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Zhang H, Houadj L, Wu KY, Tran SD. Diagnosing and Managing Uveitis Associated with Immune Checkpoint Inhibitors: A Review. Diagnostics (Basel) 2024; 14:336. [PMID: 38337852 PMCID: PMC10855398 DOI: 10.3390/diagnostics14030336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 01/29/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024] Open
Abstract
This review aims to provide an understanding of the diagnostic and therapeutic challenges of uveitis associated with immune checkpoint inhibitors (ICI). In the wake of these molecules being increasingly employed as a treatment against different cancers, cases of uveitis post-ICI therapy have also been increasingly reported in the literature, warranting an extensive exploration of the clinical presentations, risk factors, and pathophysiological mechanisms of ICI-induced uveitis. This review further provides an understanding of the association between ICIs and uveitis, and assesses the efficacy of current diagnostic tools, underscoring the need for advanced techniques to enable early detection and accurate assessment. Further, it investigates the therapeutic strategies for ICI-related uveitis, weighing the benefits and limitations of existing treatment regimens, and discussing current challenges and emerging therapies in the context of their potential efficacy and side effects. Through an overview of the short-term and long-term outcomes, this article suggests recommendations and emphasizes the importance of multidisciplinary collaboration between ophthalmologists and oncologists. Finally, the review highlights promising avenues for future research and development in the field, potentially informing transformative approaches in the ocular assessment of patients under immunotherapy and the management of uveitis following ICI therapy.
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Affiliation(s)
- Huixin Zhang
- Faculty of Medicine, Laval University, Quebec, QC G1V 0A6, Canada;
| | - Lysa Houadj
- Faculty of Medicine, University of Sherbrooke, Sherbrooke, QC J1G 2E8, Canada;
| | - Kevin Y. Wu
- Department of Surgery, Division of Ophthalmology, University of Sherbrooke, Sherbrooke, QC J1G 2E8, Canada
| | - Simon D. Tran
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, QC H3A 1G1, Canada
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Shen Y, Gong Y, Su L. Diagnostic Challenges in PD-1 Inhibitor Induced Panuveitis in a Teenage Girl with Chest Soft Tissue Sarcoma - A Case Report. Ocul Immunol Inflamm 2023; 31:2065-2068. [PMID: 37442377 DOI: 10.1080/09273948.2023.2233015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/12/2023] [Accepted: 06/30/2023] [Indexed: 07/15/2023]
Abstract
PURPOSE To report a case of programmed cell death receptor-1 (PD-1) inhibitor induced panuveitis. METHOD Observational case report of a 13-year-old Chinese girl presented as panuveitis. The clinical course, imaging performance, laboratory examination, differential diagnosis, treatment and prognosis were described. RESULT Patient presented with bilateral anterior granulomatous uveitis, vitritis, papillitis, and various creamy yellow nodular lesions in the mid-peripheral fundus. She had a history of biopsy proven alveolar soft tissue sarcoma on the chest wall and pulmonary metastasis, and a PD-1 inhibitor (sintilimab) was intravenously administered. Blood tests, magnetic resonance imaging of the cranium and the orbit, aqueous humor assay of inflammatory cytokines and microbial DNA were performed to distinguish infectious and non-infectious uveitis, choroidal metastases, and intravenous injection-related endophthalmitis. The oncologist evaluated that the sarcoma was stable and terminated sintilimab dosage. After sintilimab withdrawal, the blurred vision improved. Then, the patient received oral corticosteroids, resulted in resolution of the panuveitis. A diagnosis of PD-1 inhibitor induced panuveitis was made. CONCLUSION For patients taking PD-1 inhibitors, the major diagnostic challenge is to identify whether the cause of the uveitis is due to the antitumor treatment or not. It is suggested to be screened by eye care specialist and timely referral to uveitis specialist with any suspicion of intraocular inflammation for these patients.
