A case report of pseudo-exfoliation syndrome with prolonged corneal epithelial regeneration because of erlotinib-induced unilateral corneal ulcer and anterior uveitis.

Abstract

Erlotinib hydrochloride (Tarceva®) is a molecular targeted therapeutic agent that targets epidermal growth factor (EGF) that is overexpressed in tumours and exerts an antitumour effect. Side effects are often low, with many skin symptoms, 75% rash, less than 1% for ocular symptoms and less than 0.1% for corneal ulcers. To the best of our knowledge, there have been 8 reports of anterior uveitis by erlotinib so far, except in one case (Todokoro et al. 2016), occurring in both eyes. The patient was an 87-year-old Japanese male who had previously visited our ophthalmology with pseudo-exfoliation (PXE) syndrome in both eyes and age-related macular degeneration of the right eye in May 2018. The best-corrected visual acuity (BCVA) measurement showed log MAR +2.0 in the right eye and log MAR +0.10 in the left eye. The intraocular pressure (IOP) was 11 mmHg (GAT) in both eyes. Both eyes had intraocular lenses inserted after cataract surgery. He has been prescribed Travoprost eyedrops at once in a day for about a year. On 30 October 2018, he suddenly decreased his vision. He complained of pain in the back of the left eye. His BCVA on the left eye had dropped from log MAR +0.10 to log MAR +2.0. His IOP was 10 mmHg for the right eye and 33 mmHg for the left eye. There was an oval erosion around at 7 o'clock on the cornea in the left eye (Fig. 1A). There were numerous cells in the anterior chamber, and there was an increase in IOP. Fibrin has been deposited in the anterior chamber. Culture tests of the conjunctiva and cornea prior to eye treatment showed only resident Staphylococcus epidermidis. MRSA was negative. At 3 days later, his vision had further declined, resulting in a 30 cm hand motion. The corneal infiltration became an ulcer and expanded (Fig. 1B-1,B-2). Hypopyon appeared in the anterior chamber (Fig. 1B-2). Two days later, inflammation was suppressed. His vision was log MAR +2.0, and hypopyon had disappeared in anterior chamber, but corneal epithelium could not be regenerated (Fig. 1C). The IOP of his left eye dropped to 18 mmHg. Tarceva® was discontinued again because of medical side effects. In addition, scarring progressed at the site where the corneal epithelium was defect, and visual acuity improved to log MAR 0 before the onset of the disease (Fig. 1D-1,D-2). The patient passed away by heart failure on 3 August 2019. He has unilateral infectious corneal ulcer and anterior uveitis caused by taking erlotinib hydrochloride. He developed hypopyon during the course of the inflammation. We reduced inflammation in this case by instilling and dripping antibiotics. We also experienced a case in which erlotinib was temporarily discontinued and long eyelashes were removed and visual acuity was restored to encourage his corneal epithelium to regenerate. His previous surgery for squamous cell carcinoma in maxillary sinus involved opening the anterior wall of the maxilla, removing the tumour and treating with radiation. He had contractures on his left face and lower eyelid, he could not properly close his eyes, he had dry corneas, and the EGFR inhibitor impaired the healing process of tissue repair. We experienced corneal ulcer triggered by taking erlotinib hydrochloride. The probable cause is that eyelashes prolonged or overgrown due to side effects came into contact with the cornea. In addition, he has PEX, so once the inflammation occurs, it is difficult to fix it, and the inflammation may have prolonged (Sarenac Vulovic et al. 2016; Borrás 2018). Keep in mind the side effects of anticancer drugs on the eyes, and if we have an eye disorder, we need to take early treatment in cooperation with other departments.