Abstract
Purpose
To report a case of daratumumab-induced bilateral angle closure glaucoma and myopia that showed no recurrence after repeated drug administration with prophylactic cycloplegia.
Observations
A 63-year-old man with relapsing multiple myeloma presented with acute bilateral eye pain and blurred vision 14 hours after first daratumumab infusion. Eye examination revealed raised intraocular pressure and shallow anterior chamber. Anterior segment ocular coherence tomography and ultrasound biomicroscopy showed ciliochoroidal effusions in both eyes. The diagnosis of bilateral acute angle closure glaucoma and induced myopia was made. Cycloplegia- and intraocular-pressure-lowering medications were given, which gradually deepened the anterior chambers and normalized intraocular pressure and refraction. The ciliochoroidal effusions completely resolved on day 14. The cycloplegic was given as a premedication for subsequent infusions. There was no recurrence of effusion throughout his 6-month daratumumab treatment course.
Conclusions and importance
Daratumumab can induce ciliochoroidal effusion, which results in acute secondary angle closure and myopia. The potential prophylactic effect of the cycloplegic drug may enable continuation of daratumumab infusion under close monitoring.
Introduction
Daratumumab (Darzalex, Janssen, Biotech, Horsham, PA) is a human anti-CD38 monoclonal antibody that is used to treat multiple myeloma. It was approved by the United States Food and Drug Administration in 2015. Recently, daratumumab has been reported by Lee et al. and Edwards et al. to cause ciliochoroidal effusion and acute angle closure glaucoma. , Here, we report another case of daratumumab-induced bilateral angle closure; however, our case did not show any recurrence of glaucoma episode after continuing the infusion of monoclonal antibody with prophylactic cycloplegia.
Case report
A 63-year-old man with relapsing multiple myeloma and cast nephropathy was scheduled for 16 mg/kg/week daratumumab administration during the first 8 weeks of treatment and received dexamethasone 20 mg, chlorpheniramine 10 mg and acetaminophen 1000 mg as premedication to prevent infusion-related reactions (IRRs). He presented with acute bilateral eye pain with raised intraocular pressure (IOP) up to 50 mmHg on both eyes, 14 hours after his first daratumumab infusion. His visual acuity was 20/160 in the right eye and 20/200 in the left eye. The refraction was −1.75 diopter in the right eye and −2.50 diopter in the left eye, demonstrating myopic shifts from his prior measurement of −0.50 diopter in both eyes 9 months earlier. Visual acuity after correcting the refractive error was 20/25 in both eyes. The eye examination revealed corneal microscopic cystic edema, diffuse conjunctival chemosis with mild injection and shallow anterior chamber without iris bombe appearance. Both eyes were pseudophakic. Dynamic gonioscopy showed 360° of angle closure (Shaffer grade 0) without peripheral anterior synechiae in either eye. There was no evidence of neovascularization of the angle. Anterior segment optical coherence tomography (AS-OCT) and ultrasound biomicroscopy (UBM) showed 360-degree bilateral ciliochoroidal effusion ( Figs. 1 and 2 ). On the fundus examination, the optic nerves appeared pink with a cup to disc ratio of 0.3 in both eyes.
Bilateral drug-induced acute angle closure glaucoma was diagnosed and the patient was prescribed 1% atropine eyedrop twice a day to both eyes along with topical IOP-lowering medications (0.5% timolol maleate eyedrop twice a day, 0.15% brimonidine tartrate eyedrop three times a day, 2% dorzolamide hydrochloride eyedrop three times a day and 0.01% bimatoprost eyedrop once a day). Oral glycerin (1 g/kg) and acetazolamide (250 mg) every 6 hours were also prescribed and subsequently tapered off at day 3. Both oral medications were discontinued at day 4. Serial examinations showed gradual deepening of the anterior chamber and decrease of suprachoroidal fluid ( Figs. 3 and 4 ). At day 7, the visual acuity returned to 20/20 and refraction was +0.50 diopter in both eyes. His IOP was 8 mmHg on both eyes. The topical medications were reduced to 1% atropine, 0.5% timolol and 0.01% bimatoprost eyedrops. Given his very limited cancer treatment options, after an extensive discussion with hemato-oncologists, the patient decided to continue with the second infusion at day 7 per the weekly-scheduled cancer regimen. AS-OCT and UBM were performed 12 hours prior to the second infusion. The results showed a wide angle in both eyes with minimal suprachoroidal collection in all quadrants of both eyes. Without discontinuation of 1% atropine twice daily, the patient showed no sign of recurrent angle closure after the second infusion. There was no worsening of the suprachoroidal fluid detected using AS-OCT on the first day after the second infusion (day 8 after the first infusion; Fig. 4 ). His IOPs were normalized (ranging between 10 and 12 mmHg) and IOP-lowering medications were completely discontinued on day 9. AS-OCT revealed the complete resolution of the suprachoroidal fluid on day 14 ( Fig. 4 ). It should be noted that he also received high filter hemodialysis on days 5, 6 and 8 (6 hours after the second daratumumab infusion) because of his nephropathy.
