Table 10.

Management of Ocular irAEs in Patients Treated With ICPis

10.0 Ocular Toxicities
Counsel all patients to inform their health care provider immediately if they experience any of the following ocular symptoms  Blurred vision  Change in color vision  Photophobia  Distortion  Scotomas  Visual field changes  Double vision  Tenderness  Pain with eye movement  Eyelid swelling  Proptosis
Evaluation, under the guidance of ophthalmology  Check vision in each eye separately  Color vision  Red reflex  Pupil size, shape, and reactivity  Fundoscopic examination  Inspection of anterior part of eye with penlight
Prior conditions  Exclude patients with history of active uveitis  History of recurrent uveitis requiring systemic immunosuppression or continuous local therapy
Additional considerations  Ocular irAEs are many times seen in the context of other organ irAEs  High level of clinical suspicion as symptoms may not always be associated with severity  Best to treat after ophthalmologist eye examination
10.1 Uveitis/iritis
Definition: Inflammation of the middle layer of the eye
Diagnostic work-up: as per above
Grading	Management
G1: Asymptomatic	Continue ICPi  Refer to ophthalmology within 1 week  Artificial tears
G2: Medical intervention required, anterior uveitis	Hold ICPi temporarily until after ophthalmology consult  Urgent ophthalmology referral  Topical corticosteroids, cycloplegic agents, systemic corticosteroids  May resume ICPi treatment once off systemic corticosteroids, which are purely indicated for ocular adverse effects or once corticosteroids for other concurrent systemic irAEs are reduced to ≤ 10 mg; continued topical/ocular corticosteroids are permitted when resuming therapy to manage and minimize local toxicity  Re-treat after return to G1 or less
G3: Posterior or panuveitis	Permanently discontinue ICPi  Urgent ophthalmology referral.  Systemic corticosteroids and intravitreal/periocular/topical corticosteroids
G4: 20/200 or worse	Permanently discontinue ICPi  Emergent ophthalmology referral  Systemic corticosteroids (IV prednisone 1–2 mg/kg or methylprednisolone 0.8–1.6 mg/kg) and intravitreal/periocular/topical corticosteroids per ophthalmologist opinion
Additional considerations: Consider use of infliximab or other TNF-α blockers in cases that are severe and refractory to standard treatment121,122
10.2 Episcleritis
Definition: Inflammatory condition affecting the episcleral tissue between the conjunctiva and the sclera that occurs in the absence of an infection
Diagnostic work-up: As per 10.0
Grading	Management
G1: Asymptomatic	Continue ICPi  Refer to ophthalmology within 1 week  Artificial tears
G2: Vision 20/40 or better	Hold ICPi therapy temporarily until after ophthalmology consult  Urgent ophthalmology referral  Topical corticosteroids, cycloplegic agents, systemic corticosteroids
G3: Symptomatic and vision worse than 2/40	Permanently discontinue ICPi  Urgent ophthalmology referral  Systemic corticosteroids and topical corticosteroids with cycloplegic agents
G4: 20/200 or worse	Permanently discontinue ICPi  Emergent ophthalmology referral  Systemic corticosteroids and topical corticosteroids with cycloplegic agents
Additional considerations: Consider use of infliximab or other TNF-α blockers in cases that are severe and refractory to standard treatment121,122
10.3 Blepharitis
Definition: Inflammation of the eyelid that affects the eyelashes or tear production
Diagnostic work-up: As per 10.0
Grading	Management
No formal grading system	Warm compresses and lubrication drops  Continue therapy unless persistent and serious
All recommendations are expert consensus based, with benefits outweighing harms, and strength of recommendations are moderate.

Abbreviations: ICPi, immune checkpoint inhibitor; irAE, immune-related adverse event; IV, intravenous, TNF, tumor necrosis factor.