Retina and Uveitis, Cleveland Clinic Foundation, Cleveland, Ohio, USA
Retina and Uveitis, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
Br J Ophthalmol. 2020 May;104(5):703-711. doi: 10.1136/bjophthalmol-2019-314403. Epub 2019 Aug 13.
BACKGROUND/AIMS: Immunotherapy and targeted therapy for metastatic cancer may cause immune-related adverse events (irAEs) such as uveitis. If irAEs are severe or require systemic steroids, cancer therapy is often held or discontinued. Local steroid therapy for cancer therapy-associated uveitis allows the continuation of cancer therapy. This series demonstrates successful management of cancer therapy-associated uveitis with local therapy based on uveitis subtype.
This is an Institutional Review Board-approved retrospective case series of patients with uveitis secondary to immunotherapy or targeted therapy managed with local treatment, and focused literature review.
Five patients (median age: 54, range 31 to 75) were included. Time to uveitis onset following cancer therapy initiation was 3 to 12 months. All patients received checkpoint inhibitor therapy; one patient additionally received targeted therapy. Two patients presented with anterior uveitis, two with panuveitis and one with posterior uveitis. Four of five patients demonstrated evidence of posterior segment inflammation on multimodal imaging. Anterior uveitis was successfully treated with topical prednisolone acetate 1% (PA 1%) alone, and posterior segment involvement recalcitrant to topical PA 1% was treated successfully with topical difluprednate, intravitreal triamcinolone acetonide or a combination. Patients with isolated anterior uveitis did not require maintenance topical therapy; those with posterior and panuveitis required chronic low-dose topical therapy.
Based on our series as well as the existing literature demonstrating the use of local therapy for irAEs, we propose an approach to local therapy for cancer therapy-associated uveitis starting with topical steroids and initiating injectable steroids in cases of recalcitrant panuveitis or posterior uveitis. Subclinical inflammation on posterior segment imaging responds robustly to difluprednate or intravitreal steroid therapy, and patients with posterior segment involvement may require more aggressive management and long-term maintenance.
背景/目的：转移性癌症的免疫治疗和靶向治疗可能会引起免疫相关的不良反应（irAEs），如葡萄膜炎。如果 irAEs 严重或需要全身类固醇治疗，通常会暂停或停止癌症治疗。癌症治疗相关性葡萄膜炎的局部类固醇治疗可允许继续进行癌症治疗。本系列根据葡萄膜炎亚型展示了基于局部治疗成功管理癌症治疗相关性葡萄膜炎的方法。
这是一项经机构审查委员会批准的回顾性病例系列研究，纳入了接受局部治疗的免疫治疗或靶向治疗相关性葡萄膜炎患者，并进行了重点文献复习。
纳入了 5 名患者（中位年龄：54 岁，范围 31 至 75 岁）。从癌症治疗开始到葡萄膜炎发病的时间为 3 至 12 个月。所有患者均接受了检查点抑制剂治疗；1 名患者还接受了靶向治疗。2 名患者表现为前葡萄膜炎，2 名患者表现为全葡萄膜炎，1 名患者表现为后葡萄膜炎。5 名患者中的 4 名在多模态成像上显示出后节炎症的证据。单纯前葡萄膜炎患者用 1%醋酸泼尼松龙（PA 1%）局部治疗成功，而对局部 PA 1%难治性的后节受累患者用双氯芬酸钠、曲安奈德眼内注射或两者联合治疗成功。单纯前葡萄膜炎患者无需维持局部治疗；而后节和全葡萄膜炎患者需要慢性低剂量局部治疗。
基于我们的系列研究以及现有的文献证明局部治疗对 irAEs 的疗效，我们提出了一种针对癌症治疗相关性葡萄膜炎的局部治疗方法，从局部使用皮质类固醇开始，如果出现难治性全葡萄膜炎或后葡萄膜炎，则开始使用注射用皮质类固醇。后节成像上的亚临床炎症对双氯芬酸钠或眼内类固醇治疗反应良好，后节受累患者可能需要更积极的治疗和长期维持。