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Affiliation(s)
- Yinchen Shen
- Department of Ophthalmology, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yuanyuan Gong
- Department of Ophthalmology, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Li Su
- Department of Ophthalmology, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Lin AC, Park SJ, Daniels GA, Borooah S. Pigmentary retinopathy associated with immune therapy for advanced cutaneous melanoma. Am J Ophthalmol Case Rep 2023; 30:101849. [PMID: 37131528 PMCID: PMC10149182 DOI: 10.1016/j.ajoc.2023.101849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/23/2023] [Accepted: 04/06/2023] [Indexed: 05/04/2023] Open
Abstract
Purpose To describe a case of bilateral retinal pigmentary changes in the setting of immune checkpoint inhibitor therapy (ICIT). Observations A 69-year-old man with a history of advanced cutaneous melanoma was started on combination ICIT with nivolumab and ipilimumab and stereotactic body radiation therapy. Soon after, he developed photopsias and nyctalopia with findings of discrete retinal pigmentary changes bilaterally. Initial visual acuities were 20/20 and 20/30 in the right and left eye, respectively. Multi-modal imaging revealed sub-retinal deposits with progressive changes in pigmentation and autofluorescence, associated with decreased peripheral fields on formal perimetry. A full-field electroretinogram revealed attenuated and delayed a- and b-waves. Positive serum retinal autoantibodies were identified. The patient developed left-sided optic nerve edema and center-involving cystoid macular edema which improved after treatment with sub-tenon's triamcinolone. Conclusions The use of ICIT has greatly expanded in oncologic practice with subsequent increases in immune related adverse events that pose significant systemic and ophthalmologic morbidities. We propose that the new retinal pigmentary changes seen in this case are the sequelae of an autoimmune inflammatory response against pigmented cells. This adds to the rare side effects that may occur after ICIT.
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Affiliation(s)
- Andrew C. Lin
- Shiley Eye Institute, University of California, San Diego, La Jolla, CA, 92093, USA
| | - Soo J. Park
- Division of Hematology and Oncology, Moores Cancer Center, University of California, San Diego, La Jolla, CA, 92037, USA
| | - Gregory A. Daniels
- Division of Hematology and Oncology, Moores Cancer Center, University of California, San Diego, La Jolla, CA, 92037, USA
| | - Shyamanga Borooah
- Shiley Eye Institute, University of California, San Diego, La Jolla, CA, 92093, USA
- Corresponding author. 9415 Campus Point Drive, La Jolla, CA, 92093, USA.
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Zhan Y, Zhao W, Ni K, Liu Z, Su Y, Li X, Zhang H, Zhang C. Case report: Camrelizumab associated with central retinal vein occlusion. Front Immunol 2022; 13:1025125. [PMID: 36505454 PMCID: PMC9726748 DOI: 10.3389/fimmu.2022.1025125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 10/26/2022] [Indexed: 11/24/2022] Open
Abstract
Immunotherapy has revolutionized cancer treatment and become one of the five pillars of cancer therapy. The clinical applications of immunotherapy have been adapted to range from the management of melanoma to most tumor types. As the clinical applications of cancer immunotherapies expand, understanding the treatment-related adverse events of these drugs becomes critical in clinical practice. We report a rare case of ocular immune-related side effects associated with camrelizumab that resulted in vision loss. A 56-year-old male patient was diagnosed with small cell lung cancer. The tumor involved the porta pulmonis and mediastinum upon initial diagnosis; therefore, surgery was not possible. Upon receiving the 10th immunotherapy session with camrelizumab 200 mg, the patient's visual acuity began to decrease in his right eye and a central retinal vein occlusion. Optical coherence tomography revealed significant cystoid exudation in the macular area and vitreous hemorrhage. The patient underwent vitrectomy, phacoemulsification and intraocular lens implantation after symptom onset. Following surgery, the patient's vision was limitedly restored. This is the first clinical report in China of central retinal vein occlusion and vitreous hemorrhage associated with anti-PD-1 therapy, ultimately leading to blindness. Although rare, clinical practitioners should be concerned about ocular adverse events associated with anti-PD-1 immunotherapy and develop a high index of suspicion for this possibility since ophthalmic manifestations that are rapidly detected, closely monitored, and appropriately managed are treatable.
