Ipilimumab and Nivolumab associated VKH like Immune Related Adverse Events

Ipilimumab and nivolumab are becoming increasingly common drugs in oncology. The associated immune related adverse events can have varying ophthalmic presentations. The author presents two cases of patients on nivolumab and ipilimumab for metastatic melanoma, with Vogt-Koyanagi-Harada like presentations. First, a 61 y.o. female with 20/20 in OU without an RAPD. Humphrey visual field showed enlargement of the blindspot in the OS and was full in the OD. She had bilateral +1 cell in the anterior segment. Dilated fundus exam (DFE) showed deep yellow lesions in the peripapillary choroid in OU, and multiple yellow deep ovoid scattered lesions throughout the macula in the OS with mild optic disc edema in OU. OCT showed thickening of the RNFL in the OU. Macular OCT showed pigment epithelial detachments underlying the yellow ovoid lesions. She underwent an MRI orbits and brain with and without contrast, which was unremarkable. She was treated with oral prednisone with significant improvement in her condition. Secondly, a 49 y.o. male with decreased vision to 20/100 OD and 20/200 OS, without an RAPD. Goldmann visual field showed bilateral cecocentral scotomas. DFE showed large cystic pockets of subretinal fluid. OCT showed large petalloid areas of subretinal and intraretinal fluid. IVFA showed leakage into the numerous intraretinal and subretinal cystic spaces. He was treated with oral prednisone with significant improvement. Both patients had a negative RPR, quantiferon gold, ANA, ANCA, ACE, lysozyme, and a normal CBC.