Reactions Weekly | 2021
Pembrolizumab
Abstract
Bilateral corneal graft rejection: case report An 85-year-old woman developed bilateral corneal graft rejection during treatment with pembrolizumab for metastatic urothelial cell tumour. The woman visited the ophthalmology clinic for a routine visit. She underwent a penetrating keratoplasty to the right eye (OD) in 2003 and to the left eye (OS) in 2013 due to Fuchs endothelial dystrophy with sub epithelial fibrosis. Best corrected visual acuities (BCVAs) were OS 20/40 and OD 20/50. Biomicroscopy revealed some corneal surface irregularity and dry eye syndrome; therefore, treatment with artificial tears was intensified. The intraocular pressures were OS 5.5mm Hg and OD 8mm Hg, and endothelial cell densities were OS 857 cells/mm2 and OD 1374 cells/mm2. She had been using fluorometholone [Liquifilm] drops in the OS since surgery in 2013. She had no history of previous graft rejection. During a follow-up visit 4 months afterwards, she mentioned stable visual acuity. However, a slight decrease in BCVA to OS 20/50 and OD 20/63 was noted. Biomicroscopy revealed diffuse keratic precipitate (KP) and sub epithelial infiltrates OS. In her right eye, some more subtle KPs were noted. Intraocular pressures were OS 8mm Hg and OD 7mm Hg. On the basis of these findings, she was suspected to have developed bilateral corneal graft rejection. She mentioned that she had commenced pembrolizumab treatment almost 3 months previously due to a metastatic urothelial cell tumour. At the time of the follow-up visit, she had already received four pembrolizumab infusions of 200mg with an interval of 3 weeks. Pembrolizumab was initiated as second-line therapy due to the progression of lung metastases and haematuria with previous gemcitabine and carboplatin chemotherapy. The bilateral corneal graft rejection was managed with dexamethasone [Monofree] eye drops in both eyes. Two weeks afterwards, regression of the endothelial precipitates was observed with a stable BCVA. Dexamethasone drops were slowly tapered by one drop per week and could be discontinued after 7 weeks. Meanwhile, pembrolizumab therapy was continued with no interruption. However, 8 weeks following the discontinuation of dexamethasone, corneal graft rejection recurred in the left eye. BCVA OD was stable and declined to 20/400 OS. Slit-lamp examination OS revealed corneal oedema with folds in Descemet membrane, pigmented and nonpigmented KP, and absence of any anterior chamber cells. Topical therapy with prednisolone was administered in the woman’s left eye. After consulting the treating oncologist, therapy with pembrolizumab was discontinued to prevent recurrent corneal graft rejection. Two weeks afterwards, BCVA OS ameliorated to 20/100, corneal oedema was remarkably reduced with disappearance of Descemet folds, and KP were more pigmented. Intraocular pressure was OS 7mm Hg and OD 5mm Hg. Fundoscopy was found to be normal. Topical treatment was changed to dexamethasone and tapered by one drop per week. Dexamethasone was continued once daily OS to prevent early recurrence of corneal graft rejection.