Pembrolizumab-related Bilateral Ocular Hypotony, Uveitis, Cataracts, Exudative Retinal, and Choroidal Detachments: An Unusual Success Story.

Here, we report the presentation and management of a rare case of sight-threatening bilateral panuveitis with secondary chronic hypotony, subcapsular cataracts, exudative retinal detachments, and choroidal detachments, following initiation of pembrolizumab immunotherapy for metastatic melanoma. An 82-year-old white woman presented with painful, blurry vision 3 days after initiation of pembrolizumab immunotherapy. She had developed a marked panuveitis causing secondary hypotony. The fundal view was entirely limited by acutely dense cataracts and small, uveitic pupils unresponsive to topical dilation. Urgent cataract surgery with intravitreal dexamethasone implant (Ozurdex) was completed successfully and allowed a fundal examination. This revealed bilateral, symmetrical, inferior exudative retinal detachments, and choroidal detachments secondary to chronic hypotony. After 3 months of observation and cessation of oral steroids, the panuveitis remains quiescent, hypotony persists, and the choroidal and retinal detachments are showing progressive self-resolution. The current best-corrected visual acuity is 6/24 OU. She remains under close monitoring. The immune checkpoint inhibitor, pembrolizumab, has been reported to cause sight-threatening adverse effects. We report a rare case of profound bilateral complications treated successfully with oral and intravitreal steroids. To the authors' knowledge, this has not previously been reported in the literature. Ophthalmologists and oncologists should be aware of the ocular effects of pembrolizumab and be able to identify various complications early. Here, cataract surgery with a steroid implant has been an effective sight-saving intervention. The promising visual outcome makes this an unusual success story.

Late Choroidal Effusion after Phacoemulsification in Eyes with Previous Trabeculectomy.

AIM: To present 5 cases of late choroidal detachment occurring spontaneously in pseudophakic glaucomatous eyes with previous trabeculectomy before cataract surgery. We discuss the causes, risk factors, frequency, diagnostic methods, differential diagnosis, and treatment of this disease. MATERIALS AND METHODS: In the presented 5 cases the choroidal effusion is proved by ophthalmoscopy and echography. Late choroidal detachment occurs after phacoemulsification 6 months at the earliest and 9 years at the latest (mean period 2.5 years) in glaucomatous eyes with previous trabeculectomy. To prove choroidal detachment we accomplished routine ophthalmological examination including medical history, visual acuity, tonometry, examination of anterior segment (AS) and fundus. We have done B-scan echography using А/В Ocular Ultrasound Aviso Quantel Medical. RESULTS: One of the patients had hemorrhagic detachment confirmed by B-scan echography, the other four patients had serous detachment. The examined patients had the glaucomatous disease for 10.4±6.11 years (mean±SD). Mean age at the time of choroidal effusion diagnosis was 76.8±7.6 years (68-87 years). The period between the trabeculectomy and the following phacoemulsification was 6±3.08 years (from 1 to 9 years). All patients received anti-glaucomatous topical therapy, including carbonic anhydrase inhibitors, before the occurrence of the effusion. In all cases conservative treatment with corticosteroids and cycloplegics was enough to overcome the detachment and restore visual acuity. CONCLUSION: Late choroidal effusion after phacoemulsification in eyes with previous trabeculectomy is associated with an application of unjustified powerful hypotensive topical medications after cataract surgery associated with an additional reduction of intraocular pressure in most cases.