your second ‘booster’ vaccination, and then taper it by one drop per week until you’ve resumed your usual regimen. But, don’t take my advice without talking with your surgeon, first, please!
Now for the details, which, unfortunately, don’t amount to much:
I looked into the evidence before writing this post. To date, there are no reports of corneal transplant rejection after the COVID vaccine, nor are there any formal recommendations regarding steroid eye drops before and after receiving the COVID vaccine from any of the professional associations in ophthalmology.
To the extent that the Flu vaccine offers a reasonable comparison, I looked that up, too. But the evidence is sparse, at best. A handful of surgeons have reported corneal transplant rejection of varying severity after the Flu vaccine in patients with DSAEK and full-thickness transplants (there are no reports of rejection after Flu vaccination with DMEK). But these anecdotal reports are considered too isolated to substantiate practice guidelines. Only one large, multi-centered study, the Cornea Preservation Time Study, has evaluated risk factors for corneal transplant rejection. (And it should be noted that rejection was not the primary issue investigated; rejection was considered a ‘secondary’ issue, meaning that it was not the study’s main focus.) This study, which enrolled 1330 eyes from 1090 patient participants across the United States, found that immunizations were not linked with rejection.
Based on the literature, I can understand why there’s a wide range of steroid regimens recommended by corneal transplant surgeons at the start of every Flu season. Prior to moving to Iowa from NYC, my practice was to let my patients’ degree of concern guide treatment since the evidence didn’t support changing their steroid frequency for the Flu vaccine. For patients who were worried about triggering a rejection episode, I’d increase the frequency of their steroid followed by a rapid taper down to their usual dose; for patients who weren’t worried, I wouldn’t. I’ve always known that my practice was not universal and that many of my colleagues from around the country – many with more years of experience than me – insisted on increasing their patients’ steroid regimen at the time of vaccination. But I didn’t quite grasp their perspective until I got to Iowa.
Since I moved to Iowa in July 2020, I’ve had to change many aspects of my corneal practice to adapt to a quaternary-level referral center, where we take care of patients with very complex eye problems. Among other things, I have had to change what I tell many of my corneal transplant patients when it comes to the issue of vaccination. Here’s why.
About a month ago, when the phone calls about the imminent COVID vaccine started to trickle in, I sat down with my partners, Dr. Jennifer Ling and Dr. Mark Greiner, for some “coffee talk” (yes – over Zoom). We agreed that we had too many corneal transplant patients with too many different kinds of transplants and not enough staff to permit an individualized approach, or even a categorized one. We needed a policy for when the phones would ring off the hook in January.
When I cited the literature and summarized my practice in NYC, both Drs. Ling and Greiner agreed that the prevailing evidence supports doing nothing to patients’ steroid regimen when they receive the COVID or any other vaccine. But Dr. Greiner was quick to point out that many of our patients can be significantly more complex than individuals who have undergone a DMEK for Fuchs dystrophy. The University of Iowa Hospitals & Clinics is a referral center for patients with high-risk full-thickness corneal transplants, repeat partial- and full-thickness transplants for recurrent graft failures, transplants for glaucoma- and retina-surgery-associated corneal damage, transplants for blinding corneal infections, transplants for trauma, transplants for congenital eye malformations in children, transplants for keratoconus, and the list goes on… in addition to patients with Fuchs who receive DMEK and DSO. (Here’s a fun historical tidbit: The breadth and complexity of the University of Iowa’s patient population is one reason that the first Cornea textbook was written by Jay Krachmer, when he was on the faculty here in the ’80s.) Dr. Ling added that the Cornea Preservation Time Study was comprised almost entirely (94%) of patients with Fuchs Endothelial Corneal Dystrophy without other complicating factors, which is why the study’s findings don’t really apply to patients with conditions other than Fuchs treated with partial thickness transplants.
So, for simplicity, we agreed to make our policy to increase steroids to four times daily starting 1 week before vaccination and continuing 1 week after it, followed by a weekly taper – and that we would modify our advice based on each individual’s past ocular history, watching for potential issues like steroid-induced high eye pressure and glaucoma. We also agreed to redouble efforts to ensure that all of our corneal transplant patients knew the “RSVP” acronym by heart – Redness, Sensitivity to light, Vision changes, and Pain – and that they knew to call our office, COVID vaccine or not, with any of these symptoms.
At the end of our discussion, I asked Dr. Greiner, who’s a good friend of mine from the Terry fellowship, how many times he had seen rejection after a vaccine, and he said, “A few.” I asked if he ever saw anyone need a replacement transplant as a result of rejection after a vaccine, and he said “Once.” Leaning forward in my chair, I finally asked him whether he had ever seen any of our high-risk transplant recipients reject their cornea despite increasing steroid eye drop frequency before and after the vaccination, to which he reassuringly responded, “Never.”
Still not sure what to do with your steroid when it’s your turn to get the COVID vaccine? Talk to your corneal surgeon to find the right strategy for you.
Christopher S. Sales, MD, MPH
