A 55-year-old woman with orbital inflammation

Orbital inflammation following zoledronic acid infusion

INTRODUCTION

Bisphosphonates, including zoledronic acid, are widely used for the treatment of osteoporosis, Paget's disease, and malignant bone metastases by inhibiting osteoclast-mediated bone resorption. While bisphosphonates are commonly associated with mild side effects such as fever, more severe complications like osteonecrosis of the jaw and hypocalcemia are less common but possible. A rare but clinically significant potential adverse effect that has previously been reported is orbital inflammation (OI), with patients presenting with symptoms of eye pain, orbital swelling, and conjunctival injection.

CASE REPORT

This case report details the experience of a 76-year-old man who developed OI after his first zoledronic acid infusion for osteoporosis. The patient presented with left eye pain, swelling, and diplopia 2 days post-infusion, along with systemic symptoms of chills and vomiting. MRI confirmed orbital inflammation, and elevated inflammatory markers were noted with no evidence of systemic infection or autoimmune disease. The patient was treated with IV methylprednisolone (1000 mg daily for 3 days), leading to significant symptom improvement within 12 h. A subsequent 7-week prednisone taper was well-tolerated, with full resolution of symptoms at follow-up.

DISCUSSION

This report underscores both the importance of recognizing rare events such as OI after ZA infusion and uncertainty about the best treatment regimen. While corticosteroids are the mainstay of treatment for OI, corticosteroids are deleterious for bone health and there is no consensus on optimal dosing or tapering duration. Given the clinical importance of bisphosphonates, clinicians should be aware of this potential adverse effect and consider standardized management protocols.

Medication-associated orbital inflammation: A systematic review

We performed a comprehensive systematic review to identify medication-associated orbital inflammation and to characterize its clinico-radiological features. We reviewed English-language articles describing medication-associated orbital inflammation (i.e., orbital myositis, dacryoadenitis and orbital fat) published to June, 2023. Isolated inflammation of the intraocular structures or globe alone (i.e. uveitis, scleritis, optic neuritis and perineuritis) were excluded. In medication-associated orbital inflammation, the extraocular muscles are preferentially affected, occurring in isolation or in combination with other orbital and/or intraocular structures. Clinico-radiological manifestations may be non-specific; however, certain medications may be distinguished according to the presence of systemic prodrome, laterality, associated intraocular inflammation, and predisposition to involve certain orbital structures. Rapid identification, discontinuation of the provoking medication, and systemic corticosteroid therapy (if appropriate) typically achieves a favorable visual prognosis. As new medications become adopted by clinicians, rare adverse effects will be further delineated.Medication-associated orbital inflammation is an important diagnostic consideration in orbital inflammatory disease. A careful medication history and clinical assessment may be revealing, permitting timely discontinuation of the offending agent and initiation of appropriate management.

Acute Iridocyclitis Associated With Intravenous Zoledronic Acid: A Case Report

Bisphosphonates are widely used drugs for the management of osteoporosis. Intravenous (IV) zoledronic acid (ZA) is frequently prescribed in cases of oral bisphosphonate intolerance or non-compliance. Well-known immediate ZA side effects include flu-like symptoms such as nausea, myalgias, bone and joint pains, and fever. Here we report a case of a rare side effect of acute anterior uveitis following initial dosing of ZA in a 71-year-old female with osteoporosis who had been vitamin D deficient a couple of months earlier. She presented with headache, bilateral eye redness, and pain post ZA infusion. Findings of diffuse conjunctival injection, and flare with cells in the anterior chamber were suggestive of anterior uveitis. Her symptoms resolved with prednisolone eye drops in three weeks. Ocular inflammation is a rare but serious side effect of this commonly administered drug. Optimizing vitamin D levels prior to treatment may help to prevent this condition. Clinicians should be aware of the rare occurrence of post-ZA ocular inflammation. Early recognition and prompt treatment are essential.

