Ocular Toxicities: Management of irAEs Guideline (Part 12)

An interview with Dr. Marc Ernstoff from the National Cancer Institute, author on “Management of Immune-Related Adverse Events in Patients Treated With Immune Checkpoint Inhibitor Therapy: ASCO Guideline Update.” He reviews identification, evaluation & management of ocular toxicities in patients receiving ICPis, including uveitis, iritis, and episcleritis in Part 12 of this 13-part series. For more information visit www.asco.org/supportive-care-guidelines   TRANSCRIPT SPEAKER: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. BRITTANY HARVEY: Hello, and welcome to the ASCO Guidelines podcast series, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content, and offering enriching insight into the world of cancer care. You can find all the shows, including this one, at asco.org/podcasts. My name is Brittany Harvey, and today we're continuing our series on the management of immune-related adverse events. I am joined by Dr. Marc Ernstoff from the National Cancer Institute in Bethesda, Maryland, author on Management of Immune-Related Adverse Events in Patients Treated with Immune Checkpoint Inhibitor Therapy: ASCO Guideline Update, and Management of Immune-Related Adverse Events in Patients Treated with Chimeric Antigen Receptor T-Cell Therapy: ASCO Guideline. And today we're focusing on ocular toxicities in patients treated with immune checkpoint inhibitor therapy. Thank you for being here, Dr. Ernstoff. MARC ERNSTOFF: Thank you, Brittany. BRITTANY HARVEY: First, I'd like to note that ASCO takes great care in the development of its guidelines and ensuring that the ASCO conflict of interest policy is followed for each guideline. The full conflict of interest information for this guideline panel is available online with the publication of the guidelines in the Journal of Clinical Oncology. Dr. Ernstoff, do you have any relevant disclosures that are directly related to this guideline? MARC ERNSTOFF: I have no further disclosures at this time. BRITTANY HARVEY: Great. Thank you. Then let's get into these ocular toxicities. So first, what are the immune-related ocular toxicities addressed in this guideline? MARC ERNSTOFF: So the ocular toxicity is addressed in the guidelines represent a relatively uncommon side effect of immune checkpoint inhibition, and represents inflammation of all components of the eye from the superficial component to the internal uveal component. So there is iritis. There's episcleritis and uveitis, are the ones that are usually identified by physical examination and by complaints. BRITTANY HARVEY: Understood. Then so let's start with what are the key recommendations for identification, evaluation, and management of uveitis and iritis? MARC ERNSTOFF: So those are excellent questions. I think that it's important for clinicians to recognize that while most of the eye toxicities are relatively minor, low grade, and can be managed effectively, there are some that are very important to identify, particularly as they may lead to blindness, particularly uveitis or pan uveitis. So identification of these symptoms and signs are important. So evaluation of the patient by asking whether there are any eye symptoms-- dryness or irritation-- is important in your evaluation of the patient's side effects. In addition, looking at the eye, both with a penlight, looking for any inflammatory signs, and doing a ophthalmologic examination to make sure there's no cloudiness or anything identified in the retina is important. BRITTANY HARVEY: Great. And then furthermore, what are the key recommendations for identification, evaluation, and management of episcleritis? MARC ERNSTOFF: So episcleritis can usually be seen by irritation in the superficial areas of the eye. It usually can be managed. If it's low grade, it can be managed with topical steroids and continuation of the immune checkpoint inhibitor. On the other hand, if it's more bothersome and not responding to topical therapy, evaluation by an ophthalmologist, potentially interruption of immune checkpoint inhibitor, is important. And if it's severe, systemic steroids might be required at that time. BRITTANY HARVEY: Great. Thank you for reviewing how to best identify and manage that particular toxicity. So then in your view, how will these recommendations for the management of ocular toxicities impact both clinicians and patients? MARC ERNSTOFF: So again, I think it's important that both from symptom management, that these, many times, can be managed with topical steroids and tears effectively, and that a patient's therapy can continue, which I believe is important. On the other hand, identifying areas that may be beyond the expertise of an oncologist, would require evaluation by an ophthalmologist, including a slit light examination. It is important to recognize that uveitis can have minimal symptoms and yet be more severe in its condition, requiring intervention and holding of immune checkpoint. And if really severe-- grade 3 or 4-- the interruption and discontinuation of immune checkpoint inhibition is probably going to be required to manage the side effect. Again, if undiagnosed and untreated, it can lead to blindness. So while not quote life-threatening, clearly a major impact in quality of life of a patient that is preventable, if identified. BRITTANY HARVEY: Great. Thank you so much for viewing these recommendations for the management of ocular toxicities, to ensure both the quality of life of patients and the best practices for management of these toxicities. So I want to thank you for your work on these guidelines and for taking the time to speak to you today, Dr. Ernstoff. MARC ERNSTOFF: Thank, you very much, Brittany. BRITTANY HARVEY: And thank you to all of our listeners for tuning in to the ASCO Guidelines podcast series. Stay tuned for additional episodes on the management of immune related-adverse events. To read the full guideline, go to www.asco.org/supportive-care-guidelines.  You can also find many of our guidelines and interactive resources in the free ASCO guidelines app, available in iTunes or the Google Play store. 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