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Affiliation(s)
- Yixiang Zhan
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China,School of Medicine, Nankai University, Tianjin, China
| | - Weipeng Zhao
- Department of Breast Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, China
| | - Kemin Ni
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China,School of Medicine, Nankai University, Tianjin, China
| | - Zhaoce Liu
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China,School of Medicine, Nankai University, Tianjin, China
| | - Yanjun Su
- Department of Lung Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin Lung Cancer Center, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin, China
| | - Xichuan Li
- Tianjin Key Laboratory of Animal and Plant Resistance, College of Life Sciences, Tianjin Normal University, Tianjin, China,*Correspondence: Xichuan Li, ; Heng Zhang, ; Chunze Zhang,
| | - Heng Zhang
- Department of Oncology, Tianjin Union Medical Center, Tianjin, China,*Correspondence: Xichuan Li, ; Heng Zhang, ; Chunze Zhang,
| | - Chunze Zhang
- Department of Colorectal Surgery, Tianjin Union Medical Center, Tianjin, China,The Institute of Translational Medicine, Tianjin Union Medical Center of Nankai University, Tianjin, China,Tianjin Institute of Coloproctology, Tianjin Union Medical Center, Tianjin, China,*Correspondence: Xichuan Li, ; Heng Zhang, ; Chunze Zhang,
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Ocular Inflammation Induced by Immune Checkpoint Inhibitors. J Clin Med 2022; 11:jcm11174993. [PMID: 36078923 PMCID: PMC9456546 DOI: 10.3390/jcm11174993] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 08/22/2022] [Accepted: 08/23/2022] [Indexed: 11/16/2022] Open
Abstract
Ocular immunotherapy-related adverse events (IRAEs), although rare, can be sight-threatening. Our objective was to analyze ocular IRAEs diagnosed in France from the marketing of immune checkpoint inhibitors (ICPIs) until June 2021 and to review the literature. We collected the cases of 28 patients (36 ocular IRAEs), occurring after an average of 17 weeks (±19). Forty-six percent of patients were treated for metastatic melanoma. Anti-PD1 agents were responsible for 57% of the IRAEs. Anterior uveitis was the most common (44%), followed by panuveitis (28%). Of 25 uveitis cases, 80% were bilateral and 60% were granulomatous. We found one case with complete Vogt-Koyanagi–Harada syndrome and one case of birdshot retinochoroidopathy. The other IRAEs were eight ocular surface disorders, one optic neuropathy, and one inflammatory orbitopathy. Seventy percent of the IRAEs were grade 3 according to the common terminology of AEs. ICPIs were discontinued in 60% of patients and 50% received local corticosteroids alone. The literature review included 230 uveitis cases, of which 7% were granulomatous. The distributions of ICPIs, cancer, and type of uveitis were similar to our cohort. Ocular IRAEs appeared to be easily controlled by local or systemic corticosteroids and did not require routine discontinuation of ICPIs. Further work is still warranted to define the optimal management of ocular IRAEs.
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Heng JS, Kim JM, Jones DK, Stoessel KM, Weiss SA, Sznol M, Kluger HM, Walter SD, Silverstein NA, Pointdujour-Lim R. Autoimmune retinopathy with associated anti-retinal antibodies as a potential immune-related adverse event associated with immunotherapy in patients with advanced cutaneous melanoma: case series and systematic review. BMJ Open Ophthalmol 2022; 7:e000889. [PMID: 35047671 PMCID: PMC8724805 DOI: 10.1136/bmjophth-2021-000889] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 12/04/2021] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To demonstrate the spectrum of autoimmune retinopathy (AIR) associated with immunotherapy for advanced cutaneous melanoma. METHODS AND ANALYSIS Retrospective chart review on patients with advanced cutaneous melanoma who developed AIR after initiating immunotherapy. Complete ophthalmic examination and relevant ancillary testing were performed on each patient. The presence of AIR-associated anti-retinal antibodies was confirmed by western blot and/or immunohistochemical staining. Ophthalmic and systemic outcomes after treatment for AIR were followed over time. A systematic review of AIR associated with immunotherapy for cutaneous or non-ocular mucosal melanoma was carried out in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS Case 1 developed photopsia and nyctalopia with electroretinographic findings characteristic for melanoma-associated retinopathy 1 week after initiating ipilimumab/nivolumab immunotherapy. Case 2 experienced new severe bilateral visual field loss associated with anti-retinal and anti-optic nerve antibodies while on maintenance nivolumab immunotherapy. Case 3 developed decreased visual acuity due to acute exudative polymorphous vitelliform maculopathy within 2 weeks of initiating ipilimumab/nivolumab immunotherapy. All patients had concurrent extraocular immune-related adverse events in addition to the presence of anti-retinal antibodies on serological testing. 14 published cases of AIR associated with immunotherapy for cutaneous or non-ocular mucosal melanoma were identified and reviewed. CONCLUSIONS Immune checkpoint inhibition can trigger the development of AIR with varied clinical manifestations in patients with advanced cutaneous melanoma. This study highlights the need for close monitoring in cutaneous melanoma patients receiving immunotherapy who develop new visual symptoms with or without funduscopic changes, as well as the potential role for screening of patients prior to initiating immunotherapy.
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Affiliation(s)
- Jacob S Heng
- Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jenna M Kim
- Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, Connecticut, USA
| | - D Kyle Jones
- Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, Connecticut, USA
| | - Kathleen M Stoessel
- Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sarah A Weiss
- Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Mario Sznol
- Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Harriet M Kluger
- Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Scott D Walter
- Retina Consultants, P.C, Hartford, Connecticut, USA
- Hartford HealthCare Cancer Institute, Hartford Hospital, Hartford, Connecticut, USA
| | | | - Renelle Pointdujour-Lim
- Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, Connecticut, USA
- Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut, USA
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