Outcome of Nivolumab-Induced Vogt–Koyanagi–Harada Disease-Like Uveitis in a Patient Managed without Intravenous Methylprednisolone Therapy

Abstract

Background. In recent years, immune checkpoint inhibitors (ICI) have been often used for several types of cancers. Immune-related adverse events (irAEs) are autoimmune responses caused by ICI. Among the different types of irAEs, uveitis is common in ophthalmology. Moreover, there are reports on Vogt–Koyanagi–Harada (VKH) disease-like uveitis. In most cases, VKH, as in the usual VKH, is managed with intravenous methylprednisolone therapy. Case Report. A 72-year-old man was diagnosed with gastric cancer, and he was treated with nivolumab, a type of ICI. After eight cycles of nivolumab therapy, he developed fulminant type 1 diabetes mellitus and diabetic ketoacidosis. Thus, the treatment was discontinued. Subsequently, the patient was referred to our department due to bilateral blurry vision. He had decreased visual acuity in both eyes, and slit lamp examination revealed the presence of bilateral anterior chamber cells and keratic precipitates. Fundus examination showed bilateral serous retinal detachment (SRD), wavy retinal pigment epithelium (RPE), and choroidal thickening. Cerebrospinal fluid examination revealed prominent pleocytosis. Thus, we initiated eye drop therapy and subtenon injection of triamcinolone acetonide on the right eye only. After 1 month, SRD and wavy RPE disappeared, and the patient’s visual acuity improved. Further, both eyes had similar improvements in visual acuity and abnormal findings. Oral prednisolone was subsequently administered for hearing loss. However, intravenous methylprednisolone was not used, and ophthalmologic findings and visual acuity did not change before and after systemic steroid therapy. One year after disease onset, SRD and wavy RPE did not relapse. Conclusion. Nivolumab-induced VKH disease-like uveitis can have good outcomes even in a patient managed without intravenous methylprednisolone therapy.

Diagnosing and Managing Uveitis Associated with Immune Checkpoint Inhibitors: A Review

“…A study of individual case safety reports from the WHO international pharmacovigilance database found that ICIs and protein kinase inhibitors were the only drugs associated with druginduced VKH-like uveitis [68]. Our literature search yielded 24 retrospective studies, case reports, and case series analyzing VKH-like uveitis in the context of ICI therapy, totalling 41 patients [68][69][70][100][101][102][103][134][135][136][137][138][139][140][141][142][143][144][145][146][147][148][149][150]. Details of the included study data are found in Appendix B (Table A4).…”

Ocular involvement in allergic drug reactions

“…Deeper ocular inflammation and systemic disease require intravenous high-dose corticosteroids followed by a slow taper of high-dose oral steroids. Immunosuppressive medications such as azathioprine, cyclosporine, mycophenolate, and rituximab have also been used [73]. Patients should be monitored for ocular complications that can occur in VKH including cataracts, glaucoma, and choroidal atrophy [74 ▪▪ ].…”