History of present illness
A 34-year-old woman with history of cutaneous melanoma (stage 3 lesion excised 8 months before presentation) on her leg was referred by an outside ophthalmologist for further evaluation. She reports that her vision became blurry about 1 week before presentation and that her eyes started being red at the same time. She has had mild pain with eye movements but no photophobia. She reports flashes of light that started 4 days before presentation and floaters 3 days before presentation.
Ocular examination findings
At her initial presentation, visual acuity was count fingers at 3 feet in the right eye and 20/400 in the left eye. The left eye had constricted fields to confrontation, but pupils were noted to be normal with no afferent pupillary defect. Both eyes showed inferior keratic precipitates, 2+ cell and 1+ flare, and iris nodules. Dilated ophthalmoscopy revealed bilateral rare, pigmented cells in the vitreous, bilateral hyperemic optic discs with mildly blurred margins, and bilateral macular subretinal fluid (SRF), choroidal folds, and scattered yellow subretinal deposits. The right eye had a bullous serous detachment of the inferior retina, and the left eye had multiple focal areas of SRF ( Fig. 59.1 ).
Questions to ask ( Fig. 59.2 )
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Does the patient have systemic symptoms such as headache or tinnitus or have signs of vitiligo or poliosis? Evaluation for signs of Vogt-Koyanagi-Harada (VKH) syndrome is important.
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She reports only a mild headache a few times per week, unchanged recently.
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What is the current status of the patient’s cancer? Is it in remission? Does the patient have a recent neurological imaging study and up-to-date systemic screening? With a history of systemic/metastatic cancer it is important to understand the patient’s current medical status and to have documentation of normal neuroimaging.
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The cancer was evaluated and treated within the past year. She had a systemic workup that included both positron emission tomography/computed tomography and magnetic resonance imaging brain scans that were both negative.
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What past or current treatment is the patient receiving for treatment of the melanoma? What medications does the patient take? There are multiple different chemotherapeutic regiments that are associated with retinal toxicity and ocular inflammation, such as mitogen-activated protein kinase (MEK) inhibitors, checkpoint inhibitors, alkylating agents, and anaplastic lymphoma kinase inhibitors.
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She had been taking MEK inhibitors (dabrafenib and trametinib) for about 6 months before onset of symptoms.
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Assessment
This is a case of a 34-year-old woman with history of cutaneous melanoma and taking MEK inhibitors with bilateral panuveitis, serous and bacillary retinal detachments, and decreased vision.
Differential diagnosis
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VKH syndrome
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Medication-induced retinal toxicity
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Central serous chorioretinopathy
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Tuberculosis choroiditis
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Panuveitis related to dabrafenib and trametinib
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Syphilis
Working diagnosis
Panuveitis related to dabrafenib and trametinib
Multimodal testing and results
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Optical coherence tomography (OCT) ( Fig. 59.3 )
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Multiple bacillary detachments with hyper- and hyporeflective collections under the neurosensory retina in each macula, as well as loss of normal choroidal vascular architecture.
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