Clinical Review & Education

Ophthalmic Images
Bilateral Acute Macular Neuroretinopathy After Vaccination
Against SARS-CoV-2

Benedikt A. J. Book, MD; Barbara Schmidt, MD; Andreas M. H. Foerster, MD

A

Infrared reflectance imaging, left eye 

B

Spectral-domain optical coherence tomography,
left eye

200 µm

200 µm

Figure. A, Infrared reflectance imaging of the left eye showing 2 circumscribed lesions (arrowheads). B, Spectral-domain
optical coherence tomography of the left eye over 1 lesion showing outer plexiform layer thickening (arrowhead).
The vertical green arrow in image A indicates the direction of the optical coherence tomography B scan shown in image B.

A 21-year-old woman in good health (best-corrected visual acuity,
20/16 OU) reported bilateral paracentral scotomas 3 days after re-
ceiving her first COVID-19 vaccine (Vaxzevria [AstraZeneca]). Oph-
thalmoscopy showed bilateral circumscribed paracentral dark le-
sions that were easily visible on infrared reflectance imaging (Figure,
A) and matched with outer plexiform layer thickening and discon-
tinuity of the photoreceptor inner-segment ellipsoid band on opti-
cal coherence tomography (Figure, B). Microperimetry demon-
strated bilateral scotomas corresponding to these lesions. Bilateral
acute macular neuroretinopathy was diagnosed. No additional ocu-

lar, orbital, and cerebral pathologies were found on clinical ophthal-
mic, neurological, and imaging workups, including magnetic reso-
nance angiography. Apart from birth control use (levonorgestrel and
ethinylestradiol), the patient’s medical history was unremarkable.
Because acute macular neuroretinopathy was recently described in
patients with COVID-19,1 polymerase chain reaction testing for SARS-
CoV-2 was performed, with a negative result. Given the idiopathic
nature of acute macular neuroretinopathy and the hundreds of mil-
lions of people receiving COVID-19 vaccination, conclusions as to cau-
sality or direct correlation should not be drawn from this case.

ARTICLE INFORMATION

Author Affiliations: Department of
Ophthalmology, University Hospital Essen, Essen,
Germany (Book, Foerster); Department of
Ophthalmology, Evangelisches Krankenhaus
Mülheim, Mülheim, Germany (Schmidt).

Corresponding Author: Benedikt A. J. Book, MD,
University Hospital Essen, Hufelandstr 55, Essen
45147, Germany (benedikt.book@uk-essen.de).

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for
granting permission to publish this information.

REFERENCE

1. Virgo J, Mohamed M. Paracentral acute middle
maculopathy and acute macular neuroretinopathy
following SARS-CoV-2 infection. Eye (Lond).
2020;34(12):2352-2353. doi:10.1038/s41433-020-
1069-8

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