Ocular Side Effects of Bisphosphonates: A Review of Literature

In rare cases, bisphosphonates are well established to cause ocular inflammation, presenting as uveitis, episcleritis, scleritis, orbital inflammation, and/or conjunctivitis. Some reports of bisphosphonate-associated neuro-ophthalmic complications also exist. We identified 101 reports in the literature relating to bisphosphonate-associated ocular complications. In a great majority of cases, symptoms resolve after discontinuation of the drug and anti-inflammatory treatment. Many cases recur if rechallenged with the same bisphosphonate. First-generation nonamino bisphosphonates, including clodronate and etidronate, are not associated with ocular inflammation. Only 2nd- and 3rd-generation amino bisphosphonates, including pamidronate, alendronate, risedronate, ibandronate, and zoledronate are associated with these complications. The mechanism of bisphosphonate-induced ocular inflammation may be related to activation of γ/δ T cells or M1 macrophages. Intravenous forms, such as pamidronate and zoledronate, tend to have higher rates and faster onset of ocular inflammation, generally presenting within days of infusion. In oral bisphosphonates, such as alendronate and risedronate, these complications present with more sporadic timing. Rates of complications are also higher when bisphosphonates are used for malignancy, as doses tend to be higher compared with doses for osteoporosis.

Aminobisphosphonate-associated orbital and ocular inflammatory disease

PURPOSE

Aminobisphosphonates may cause orbital/ocular inflammation. Awareness of the clinical presentation and disease course is crucial. The purpose of this study was to analyse demographics, clinical presentation, disease course and treatment of aminobisphosphonate-associated orbital/ocular inflammation in a large series of patients.

METHODS

A retrospective study of patients with aminobisphosphonate-associated orbital/ocular inflammation and a literature review to differentiate disease presentation and course between various aminobisphosphonates.

RESULTS

Eight patients from our institution (6 women and 2 men, median age 62 years) were included. The used drugs were zoledronate, alendronate and risedronate. The most common clinical presentation was conjunctival hyperaemia/chemosis. Scleritis was the most common manifestation, followed by diffuse orbital inflammation and anterior uveitis. Ultrasound aided in diagnosis in all our patients. The aminobisphosphonate was halted in all patients, and some patients had anti-inflammatory treatment. Literature review included 68 patients (83 eyes), of them the most abundant drugs causing orbital/ocular inflammation were pamidronate (38 eyes) and zoledronate (35 eyes). Overall, among 76 patients, all drugs induced orbital disease, while uveitis was induced mostly by zoledronate and pamidronate, less by alendronate and not found among risedronate users. Time interval from drug administration to symptoms was hours to 28 days. Resolution was achieved in all patients, after 1-60 days from disease presentation, and the longer resolution period was found among alendronate users.

CONCLUSION

Orbital/ocular inflammation was mostly caused by intravenous aminobisphosphonates. Uveitis was not induced by risedronate. The putative aminobisphosphonate should be halted at the onset of orbital/ocular involvement and prognosis is favourable.

Bisphosphonate-induced orbital inflammation: more common than once thought?

To report two cases of bisphosphonate-induced orbital inflammation, discuss the clinic-radiological features and management options, and highlight the increasing frequency of an association previously considered extremely rare. A retrospective review of two cases presenting to our department, and review of the literature reporting this association. Two new cases of bisphosphonate-induced orbital inflammation were added to the literature. The first occurred in the context of a risedronate re-challenge, and the second with zoledronic acid. Both cases were managed successfully with topical steroids. Clinicians prescribing bisphosphonates, particularly for the first time, should be aware of the increasingly reported association with orbital inflammation. The presence of suggestive clinical features should prompt urgent referral to an ophthalmologist for appropriate management.

Bisphosphonate-Induced Orbital Inflammation: A Case Series and Review

INTRODUCTION

To present a series of patients with bisphosphonate induced orbital inflammation, and to review the clinical presentation, radiological features, treatment options and outcomes.

METHODS

We present a multicentre, retrospective case series review of patients with a clinico-radiological diagnosis of bisphosphonate induced orbital inflammation and review all the reported cases of this complication in the literature.

RESULTS

Four new patients with bisphosphonate induced orbital inflammation were added to the 25 cases in the literature. Intravenous zoledronate was the commonest precipitant (22/29, 75.9%) and inflammation occurred 1-28 (mean 3) days post-infusion. Orbital imaging identified orbital inflammation in 22/29 cases and extra-ocular muscle enlargement in 8/29. Five patients presented with reduced vision of which one - with anterior ischaemic optic neuropathy - did not resolve. The vision resolved in all except one patient, with most requiring steroid treatment.

CONCLUSIONS

Bisphosphonates have a pro-inflammatory effect, which can precipitate orbital inflammation. This rare, but potentially serious complication of bisphosphonate treatment should be considered by clinicians using bisphosphonate treatment and by ophthalmologists seeing patients with orbital inflammatory disease.