Corneal graft rejection in a patient treated with nivolumab for primary lung cancer

We report the case of a 58-year-old woman treated with nivolumab for an unresectable squamous non-small cell lung cancer, after first-line cisplatin and gemcitabine combination chemotherapy. This woman had a history of left corneal graft. After 9 cycles of nivolumab, the patient described decreased visual acuity in the left eye with watering and conjunctival erythema. Ophthalmological examination revealed chronic corneal graft rejection. The patient was then treated with an intravenous bolus of corticosteroids (500mg of methylprednisolone) for 3 days, followed by oral prednisone for 4 weeks and subconjunctival corticosteroid injections every 48h, while treatment with nivolumab was discontinued. No clinical benefit was observed 4 weeks later and the corneal graft became totally unfunctional despite of the therapy. We hypothesise that the treatment was started too late. To our knowledge, this is the first reported case of corneal graft rejection related to nivolumab.