Ocular toxicities associated with antibody drug conjugates and immunotherapy in oncology: clinical presentation, pathogenesis, and management strategies

Incidence and Mitigation of Corneal Pseudomicrocysts Induced by Antibody-Drug Conjugates (ADCs)

Purpose of Review

This study is to highlight the incidence of corneal pseudomicrocysts in FDA-approved antibody-drug conjugates (ADCs), and success of preventive therapies for pseudomicrocysts and related ocular surface adverse events (AEs).

Recent Findings

ADCs are an emerging class of selective cancer therapies that consist of a potent cytotoxin connected to a monoclonal antibody (mAb) that targets antigens expressed on malignant cells. Currently, there are 11 FDA-approved ADCs with over 164 in clinical trials. Various AEs have been attributed to ADCs, including ocular surface AEs (keratitis/keratopathy, dry eye, conjunctivitis, blurred vision, corneal pseudomicrocysts). While the severity and prevalence of ADC-induced ocular surface AEs are well reported, the reporting of corneal pseudomicrocysts is limited, complicating the development of therapies to prevent or treat ADC-related ocular surface toxicity.

Summary

Three of 11 FDA-approved ADCs have been implicated with corneal pseudomicrocysts, with incidence ranging from 41 to 100% of patients. Of the six ADCs that reported ocular surface AEs, only three had ocular substudies to investigate the benefit of preventive therapies including topical steroids, vasoconstrictors, and preservative-free lubricants. Current preventive therapies demonstrate limited efficacy at mitigating pseudomicrocysts and other ocular surface AEs.

Ocular toxicity associated with anti-HER2 agents in breast cancer: A pharmacovigilance analysis using the FAERS database

Anti-human epidermal growth factor receptor 2 (HER2) agents have exhibited pronounced tumor-inhibitory activity, yet the accompanying ocular toxicity has frequently been underestimated. We aim to conduct a comprehensive comparative analysis of ocular toxicity risk related to various anti-HER2 agents. We executed a retrospective pharmacovigilance investigation based on the FDA Adverse Event Reporting System (FAERS) database, covering the period from Q2 2018 to Q1 2023. The disproportionality analysis was performed to assess ocular toxicity risk. Multivariate logistic regression was implemented to mitigate potential biases. Moreover, the time to onset of ocular toxicity was also evaluated. A total of 3467 ocular adverse event (AE) reports concerning anti-HER2 agents were collected. At the preferred term (PT) level, there were 69 positive signals, among which excessive eye blinking, abnormal sensation in the eye, and asthenopia presented a significant risk. In comparison to tyrosine kinase inhibitors (TKIs), antibody drugs were associated with a broader range of ocular disorders at Standardized MedDRA Queries (SMQ)levels, including conjunctival disorders, corneal disorders, ocular infections, ocular motility disorders, optic nerve disorders, and retinal disorders. In terms of onset time, pertuzumab displayed an earlier onset at 21.5 days, while trastuzumab deruxtecan had the latest at 91.5 days. In summary, our study reveals varying degrees of ocular toxicity related to anti-HER2 agents, with a significantly higher risk observed in antibody drugs. Additionally, novel ocular toxicity signals, not documented in product labels, have been detected. In the future, further research will be necessary to validate our findings.

Immune checkpoint monoclonal antibody-related adverse effects in neuro-ophthalmology

Immunotherapy has renovated the field of oncology. Usually, cancer is treated by surgery, chemotherapy, and radiation. Immunotherapy is a promising treatment that harnesses the patient's own immune system to target cancer. Immune checkpoint inhibitors (ICIs) have proven to be a promising treatment avenue for managing cancer; however, their use had been associated with a unique spectrum of adverse side effects called immune-related adverse events (irAEs). As ICIs become increasingly relevant in cancer management, it is crucial to address these irAEs affecting various systems in the body, including the skin, liver, gastrointestinal tract, endocrine system, and the eye. Ocular toxicity and sight-threatening events are among the reported irAEs, impacting diverse ocular tissues. The most commonly reported ocular irAEs (OirAEs) are blurred vision, conjunctivitis, ocular surface disease uveitis, scleritis, and retinopathy. Nevertheless, the frequency and severity of these OirAEs can vary, even within the same class of ICIs. Thus, OirAEs can significantly impact the quality of life and patient compliance. Therefore, we aim to comprehensively analyze uncommon and severe ICI-related OirAEs associated with lung cancer by providing a comprehensive and updated review of immune checkpoint monoclonal antibody-related adverse effects in neuro-ophthalmology irAEs. Through a review of the relevant literature, we intend to illustrate the epidemiology, clinical characteristics, contributory factors, diagnosis, and management of ICI-associated ocular side effects. We will also discuss guidelines and best practice strategies for the prevention, monitoring, and management of these OirAEs.