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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Uveitis
Case 21
Patient Presentation: A 66-year-old man was referred to a tertiary uveitis clinic with bilateral decreased vision over one week. His past medical history was significant for metastatic melanoma, for which he was treated with dual MEK-inhibitor therapy including encorafenib and binimetinib over the preceding 5 months. He had no other past medical or ocular history. On review of systems, he reported frontal headaches and rhinorrhea for the past 2 weeks, but denied tinnitus, hearing changes, rashes, chest pain, shortness of breath, back pain, or gastrointestinal issues.
On examination, his uncorrected distance visual acuity was 20/400 OD and HM OS (with no improvement with pinhole acuity). His intraocular pressure was 11 mmHg in both eyes; there was no RAPD. Slit lamp examination revealed trace AC cells OU with no flare, 360° posterior synechiae, and 1+ vitreous cell (no vitreous haze).
Fundus photos were taken at the time of presentation and are shown below:
OCT macula images were taken and are shown below:
Question 1: What are the main findings in the OCT macula images above?
Question 2: What is the most likely diagnosis?
Question 3: Please select all the correct options for initial management of our case.
References:
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Ocular Effects of MEK Inhibitor Therapy: Literature Review, Clinical Presentation, and Best Practices for Mitigation. Jeng-Miller KW, Miller MA, Heier JS. The Oncologist. 2024;29(5):e616-e621. doi:10.1093/oncolo/oyae014.
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Ocular Safety Profile of BRAF and MEK Inhibitors: Data From the World Health Organization Pharmacovigilance Database. Mettler C, Monnet D, Kramkimel N, et al. Ophthalmology. 2021;128(12):1748-1755. doi:10.1016/j.ophtha.2021.05.008.
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Ocular Toxicities of MEK Inhibitors and Other Targeted Therapies. Stjepanovic N, Velazquez-Martin JP, Bedard PL. Annals of Oncology : Official Journal of the European Society for Medical Oncology. 2016;27(6):998-1005. doi:10.1093/annonc/mdw100.
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Ocular Adverse Events Associated With Mek Inhibitors. Méndez-Martínez S, Calvo P, Ruiz-Moreno O, et al. Retina (Philadelphia, Pa.). 2019;39(8):1435-1450. doi:10.1097/IAE.0000000000002451.
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MEK Inhibitors: A New Class of Chemotherapeutic Agents With Ocular Toxicity. Duncan KE, Chang LY, Patronas M. Eye (London, England). 2015;29(8):1003-12. doi:10.1038/eye.2015.82.
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Ocular Toxicities of MEK Inhibitors in Patients With Cancer: A Systematic Review and Meta-Analysis. Han J, Chen J, Zhou H, Hao L, Wang Q. Oncology (Williston Park, N.Y.). 2023;37(3):130-141. doi:10.46883/2023.25920987.
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Characterization of Serous Retinopathy Associated With Cobimetinib: Integrated Safety Analysis of Four Studies. Barteselli G, Goodman GR, Patel Y, et al. Drug Safety. 2022;45(12):1491-1499. doi:10.1007/s40264-022-01248-2.
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Ocular Toxicity in Metastatic Melanoma Patients Treated With Mitogen-Activated Protein Kinase Kinase Inhibitors: A Case Series. Niro A, Strippoli S, Alessio G, et al. American Journal of Ophthalmology. 2015;160(5):959-967.e1. doi:10.1016/j.ajo.2015.07.035.
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Retinal Toxicities of Systemic Anticancer Drugs. Arora S, Surakiatchanukul T, Arora T, et al. Survey of Ophthalmology. 2022 Jan-Feb;67(1):97-148. doi:10.1016/j.survophthal.2021.05.007.
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FDA Orange Book. FDA Orange Book.
Learning Objectives:
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Identify OCT features of MEK-inhibitor–associated retinopathy.
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Distinguish VKH-like MEKAR from VKH disease and CSCR.
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Understand management principles, including steroid use and coordination with oncology.