Erlotinib-related bilateral anterior uveitis

Ocular Toxicity of Targeted Anticancer Agents

The proliferation of targeted anticancer agents over the last two decades has revolutionized cancer treatment and improved survival in many previously refractory malignancies. However, many agents are associated with characteristic ophthalmic adverse effects. It is important that ophthalmologists recognize and maintain a high index of suspicion for these side effects in patients on targeted therapy. Most ophthalmic adverse effects can be treated with specific ocular therapy without discontinuation of cancer treatment, although it is important to be aware of the life-threatening and vision-threatening circumstances that would require therapy cessation in conjunction with the patient's oncologist. This review aims to summarize the ophthalmic adverse effects of targeted and hormonal anticancer agents and briefly describe their management.

Bilateral acute anterior uveitis: a rare ocular side effect of erlotinib

Erlotinib used in the treatment of advanced non-small cell lung cancer (NSCLC) is a first-generation small-molecule tyrosine kinase inhibitor which reversibly inhibits the kinase domain of epithelial growth factor receptor (EGFR). The incidence of ocular toxicities as adverse effects (AE) of erlotinib is relatively common. However, post-marketing, acute anterior uveitis (AAU) has been reported in a small number of cases as a putative AE resulting from erlotinib therapy. We present a case of a 67-year-old, Caucasian woman, lifelong non-smoker with stage IV NSCLC who presents with decreased visual acuity and 'floaters' 6 weeks after commencing erlotinib. She was later diagnosed with erlotinib-associated bilateral AAU. This is the fifth documented case of erlotinib-associated bilateral AAU since 2010, highlighting the rarity of this AE. Thus, the possibility of AAU should always be considered in patients on EGFR-blocking therapies as significant ocular damage can occur if ophthalmic complaints are not triaged and assessed quickly.

Bilateral acute simultaneous onset anterior uveitis presumed secondary to erlotinib: A report of two cases

Purpose

To report two new cases of presumed erlotinib-associated bilateral acute simultaneous-onset anterior uveitis effectively treated with topical steroids.

Observations

Two patients were referred to the uveitis clinic with bilateral acute simultaneous onset, anterior uveitis six weeks after starting the chemotherapeutic agent erlotinib. Frequent topical steroid were started and the inflammation responded swiftly and completely.

Conclusions and importance

Bilateral acute simultaneous onset anterior uveitis is a potential side effect associated with erlotinib use that has not been well described. Physicians should be aware of this potential association in patients with recent treatment with erlotinib who complain of blurred vision, photophobia, or redness of the eyes. In some cases, the inflammation responds well to topical therapy and medication can be continued.

Erlotinib-associated severe bilateral recalcitrant keratouveitis after corneal EDTA chelation

Purpose

We report a case of erlotinib-associated severe recalcitrant bilateral keratouveitis after uneventful corneal ethylenediaminetetraacetic acid (EDTA) chelation in a patient with non-small cell lung cancer (NSCLC); discontinuation of erlotinib led to complete resolution.

Observations

An elderly person presented with band keratopathy (BSK) of undetermined etiology in the both eyes, associated with foreign body sensation and constant tearing. The patient was on oral erlotinib treatment 150 mg PO daily for 1 year for NSCLC status post radiation therapy. Corneal EDTA chelation was performed in both eyes under topical anesthesia for BSK. Four days after surgery, the patient presented with severe pain in both eyes. Slit lamp evaluation revealed 5 mm × 7 mm epithelial defect with clear margins in the right eye and 6 × 7 mm epithelial defect with thick central corneal infiltrate in the left eye. Hypopyon was noticed in both eyes and intense inflammation obscured the details of anterior segment. Intense antibiotic treatment was initiated. After discussion with the oncology services, oral erlotinib was temporarily discontinued. This resulted in resolution of keratitis and hypopyon in both eyes, within one week.

Conclusions

and importance: Systemic use of erlotinib suppresses local immunity, facilitates infection and enhances inflammatory reaction in the eye. Clinicians should be cautious and plan any ocular interventional treatment in collaboration with oncology team to prevent adverse outcomes.

Anterior Uveitis Caused by Ocular Side Effects of Afatinib: A Case Report

Afatinib is a second-generation epidermal growth factor receptor (EGFR) inhibitor that has been shown to be effective against EGFR-mutated non-small cell lung cancer (NSCLC) resistant to conventional EGFR inhibitors such as gefitinib and erlotinib. Although ocular side effects of gefitinib and erlotinib have been reported, those for afatinib have yet to be definitively established. This report presents details on the first case of unilateral iridocyclitis associated with the side effects of afatinib therapy. A 75-year-old Japanese male ex-smoker with EGFR-mutated NSCLC underwent afatinib therapy for multiple metastases. At 2 weeks, bilateral conjunctivitis developed. Topical medication and a 1-week afatinib washout period resulted in the improvement of the conjunctivitis. However, 3 days after the resumption of afatinib, the patient developed unilateral granulomatous anterior uveitis in his right eye. Best-corrected visual acuity (BCVA) measurement indicated a decimal visual acuity of 0.2, while the slit-lamp findings were characterized by granulomatous inflammation, keratic precipitates, Koeppe nodules and posterior synechiae. There was no evidence suggesting other intraocular inflammatory disease or metastatic tumor. The left eye was intact. The use of topical medication including steroids and a washout of afatinib resulted in a gradual subsiding of the anterior uveitis. After resolution of the anterior uveitis, oral afatinib was resumed. BCVA of the right eye finally recovered to a decimal acuity of 1.0. Ophthalmologists should be aware of the possibility that side effects associated with afatinib could cause granulomatous anterior uveitis.

Follow-up of erlotinib related uveitis

The authors report the follow-up of a 68-year-old lady with bilateral anterior uveitis secondary to erlotinib. Erlotinib was started and stopped after symptoms and signs suggestive of severe bilateral anterior uveitis were noted. The patient developed signs of a non-ST elevation myocardial infarction, 12 days after stopping the erlotinib, and recovered without major problems. The patient also reported intermittent low-grade fever since starting erlotinib which resolved after stopping this drug. No further symptoms of uveitis were noted up to 6 month follow-up. The patient reported improved well being, resolution of ocular symptoms and intermittent low-grade fever at last follow-up (6 months after stopping erlotinib).