Bisphosphonate-Induced Orbital Inflammation: A Case Series and Review

An evidence-based approach to diagnosing patients presenting with orbital inflammatory syndromes (An American Ophthalmological Society Thesis)

PURPOSE

The initial management of patients presenting with orbital inflammatory syndromes (OIS) varies - with some pursuing a diagnostic workup while others treat without any testing. The evidence behind this rationale is limited. A review of patients with orbital inflammation is performed with analysis of diagnostic testing to develop a workflow for such patients.

DESIGN

A retrospective review of patients presenting with acute orbital inflammation at a single institution from 2011 - 2020 was conducted.

METHODS

Orbital imaging was required for inclusion. Patients with high suspicion of neoplasm, bacterial infection, vascular malformation, or thyroid eye disease were excluded. Review of presenting clinical findings, laboratory workup, orbital imaging, and biopsy were performed. Statistical analysis was performed identifying statistically significant diagnostic and treatment maneuvers.

RESULTS

In total, 172 patients met inclusion criteria (66% female, mean age 46 years). The primary clinical presentation was myositis, dacryoadenitis, and infiltrative in 67, 73, and 32 patients (39.0, 43.0, 18.6%, respectively). Laboratory studies were conducted in 145 (84%) while biopsy was performed in 55 (32%). Specific orbital inflammation (SOI) was diagnosed in 29 (16.9%) with most frequent diagnoses being sarcoidosis, IgG4-related disease, inflammatory bowel disease, and systemic lupus erythematosus. The majority (147, 85.5%) was initially treated with steroids, but steroid-sparing agent use was statistically higher in patients with SOI.

CONCLUSIONS

In patients presenting with OIS, distinguishing myositis, dacryoadenitis, and infiltrative disease has workup and differential diagnosis impacts. Because SOI is relatively common, sequelae of SOI, and potential steroid-sparing therapy needs, diagnosis via an evidence-based systemic approach is critical.

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.

Alendronate reduces periosteal microperfusion in vivo

Objectives

Bisphosphonates are known to induce a severe adverse effect known as medication-related osteonecrosis of the jaw (MRONJ). Previous studies have proven the impact of bisphosphonates on microperfusion; therefore, this study aimed to investigate alendronate-induced microcirculatory reactions in the calvarial periosteum of rats.

Study design

Bone chambers were implanted into 48 Lewis rats. Microhemodynamics, inflammatory parameters, functional capillary density and defect healing were examined after alendronate treatment for two and six weeks using repetitive intravital fluorescence microscopy for two weeks.

Results

Microhemodynamics remained unchanged. In alendronate-treated rats, inflammation was slightly increased, functional capillary density was significantly reduced (day 10: controls 100.45 ± 5.38 cm/cm2, two weeks alendronate treatment 44.77 ± 3.55 cm/cm2, six weeks alendronate treatment 27.54 ± 2.23 cm/cm2) and defect healing was decelerated. The changes in functional capillary density and defect healing were dose-dependent.

Conclusion

The bisphosphonate alendronate has a significant negative impact on periosteal microperfusion in vivo. This could be a promising target for the treatment of MRONJ.

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.

Acute-Onset Orbital Inflammation in a Patient With Multiple Myeloma

A 72-year-old man presented with right eye conjunctival injection, chemosis, eyelid edema, and pain with eye movements. Examination of the right eye was notable for visual acuity of 20/50, reduced ocular motility in all gazes, proptosis, and chemosis. Treatment with vancomycin and ceftriaxone and ampicillin-sulbactam was followed by a worsening in symptoms. What would you do next?

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.

Osteoporosis, bisphosphonates, and ocular inflammation

BACKGROUND

Osteoporosis, as a musculoskeletal disease, is very common, especially in the era of aging society. It is described by a reduction in bone strength and increased risk of fractures, which are linked to considerable morbidity, mortality, and high healthcare burdens. Bisphosphonates are the most commonly used drugs to manage osteoporosis and they consequently reduce fracture risk. However, one of the clinical challenges is fear of side effects in patients who are using bisphosphonates as the administration of these drugs is lengthy. Ocular inflammation has been reporting as one of the potential vision-threatening side effects of bisphosphonates.

