Objective:

To describe plasma exchange (PLEX) as a successful treatment option for a case of optic neuritis secondary to immune checkpoint inhibitor (ICI) therapy.

Background:

Although there has been increasing use of ICI therapies due to their efficacy and lower toxicity in comparison to other immunotherapies, there has also been a surge of ICI-related neurological adverse effects. Treatment protocols for ICI-related neurologic complications are minimal and typically have poor outcomes. Pembrolizumab is a PD-1 receptor inhibitor that has been associated with neuro-ophthalmological complications including myasthenia gravis and bilateral optic neuritis.

Design/Methods:

Descriptive study

Results:

A 53-year-old female with left vulvar carcinoma resistant to treatment with radiation and triple chemotherapy with Carboplatin/Paclitaxel/Bevacizumab was transitioned to Pembrolizumab. She had received a total of 9 doses of Pembrolizumab when she developed bilateral eye pain and blurry vision. MRI of the brain and orbits was positive for enhancement of the bilateral optic discs and retro-bulbar portion of the right optic nerve concerning for bilateral optic neuritis. Cerebrospinal fluid analysis at this time was non-diagnostic with normal cells and protein. She was treated with two rounds of high dose steroids including Dexamethasone (4 days taper) and 1000 mg solumedrol for 5 days, respectively, with no clinical benefit. Given significant impairment in vision (20/200 OD, HM+ OS), she was treated with PLEX for five sessions. Following PLEX, there was significant improvement in her vision with return of visual acuity to 20/20(OD) and 20/25(OS) and stable vision during ophthalmology clinic visit two weeks later.

Conclusions:

Recommendations for the treatment of ICI-related optic neuritis includes the use of high-dose pulse steroids and prolonged oral taper, although visual prognosis remains poor. Our case study provides evidence for a tremendous recovery with PLEX for pembrolizumab-associated optic neuritis. Aggressive acute initial management of ICI-related complications should be considered, especially in cases of increased morbidity and mortality.