Diffuse ocular and orbital inflammation after zoledronate infusion—case report and review of the literature

Abstract

Bisphosphonates have become a commonly used class of medications to treat osteoporosis and other bone diseases. Zoledronate (zoledronic acid) can be dosed annually via intravenous infusion, making it an appealing option for patients and physicians. We report the case of a 68-year-old woman who developed severe, unilateral, ocular inflammation, including corneal endotheliitis, anterior uveitis with hyphema, scleritis, and orbital inflammation beginning 12 hours after receiving her first zoledronate infusion. Symptoms escalated but ultimately resolved with topical steroids and high-dose systemic corticosteroids. To our knowledge, this is the first report of unilateral diffuse inflammation of the eye and orbit, including corneal inflammation developing within 12 hours of a first zoledronate infusion.

Zoledronate-induced acute anterior uveitis: a three-case report and brief review of literature

“…Orbital inflammation after bisphosphonate administration was also observed. It typically begins 2-6 days after infusion with a concomitant anterior uveitis seen in 29% of reports [4]. Peterson JD et al reported some degree of bilateral involvement in 29% of cases [23], which might differentiate this entity from idiopathic orbital inflammation.…”

“…Among bisphosphonates, zoledronate is frequently prescribed for patients who do not tolerate oral bisphosphonates or have metastatic bone disease because of its lower frequency of administration and higher potency. A single dose per year often leads to better compliance for patients who need long-term anti-osteoporosis therapy [4], thereby securing the efficacy of the medication. However, adverse drug reactions were frequently observed following the administration of zoledronate, which included not only the symptoms and signs of an acute phase reaction (APR) such as pyrexia, myalgia, arthralgia, bone pain, and influenza-like illness, but also ocular adverse effects like scleritis, conjunctivitis, and iritis [5,6].…”

A Review of Corneal Endotheliitis and Endotheliopathy: Differential Diagnosis, Evaluation, and Treatment

“…Elevated systemic levels of digoxin can cause corneal edema with Descemet’s folds likely due to the inhibition of the sodium–potassium pump in the corneal endothelium [41]. Zoledronate infusion used in treatment of osteoporosis has been reported as causing ocular inflammation including endotheliitis with extensive corneal edema and Descemet’s folds [42].…”

Ocular Side Effects of Systemic Drugs

“…• Phenylephrine-may cause rebound miosis and decrease mydriasis (54) J) Bisphosphonates Fosamax,a bisphosphonate that is prescribe for post menopausal women to prevent calcium bone loss,can cause orbital inflammation, uveitis and scleritis (55). The proposed mechanism of ocular inflammation is an idiosyncratic γΔ T cell cytokine release involving IL-1 and IL-6 caused by bisphosphonates' similar structure to pyrophosphate molecules (56,57).…”