PURPOSE

To review previously reported ocular inflammation in patients taking bisphosphonates.

METHOD

A literature survey was conducted using databases in order to collect data for a narrative review of published reports regarding ocular side effects of bisphosphonates.

RESULTS

People taking bisphosphonates were at a relatively low risk of ocular inflammation, with the onset from a few hours after exposure up to more than 3 years. The release of inflammatory mediators mainly by activated gamma delta T cells in response to bisphosphonates was the main cause of ocular inflammation.

CONCLUSION

Strategies for treating patients with osteoporosis should consider the potential ocular side effects of bisphosphonates. Ocular inflammation, as one of the side effects of bisphosphonates, is a serious sight-threatening sign and should be taken seriously. Greater awareness of the association between bisphosphonate use and ocular inflammation may allow for earlier identification and timely treatment of future cases.

The ocular findings related to oral bisphosphonate use

OBJECTIVE

We aimed to investigate ocular involvement findings in female osteoporosis patients using oral bisphosphonate (BP).

METHODS

A total of 51 female osteoporosis patients aged 50-75 years using oral BP for at least one year for the study group and 64 age-matched non-osteoporosis female patients for the control group were included in the study. The BP type and exposure time were noted. The ophthalmic examination findings and measurements of the flare of the patients who received oral BP due to osteoporosis and the controls were evaluated.

RESULTS

The mean duration of BP use was 3.96 years. In the study group, it was detected four of 51 patients were diagnosed with meibomian gland dysfunction (MGD) (7.8%), seven of 102 eyes had erythematous, irregular, thickened lid margin or telangiectasia around the glandular orifices. There were no pathological findings on fundus examination. The mean value of measurements of the flare (ph/ms) was 7.90±7.96 in the study group, and 5.02±0.81 in the control group. When the mean values were compared, there was a significant difference between the two groups (P=.001). A significant difference was found in the mean value of measurements of the flare between the patients using alendronate, and ibandronate with the control group (P=.001; P=.005, respectively).

CONCLUSION

Our study showed that the flare in the anterior chamber associated with chronic ocular inflammation can be seen higher rate in patients using oral alendronate, and ibandronate compared to those who do not. Morever it can be said that oral BPs may cause similar ocular side effects like as intravascular BPs.

BISPHOSPHONATE-INDUCED BILATERAL ANTERIOR UVEITIS AND CHOROIDAL EFFUSIONS WITH SECONDARY ANGLE CLOSURE

PURPOSE

To report a case of bisphosphonate-induced bilateral anterior uveitis and choroidal effusions with secondary angle closure in a 64-year-old female patient.

METHODS

Observational case report.

RESULTS

A 64-year-old woman with history of scleroderma and antiphospholipid syndrome, presented with bilateral painless blurring of vision after commencement of alendronate. Clinical examination revealed bilateral anterior uveitis and choroidal effusions with resultant secondary angle closure in the left eye. Ultrasound biomicroscopy showed bilateral anteriorly rotated ciliary bodies. There was also a -2D myopic shift in the left eye. On drug cessation, complete resolution was seen within 2 weeks.

CONCLUSION

In the absence of other plausible etiologies and with recent commencement of a new drug, we postulate that the anterior uveitis and choroidal effusions are likely due to alendronate. This is further supported by complete resolution of the inflammation and effusions once alendronate was withheld.

Pharmacologically induced uveitis

Treatments of numerous systemic and local diseases of different etiologies may be accompanied by an unwanted side effect in the form of uveitis. We inform readers about medications that have the potential to cause uveitis and analyze the strength of association of these medications with uveitis. Subsequently, cessation of medication or appropriate treatment can be individualized for each patient for the purpose of preventing further damage to tissue structure and function. Being aware of these associations, physicians may readily identify medications that may cause uveitis and avoid expensive and unnecessary clinical and laboratory testing.

