Immune Checkpoint Inhibitor (ICI) Induced Corneal Graft Rejection
Shima Bakhtiary*,Dinuka Ariyarathna, Michelle Harfield, Shivanshan Pathmanathan and A William Talbot
ABSTRACT
Purpose: To demonstrate a case of corneal graft rejection in a patient on immune checkpoint inhibitor (ICI) Cemiplimab, a PD-1 inhibitor, for metastatic cutaneous squamous cell carcinoma (CSCC).
Case: A 64-year-old male presented with sudden deterioration in left vision at the end of January 2024, just 4-5 days after commencing on Cemiplimab for his inoperable SCC of the scalp. He previously underwent a left penetrating keratoplasty (PK) for corneal decompensation and scarring secondary to severe herpes zoster ophthalmicus (HZO).
Ophthalmological examination revealed: left best-corrected visual acuity (BCVA) to count fingers (CF) only, intra-ocular pressure (IOP) of 11 mmHg, anterior segment demonstrated diffusely oedematous cornea with hyperaemic limbus, descemet membrane folds and keratic precipitates. The corneal graft sutures remained intact. A corneal topography and pachymetry assessment demonstrated central corneal thickness (CCT) measurement of 764 um.
Based on the above findings, a left corneal graft rejection was suspected. The patient was treated vigorously with hourly topical dexamethasone, in addition to systemic oral prednisone. Despite close follow-up and vigorous treatment, there was progression of corneal graft rejection with minimal preservation of his left vision.
Discussion: Cemiplimab is a PD-1 inhibitor on T-cells. This reactivation of the immune system, while beneficial in targeting tumours, can also precipitate immune-mediated damage to healthy tissues, including allografts such as corneal transplants.
This case highlights the need for vigilant ophthalmological monitoring in patients undergoing ICI therapy, particularly those with a history of corneal transplantation. Baseline ophthalmological screening should be performed prior to initiating cemiplimab or any other ICI, followed by regular follow-up to detect early signs of graft rejection.
