Vogt-Koyanagi-Harada Disease-Like Uveitis during Nivolumab (Anti-PD-1 Antibody) Treatment for Metastatic Cutaneous Malignant Melanoma

Abstract

Nivolumab is an anti-programmed cell death protein 1 monoclonal antibody that is used to treat metastatic cutaneous malignant melanoma. Although bilateral uveitis has been reported as a side effect of nivolumab administration, there are few reports of Vogt-Koyanagi-Harada disease (VKH)-like uveitis. We report such a case. A 63-year-old woman with metastatic cutaneous malignant melanoma experienced visual loss in both eyes 10 days after her second nivolumab injection. Her decimal best-corrected visual acuity (BCVA) was 0.7 in the right eye and 0.4 in the left eye. Examination revealed bilateral granulomatous keratic precipitates and posterior synechiae in the left eye. Optical coherence tomography showed multiple sites of serous retinal detachment (SRD) in the left eye and wavy retinal pigment epithelium in both eyes. Fluorescein angiography revealed multiple pinpoint-sized areas of leakage in both eyes and active leakage from the disc in her right eye. Indocyanine green angiography (IA) showed choroidal hyperfluorescence due to choroidal vascular leakage, with hypofluorescent dark spots during the late phase. These findings supported a diagnosis of VKH-like uveitis following nivolumab injections. Nivolumab was discontinued because of headache. Anterior chamber inflammation disappeared 3 weeks after starting topical corticosteroid treatment, and the SRD disappeared within 3 months. Her decimal BCVA recovered to 1.0 in the right eye and to 0.9 in the left eye. Also, the fluorescein angiography and IA findings had improved by 4 months. We concluded that careful follow-up is required after nivolumab treatment because VKH-like panuveitis might develop.

Keywords: Malignant melanoma; Nivolumab; Programmed cell death protein 1 uveitis; Vogt-Koyanagi-Harada disease.

Fig. 1

Right eye (left) and left eye (right). Vertical sections of optical coherence tomography scans before treatment. There are multiple sites of serous retinal detachment in the left eye and wavy retinal pigment epithelium in both eyes. Fluorescein angiography scans before treatment revealed multiple pinpoints of leakage in both eyes as well as active leakage from the disc in the right eye. Indocyanine green angiography also revealed choroidal hyperfluorescence due to choroidal vascular leakage, followed by hypofluorescent dark spots at a later time.

Fig. 2

Right eye (left) and left eye (right). Vertical sections of optical coherence tomography scans 4 months after treatment showed fewer serous retinal detachment sites and a reduced amount of wavy retinal pigment epithelium. Fluorescein angiography 4 months after treatment showed reduced fluorescein dye leakage. Indocyanine green angiography 4 months after treatment indicated that the multiple dark spots had almost all disappeared.

Fig. 3

Photographs 4 months after treatment showed red depigmented fundus in both eyes.