Fedratinib-induced orbital inflammation

A 69-year-old man with myelofibrosis presented with a two-day history of left periorbital swelling, blurred vision, and non-radiating dull orbital pain. On examination, there was restricted left-sided extraocular motility with conjunctival injection, chemosis, and periorbital edema. Magnetic resonance imaging demonstrated left-sided pre- and post-septal fat stranding concerning for orbital cellulitis. Two weeks before symptom onset, the patient began fedratinib therapy for myelofibrosis but discontinued this medication upon hospital admission. After restarting fedratinib, he presented with similar right-sided ophthalmic signs. A review of his medication history revealed a temporal relationship between symptom onset and fedratinib use. After medication discontinuation, his symptoms improved rapidly.

Histologic evaluation of femoral nerve demyelinating and axonal neuropathy in Wistar rats due to alendronate intake: a randomised study

Background

Bisphosphonates (BPs) are forceful inhibitors of osteoclast-mediated bone resorption. Long-term BP use is associated with multiple rare but severe adverse effects. The objective of this study was to investigate the possible effects of BPs in the structure of femoral nerve. Specimens from the femoral nerve of ten female 12-month old Wistar rats were used as control group and ten female 12-month old Wistar rats to which Alendronate (Fosamax, Merck) was administered per os for 13 weeks, were used as research group. Samples were observed under a Transmission Electron Microscope. G ratio measurements and statistical analysis with SPSS program were also performed.

Results

The control group showed no major changes of the nerve's histologic image, with the exception of some spots of thickness of the nerve myelin sheath. The research group showed major morphological changes which varied from partial disorganization or thickening of the myelin to severe myelin thickening and axon strangulation. A statistically significant difference of the G ratio between the two groups was observed.

Conclusions

The reported values (found in literature) for the morphologic measurements of the femoral nerve in Wistar rats are not complying with the ones we found in our study. There was a significant reduction of all three variables (the mean axon like diameter, the myelin thickness, G ratio) studied in the femoral nerve of the research group in contrast to control group. Our study demonstrates a possible correlation between alendronate administration and femoral nerve's function, nevertheless due to the small specimen further research is needed.

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.

Annual Injection of Zoledronic Acid Improves Bone Status in Children with Cerebral Palsy and Rett Syndrome

Osteoporosis is a common complication of cerebral palsy and Rett's syndrome. It is responsible for multiple fractures, bone pain, and impaired quality of life. In case of Rett's syndrome, a specific dysfunction of osteoblasts causes bone fragility. We observed the effects of annual zoledronic acid (ZA) infusion in a cohort of children with cerebral palsy and Rett's syndrome. 27 children under 18 years (19 with cerebral palsy and 8 girls with Rett syndrome confirmed by MCEP2 mutation) were treated with an annual injection of 0.1 mg/kg (max 4 mg) of ZA. Calcium and vitamin D were combined in all patients from the first injection of ZA. Dental examination was performed before treatment. Data were analyzed retrospectively. Bone mineral density was measured at diagnosis and yearly thereafter. Bone mass density (BMD) is decreased in patient with cerebral palsy and RS. One year after injection of ZA, we observe an increase of Lumbar spine BMD from - 2.99 to - 2.14 SD (p < 0.0001) and femoral BMD from - 4.26 to - 3.32 SD (p < 0.001) In the subgroup of patient with Rett syndrome, we also observe an increase from - 3.27 to 2.50 SD (p = 0.018) of Lumbar spine BMD. No fractures have been observed in our cohort since the first infusion. Side effects (flu-like syndrome and hypocalcemia) were more common in younger patients and after the first infusion. No serious complications were noticed. This study confirms the efficacy and the safety of an annual injection of ZA to improve bone status in children with cerebral palsy and Rett syndrome. No severe adverse effects were observed.

Bisphosphonate-induced orbital inflammation in a patient on chronic immunosuppressive therapy

Background

To report a case of orbital inflammation after bisphosphonate infusion in a patient who was already receiving immunosuppressive therapy.

