Ocular adverse events associated with immune checkpoint inhibitors: a novel multidisciplinary management algorithm

Abstract

Ocular immune-related adverse events (IrAEs) associated with use of checkpoint inhibitors (CPIs) in cancer therapeutics are relatively rare, occurring in approximately 1% of treated patients. Recognition and early intervention are essential because the degree of tissue damage may be disproportionate to the symptoms, and lack of appropriate treatment risks permanent loss of vision. International guidelines on managing ocular IrAEs provide limited advice only. Importantly, local interventions can be effective and may avoid the need for systemic corticosteroids, thereby permitting the continuation of CPIs. We present a single institution case series of eight affected patients managed by our multidisciplinary team. Consistent with previously published series and case reports, we identified anterior uveitis as the most common ocular IrAE associated with CPIs requiring intervention. Based on our experience, as well as published guidance, we generated a simple algorithm to assist clinicians efficiently manage patients developing ocular symptoms during treatment with CPIs. In addition, we make recommendations for optimising treatment of uveitis and address implications for ongoing CPI therapy.

Keywords: checkpoint inhibitor; corticosteroids; immune-related adverse events; ocular; uveitis.

Figure 1.

Non-uveitis case study. (a) Optical coherence tomography scan showing a choroidal lesion next to the fovea, possibly representing a neovascular membrane. (b) Fundus fluorescein angiography demonstrating early hyperfluorescence of the juxtafoveal lesion, supporting a diagnosis of choroidal neovascularisation. (c) Pseudocolour image of the fundus showing the dexamethasone 0.7 mg steroid implant.

Figure 2.

Management algorithm for patients treated with CPIs who present with ocular symptoms. CPI, checkpoint inhibitor; FAF, fundus autofluorescence; FFA, fundus fluorescein angiography; ICG, indocyanine angiography; OCT, optical coherence tomography.