Received Dec 2, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| FLU3 | INFLUENZA (SEASONAL) (FLUZONE) | SANOFI PASTEUR | UNK | U8848AA | IM / RA |
| FLU3 | INFLUENZA (SEASONAL) (FLUZONE) | SANOFI PASTEUR | 1 | U8848AA | IM / RA |
The patient is a 34 yo female healthcare worker with a hx of PCOS with a hx of AEFI after IIV reproduced on two occasions. She reports receipt of vaccine in 2023 resulting in a red eye, right. She did not seek care. She trialed a cell-based product in 2024 which also produced the same symptoms. She did not seek care and it resolved without intervention. In 2025, she received Fluzone, which again resulted in a red eye. She sought care from optometry who treated with oral indomethacin and topical steroid eye drops. She reports one other episode not associated with vaccine receipt and was seen and treated by ophthalmology (02/24/25). She denies other systemic symptoms. She denies issues with other vaccines and is otherwise fully vaccinated. She denies a hx of autoimmune disease for herself or her family members. 10/08/2025 Optometry Diagnosis: 1. Anterior scleritis, right eye Comment: Anterior scleritis right eye evident by deep scleral injection of lower hemisphere; no sign of intraocular inflammation. Start both oral NSAID Indomethacin and topical Pred Forte oph susp as directed below. RTC one week follow-up or sooner if symptoms worsen. 10/15/12025 Optometry Scleritis of right eye resolved with no sign of bulbar injection, inflammation or tenderness. Directed to complete 10 day regimen of both indomethicin and Pred Forte oph susp as prescribed. RTC if symptoms return. 02/24/2025 Optometry Treating as diffuse episcleritis of the right eye with FML OD QID. Differential diagnosis includes scleritis or early subclinical uveitis. - Reported no known personal or family history of autoimmune disease. Patient reported that she has a red eye that has occurred two other times in the past. Most recent red eye occurred after a flu vaccine fall 2024. She was not evaluated by an optometrist when her eye was red. She reported that the red eye resolved without intervention. - There was no evidence of cells/flare, SPK, corneal abrasion, SEI, dendrite/macropunctate keratitis, foreign body, follicles/pseudomembrane OD.
10/08/2025- RETINAL FUNDUSCOPIC EXAM; ANTERIOR SEGMENT EVALUATION; ENTRANCE TESTING; Visual Acuity Testing Modality: Snellen
patient describes symptoms consistent with this description and was evaluated by appropriate specialty providers: optometry for