Diplopia following intravenous administration of pamidronate

A 55‐year‐old woman with orbital inflammation

“…We performed a PubMed search using the terms “orbital inflammation” and “bisphosphonate” together, reviewed all references of pertinent articles, and identified 17 cases of acute bisphosphonate‐induced orbital inflammation published in the English literature (18–32) (Table 3). We also garnered additional cases from the National Registry of Drug‐Induced Ocular Side Effects (http://www.eyedrugregistry.com) located at the Casey Eye Institute in Portland, Oregon.…”

“…Patients were ages 55–89 years and received a bisphosphonate for approved indications such as bony metastases, multiple myeloma, osteoporosis, and Paget's disease of bone, as well as for off‐label uses, including osteonecrosis and Charcot joint. The majority of the patients received an IV aminobisphosphonate (either pamidronate or zoledronic acid) (19–32). Two patients received oral alendronate (18).…”

“…Two patients received oral alendronate (18). In cases of IV bisphosphonate exposure, symptoms began within hours up to 6 days following drug administration (19–32); cases involving oral alendronate presented 10 days and 3 weeks after drug initiation (18). Systemic symptoms were present in one‐third of patients (18–20, 23, 27, 29, 32).…”

“…Systemic symptoms were present in one‐third of patients (18–20, 23, 27, 29, 32). Ophthalmic symptoms primarily included unilateral eye pain (89%) (18–30, 32), diplopia (50%) (18–21, 23, 27, 31), and blurry vision (33%) (19, 24, 25, 27, 29, 32). Ophthalmic signs included lid edema (94%) (18, 20–32), conjunctival hyperemia (83%) (18, 20–32), conjunctival chemosis (78%) (19–29, 31, 32), motility defect (61%) (18–21, 23, 24, 27, 29, 31, 32), proptosis (50%) (19, 22–24, 26, 28, 31, 32), anterior uveitis (22%) (18, 23, 25, 32), fundus abnormalities (17%) (18, 22, 25), and an afferent pupillary defect (17%) (19, 24, 25).…”

“…Antibiotics were administered to 6 of 18 patients without symptomatic improvement (19, 22, 24, 29, 30). All but 2 patients required treatment with systemic steroids (21, 29), which improved symptoms. In most cases, the bisphosphonate was discontinued.…”