Keeping an Eye on Bisphosphonate Therapy in Myeloma: A Case Report of Ocular Inflammation Postzoledronic Acid Infusion

Abstract

Bisphosphonates have evolved over the past decades from oral to more potent intravenous preparations. Along with significant paradigm shift in the management of myeloma over the past years, stronger nitrogen-containing bisphosphonates, due to their antiresorptive action on the bones, have found their way as a key and integral part in the management of bone disease in myeloma. Multiple randomized controlled trials have established efficacy of bisphosphonates in reducing skeletal-related events in myeloma. Some well-documented adverse events include acute-phase reactions, esophageal irritation, and osteonecrosis of the jaw. Across all clinical indications, the incidence of inflammatory eye reactions after bisphosphonate infusion ranges from 0.046% to 1%. However, data from myeloma patients are extrapolated from few reported cases in literature with varying management strategies including discontinuation, switching to different forms, and rechallenging with steroid cover. Inflammatory eye reactions can vary from self-limiting conjunctivitis and episcleritis to serious uveitis and vision-threatening orbital inflammation. We present a similar case of a patient with IgG kappa myeloma who developed flu-like symptoms followed by severe orbital inflammation within 48–72 hours after receiving zoledronic acid infusion. The patient was successfully managed with intravenous methyl prednisolone followed by oral tapering dose of steroids and discontinuation of further bisphosphonate therapy. A complete recovery was noted in a week’s time.

Posterior scleritis following a single infusion of zoledronate for osteoporosis: A case report and literature review

“…The exact pathogenesis of these adverse reactions, especially scleritis, remains unclear; some studies suggest that the drug may be secreted by the lacrimal gland into tears, causing transient irritation to the mucosa, leading to the release of intraocular cytokines and other acute-phase proteins, or activation of γδT cells within the eye socket. 10 The patient in this case was diagnosed with primary osteoporosis, with a clear history of zoledronic acid use. Within 48 h of medication administration, the patient presented with bilateral eye redness and severe eye pain, exacerbated at night and radiating to the head.…”

“…Faryal et al reported a case where bisphosphonate therapy was used to treat severe ocular inflammation caused by multiple myeloma, with the patient showing a significant reduction in eye swelling and pain 3 days after intravenous administration of methylprednisolone 500 mg once daily. 10 Upon discharge, the patient was prescribed oral prednisolone 60 mg, gradually tapering every 3 days until symptoms subsided. Additionally, studies have found that judicious use of topical eye drops can help prevent posterior synechiae, alleviate ciliary muscle paralysis and spasms, decrease exudation, and reduce intraocular pressure.…”

“…Only three cases of zoledronic acid‐related anterior uveitis and one case of periorbital inflammation have been reported domestically, with no literature reporting scleritis. The exact pathogenesis of these adverse reactions, especially scleritis, remains unclear; some studies suggest that the drug may be secreted by the lacrimal gland into tears, causing transient irritation to the mucosa, leading to the release of intraocular cytokines and other acute‐phase proteins, or activation of γδT cells within the eye socket 10 …”

“…Faryal et al. reported a case where bisphosphonate therapy was used to treat severe ocular inflammation caused by multiple myeloma, with the patient showing a significant reduction in eye swelling and pain 3 days after intravenous administration of methylprednisolone 500 mg once daily 10 . Upon discharge, the patient was prescribed oral prednisolone 60 mg, gradually tapering every 3 days until symptoms subsided.…”