Abstract
Purpose :
Checkpoint inhibitors and immunotherapy agents are utilized in the management of various malignancies by upregulating the immune system. They prevent the inhibition of T-cell-mediated apoptosis by targeting proteins, including CTLA-4, PD-1, PD-L1. Immune-related adverse effects within our institution are reported to the Johns Hopkins Hospital Toxicity Team, a multispecialty group created to coordinate care and assist physicians in treating patients effectively.
Methods :
This is a retrospective case review of four patients seen at the Ocular Immunology Division of the Wilmer Eye Institute of Johns Hopkins Hospital from February 1, 2016 to January 31, 2018. Each patient was developed ocular side-effects after the initiation of immunotherapy treatment.
Results :
In Case 1, a 66 y/o F with non-small cell lung carcinoma treated with nivolumab, a PD-L1 inhibitor, and crizatanib, a protein kinase inhibitor, developed undifferentiated bilateral anterior uveitis, controlled with topical steroids and resolved 6 months after cessation of medications. In Case 2, a 70 y/o F with metastatic melanoma on trametinib, a MEK inhibitor, and dabrafenib, a B-Raf inhibitor exhibited optic nerve edema of left eye. She was switched to nivolumab and will follow up to determine resolution of papilledema after cessation of the initial treatment. Case 3 demonstrates a 59 y/o F with metastatic melanoma on Ipilimumab, a CTLA-4 inhibitor, and nivolumab, who presented with bilateral papilledema. The oncologist consulted with the Hospital Toxicity Team, who coordinated care across various departments. The papilledema resolved 7 months after stopping therapy. Finally, in Case 4, a 61 y/o M with metastatic urothelial carcinoma treated with the PDL-1 inhibitor Atezolizumab, presented with binocular diplopia. MRI findings showing a nodular enhancing focus along CNIII, most consistent with a CNIII neuritis versus metastasis. The patient continued atezolizumab, underwent whole brain radiation therapy, yet progressed. His condition is due to immune-mediated side effect of immunotherapy causing CNIII neuritis.
Conclusions :
Patients on checkpoint inhibitors and immunotherapy agents can develop a myriad of ocular complications, including uveitis, papilledema and neuritis. Coordinated care between the ophthalmologist and the oncologist is essential and can be facilitated by the establishment of a toxicity team at each institution.
This abstract was presented at the 2019 ARVO Annual Meeting, held in Vancouver, Canada, April 28 - May 2, 2019.