Management of Chronic Hypotony Following Bilateral Uveitis in a Patient Treated with Pembrolizumab for Cutaneous Metastatic Melanoma.

Purpose: To describe the presentation and management of severe ocular adverse events following treatment with pembrolizumab for cutaneous metastatic melanoma. Methods: Interventional case report. Results: A 73-year-old Caucasian man receiving pembrolizumab treatment for metastatic melanoma presented with panuveitis and subsequent profound hypotony, choroidal effusions, and optic disk swelling bilaterally. Oral prednisolone controlled intraocular inflammation. However, bilateral hypotony persisted which was managed over a 12-month period with ocular viscoelastic device injections into the anterior chamber of both eyes. There was also phacoemulsification with pars plana vitrectomy (PPV) and silicone oil (SO) tamponade performed on the left eye only. Intraocular pressure (IOP) stabilized (>6 mmHg) with best-corrected visual acuity of 6/60. Conclusion: We report a severe adverse event from pembrolizumab therapy resulting in uveitis and persistent hypotony. Repeat injections of high viscosity OVD achieved an increase in IOP up to 12 months. This technique may be a useful adjuvant or alternative to PPV and SO.

Can the SENSIMED Triggerfish® lens data be used as an accurate measure of intraocular pressure?

PURPOSE: The SENSIMED Triggerfish® contact lens sensor (CLS) has an embedded micro-sensor that captures spontaneous circumferential changes at the corneoscleral junction and transmits them via an antenna to a device where these measurements are stored. During laparoscopic colorectal surgery, patients are placed in Trendelenburg position which has been shown to increase intraocular pressure (IOP). Laparoscopic colorectal surgery requires both pneumoperitoneum and Trendelenburg positioning; therefore, IOP can vary significantly. We aimed to assess whether circumferential changes in the corneoscleral area can be correlated to IOP changes measured using Tono-pen® XL applanation tonometer during laparoscopic colorectal surgery. METHOD: Patients undergoing laparoscopic colorectal resections were included. On the day of surgery, baseline IOP was taken and the SENSIMED Triggerfish® CLS was then set up in one eye of the patient. During surgery (whilst under general anaesthetic), IOP measurements were taken in the contralateral eye using a Tono-pen® XL applanation tonometer every hour and any time the table was moved to record the fluctuations of IOP during surgery and any association with position change. The timings of these readings were documented. RESULTS: Twenty patients were included in this study (six males, 14 females). Average age was 64.6 years (SD = 16.3). The fluctuation in IOP measured in the reference eye ranged between 6.3 and 46.7 mmHg. The mean correlation coefficient between CLS output measurements and these IOP measurements was r = 0.291 (95% CI). CONCLUSION: Our results showed a weak correlation between the SENSIMED Triggerfish® CLS data output and IOP measurements taken using the Tono-pen® XL applanation tonometer.

Improving treatment provision of Wet AMD with intravitreal ranibizumab.

Wet age-related macular degeneration (AMD) treatment using intravitreal ranibizumab needs to be started as soon as possible and treatment must be administered based on regular review to achieve the best results. In clinical practice this tight schedule is a challenge and methods of carrying out such timely treatment is the objective of this quality improvement work. A departmental audit was carried out on the service providing treatment for patients with wet AMD in 2009. This audit identified that the appointment system did not meet the ideal standards and subsequently wet AMD patients' visual outcome were poorer than the standard set in trials where the patients were seen and treated at predetermined intervals. In order to enhance the visual benefit of the administered therapy for our patients we thought it necessary to find ways to see and treat patients sooner as well as reduce time intervals between follow-up appointments. The quality improvement was carried out through redesigning the service in the macular treatment centre of Manchester Royal Eye Hospital. Three main strategies were implemented including: changes to the appointment system, expansion of the treatment facility and employment of additional staff. Following changes made, regular re-audits were used to analyse the effectiveness of the new strategies. The changes introduced have brought appointment standards to the level of Royal College of Ophthalmologists' recommendations. Consequently visual outcomes were approaching the standards set by landmark studies. The visual improvement of treated patients seen in the 2011 audit are comparable to other reports outside clinical trials in the UK. In order to enhance the efficacy of ranibizumab for wet AMD it is essential for treatment to be initiated as soon as possible and administered to patients at the recommended time intervals. The actions we have taken were effective in helping develop a service performing to higher standards.