Eye complication (corneal irritation) as a rare side effect of nivolumab immunotherapy

What happened, in summary

A woman in her late 50s had Stage IIIB lung adenocarcinoma with cervical and mediastinal lymph-node involvement and disease affecting the central nervous system. Chemotherapy and radiation produced an incomplete response, so she began nivolumab. She received 47 cycles over 2 years, and the cancer remained stable.

Near the end of this period, she developed about 1 month of pain, irritation and discharge in both eyes. Her vision remained 20/20, but examination showed strands of damaged surface cells and mucus firmly attached to both corneas. The pattern was diagnosed as filamentary keratitis. Tear production was normal, and the examination did not support several more common causes of this condition. The timing and clinical pattern made nivolumab-related inflammation a likely explanation.

Lubricating and anti-inflammatory eye drops initially produced little improvement. Treatment was changed to an antibiotic-steroid ointment, oral acetylcysteine, vitamin A ointment and frequent artificial tears. Her oncology team stopped nivolumab for its own treatment reasons, independently of the eye problem.

Within 1 week, the discomfort and discharge were much better and the corneal filaments had disappeared. Two weeks after the revised eye treatment began, she had no ocular complaints and the eye examination was normal. The medicated ointment was then stopped while lubricating treatment continued.

One year after nivolumab ended, the primary lung cancer and previously identified secondary lesions had not progressed. She remained under oncology and eye follow-up, with stable cancer and no return of the keratitis.