Patient Presentation: A 23-year-old obese female was diagnosed with idiopathic intracranial hypertension (IIH) and referred to neurosurgery for ventriculoperitoneal shunt. A baseline ocular examination was performed prior to the procedure.
On examination, vision was 20/200 in the right eye, and 20/40 in the left eye. There was a right relative afferent pupillary defect. Slit lamp examination was normal.
A dilated fundus examination was performed demonstrating the following:
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Neuro-Ophthalmology
Case 35
Contributors: Andrew Mihalache, MD(C) and Dr. Arun Sundaram, MD MSc FRCPC
Patient Presentation: An 87-year-old female presented to a tertiary neuro-ophthalmology clinic following a referral for optic disc edema OU. The patient previously had a cutaneous melanoma excised from her left flank one year ago. Disease recurrence was identified in the left axillary lymph nodes, prompting the initiation of dabrafenib (BRAF inhibitor) and trametinib (MEK inhibitor).
Four months after starting BRAF/MEK inhibitor therapy, she experienced progressively worsening, painless vision loss OD and transient blurred vision OS. Consequently, BRAF/MEK inhibitor therapy was discontinued one week prior by the patient’s oncologist.
Visual acuity was 20/200 OD and 20/30 OS. There was no RAPD. There were no cells in the anterior chamber or vitreous.
24-2 Humphrey Visual Field testing was performed and shown below:
Question 2: Based on the RNFL OCT above, which interpretation most accurately reflects the pattern observed?
Next, a comprehensive infectious and autoimmune workup was ordered, including angiotensin-converting enzyme, antineutrophil cytoplasmic antibody, antinuclear antibody, anti-myelin oligodendrocyte glycoprotein antibody, Bartonella serology, neuromyelitis optica antibody, syphilis testing, and toxoplasmosis serology. All tests were negative.
Additionally, a contrast-enhanced MRI of the brain and orbits was performed, which showed no enhancement of the optic nerves or chiasm.
Question 3: What is the next best step in management?
Question 4: Which of the following ocular complications have been reported secondary to BRAF/MEK inhibitor therapy for metastatic melanoma?
References:
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Lim J, Lomax AJ, McNeil C, Harrisberg B. Uveitis and Papillitis in the Setting of Dabrafenib and Trametinib Therapy for Metastatic Melanoma: A Case Report. Ocul Immunol Inflamm. 2018;26(4):628-631. doi:10.1080/09273948.2016.1246666
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Huang S, Guo Z, Wang M, et al. Ocular adverse events associated with BRAF and MEK inhibitor combination therapy: a pharmacovigilance disproportionality analysis of the FDA adverse event reporting system. Expert Opin Drug Saf. 2023;22(2):175-181. doi:10.1080/14740338.2023.2189235
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Tarım B, Kılıç M. Ocular side effects of Trametinib and Dabrafenib: a case report. J Ophthalmic Inflamm Infect. 2023 Apr 12;13(1):17. doi: 10.1186/s12348-023-00339-0. PMID: 37046057; PMCID: PMC10097848.
Learning Objectives:
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To identify and interpret signs of asymmetric optic disc edema on visual field and OCT RNFL imaging.
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To recognize papillitis as a potential ocular complication of BRAF/MEK inhibitor therapy.