Case presentation

A 56-year-old woman presented to the ophthalmology clinic with acute onset of right eye pain 24 h after receiving her first Zolendronic acid infusion. She has a past medical history of chronic inflammatory demyelinating polyneuropathy, Sjogren’s syndrome, and systemic lupus erythematosus that have been controlled with immunosuppressive therapy for three years. Clinical ophthalmic exam and MRI studies were significant for right orbital inflammation. The patient was started on oral prednisone with rapid resolution of symptoms.

Conclusions

This is the first case report of a patient receiving chronic immunosuppressive therapy to develop orbital inflammation after Zoledronic acid infusion. In addition, it demonstrates that corticosteroids can be an effective first line therapy in treating orbital inflammation in similar patients. Physicians should be aware of this rare but serious potential side effect of bisphosphonates, and have bisphosphonate-related orbital inflammation on their differential for proper initiation of treatment.

Clinical impact of bisphosphonates in root canal therapy

Bisphosphonates are stable structural analogs of pyrophosphate, which suppress the activity of osteoclasts, leading to decreased bone resorption. They are essential medications in the treatment of osteoporosis. Osteonecrosis of the jaw is a serious adverse effect of bisphosphonate therapy. The prevalence of bisphosphonate-related osteonecrosis of the jaw varies from 0% to 28%, and it can be triggered by dental extraction and trauma. Root canal therapy can delay, or even eliminate, the need for tooth extraction, and therefore, may reduce the risk of bisphosphonate-related osteonecrosis of the jaw. We suggest that this might be the best treatment for teeth with pulpal and/or periapical disease.

Zoledronic acid-induced orbital inflammation in a patient with multiple myeloma

Multiple myeloma is a cancer of malignant plasma cells which stimulates osteoclasts and is associated with increased bone turnover and osteolysis. Bisphosphonates including zolendronic acid are used to prevent skeletal complications in patients with multiple myeloma. Orbital inflammation is a rare but serious complication following use of bisphosphonates. The diagnosis is made by excluding other possible causes in patients with myeloma and rapid initiation of therapy is required. Corticosteroids are the mainstay of therapy but the ideal treatment course has not been delineated. This report describes a case of this rare complication and provides a review of the literature.

Diffuse ocular and orbital inflammation after zoledronate infusion-case report and review of the literature

Bisphosphonates have become a commonly used class of medications to treat osteoporosis and other bone diseases. Zoledronate (zoledronic acid) can be dosed annually via intravenous infusion, making it an appealing option for patients and physicians. We report the case of a 68-year-old woman who developed severe, unilateral, ocular inflammation, including corneal endotheliitis, anterior uveitis with hyphema, scleritis, and orbital inflammation beginning 12 hours after receiving her first zoledronate infusion. Symptoms escalated but ultimately resolved with topical steroids and high-dose systemic corticosteroids. To our knowledge, this is the first report of unilateral diffuse inflammation of the eye and orbit, including corneal inflammation developing within 12 hours of a first zoledronate infusion.

Orbital Inflammatory Syndrome and Anterior Uveitis: A Case Series

PURPOSE

To describe four cases of orbital inflammatory syndrome (OIS) with associated anterior uveitis that have presented within 2 years to our practice.

METHODS

Charts of patients diagnosed with OIS from June 2013 to May 2015 were reviewed.

RESULTS

Four patients, three children and one adult, presented with orbital swelling, pain, and varying degrees of vision loss. Treatment with intravenous methylprednisolone resulted in significant symptomatic improvement in all cases initially; when symptoms recurred, the patients had evidence of anterior uveitis. With continued systemic therapy and the addition of topical prednisolone, the patients all achieved control of their uveitis and OIS and are well controlled with regular outpatient follow-up.

CONCLUSIONS

Reports of OIS-associated with uveitis are relatively rare. The presentation of three pediatric patients and one adult patient to the same practice with OIS and secondary uveitis within a 2-year period may indicate that the association is underreported.