| 10. Ocular toxicities |
Evaluation, under the guidance of ophthalmology: - Check vision in each eye separately.
- Color vision.
- Red reflex.
- Pupil size, shape, and reactivity.
- Fundoscopic examination.
- Inspection of anterior part of eye with penlight.
- Slitlamp examination.
- Eye pressure.
- Need to rule out myasthenia gravis.
Prior conditions: - Exclude patients with history of active uveitis.
- History of recurrent uveitis requiring systemic immunosuppression or continuous local therapy.
Additional considerations: - Clinicians should be aware that ocular irAEs commonly accompany other organ irAEs, and there should be a high level of clinical suspicion, as symptoms may not always be associated with severity. Patients with all grades of ocular symptoms should be referred to ophthalmology.
|
| 10.1. Uveitis or iritis |
Work-up and evaluation: as per 10.0: - Ophthalmology consult should be universal for the symptoms described in 10.0.
|
| Grading | Management |
| G1: Anterior uveitis with trace cells. | - Continue ICPi.
- Prompt referral to ophthalmology (usually within 1 week).
- Artificial tears.
|
| G2: Anterior uveitis with 1+ or 2+ cells. | - Hold ICPi temporarily until after ophthalmology consult.
- Urgent ophthalmology referral.
- Topical corticosteroids (eg, 1% prednisolone acetate suspension), cycloplegic agents (eg, atropine), and systemic corticosteroids.
- May resume ICPi treatment once off systemic steroids if patient has only ocular irAE, once corticosteroids are reduced to ≤10 mg/day prednisone equivalent. Continued topical or ocular steroids are permitted when resuming therapy to manage and minimize local toxicity.
- Retreat after return to ≤G1.
|
| G3: Anterior uveitis with 3+ or greater cells; intermediate posterior or pan-uveitis. | - Permanently discontinue ICPi.
- Urgent ophthalmology referral.
- Systemic corticosteroids and intravitreal or periocular/or topical corticosteroids.
- Methotrexate may be used in patients who respond poorly to systemic corticosteroids or those with severe sight-threatening inflammation.
|
| G4: Best-corrected visual acuity of 20/200 or worse in the affected eye. | - Permanently discontinue ICPi.
- Emergent ophthalmology referral.
- Systemic corticosteroids – prednisone 1 to 2 mg/kg/day or methylprednisolone 0.8 to 1.6 mg/kg/day and intravitreal or periocular or topical corticosteroids per ophthalmologist opinion.
|
Additional considerations: - Consider use of infliximab, other TNF-alpha blockers, or IVIG in cases that are severe and refractory to standard treatment.
|
| 10.2. Episcleritis |
| Work-up and evaluation: as per 10.0. |
| Grading | Management |
| G1: Asymptomatic. | - Continue ICPi.
- Prompt ophthalmology referral (usually within 1 week).
- Artificial tears.
|
| G2: vision 20/40 or better. | - Hold ICPi therapy temporarily until after ophthalmology consult.
- Urgent ophthalmology referral.
- Topical corticosteroids (eg, 1% prednisolone acetate suspension), cycloplegic agents (eg, atropine), and systemic corticosteroids.
|
| G3: Symptomatic and vision worse than 20/40. | - Permanently discontinue ICPi.
- Urgent ophthalmology referral.
- Systemic corticosteroids and topical corticosteroids with cycloplegic agents.
|
| G4: 20/200 or worse. | - Permanently discontinue ICPi.
- Emergent ophthalmology referral.
- Systemic corticosteroids and topical corticosteroids with cycloplegic agents.
|
Additional considerations: - Consider use of infliximab or other TNF-alpha blockers in cases that are severe and refractory to standard treatment.
|
