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Dermatology

A Man With Kaleidoscope Vision

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.

1 Credit CME

JAMA Ophthalmology

Published Online: June 1, 2023

JAMA Ophthalmology Clinical Challenge

Article Information and Disclosures

Anuoluwapo Sopeyin, MD¹;

Carl Wilkins, MD¹;

Meghan Berkenstock, MD¹

Author Affiliations

¹Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland

Read article on JAMA Network

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A 63-year-old man with no ocular history and a history of stage 3 cutaneous melanoma of the scalp and chronic lymphocytic leukemia was referred for kaleidoscope vision. He received nivolumab (anti–programmed cell death 1 checkpoint inhibitor) 9 months prior, obinutuzumab (B-cell lymphoma 2 inhibitor) 3 months later, and 5-mg oral prednisone daily. On presentation, nivolumab and obinutuzumab treatment was complete.

His visual acuity was 20/125 OD and 20/50 OS. Ophthalmoscopy revealed bilateral panuveitis with diffuse pigmentary abnormalities. Fluorescein angiography showed diffuse retinal pigment epithelium loss and late staining of the retinal lesions. He received 60 mg of oral prednisone daily for 2 weeks with a planned 10-week taper. However, prednisone was discontinued due to positive Lyme disease exposure 6 weeks later. At this time, the active anterior and vitreous cells had resolved.

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A 63-year-old man with no ocular history and a history of stage 3 cutaneous melanoma of the scalp and chronic lymphocytic leukemia was referred for kaleidoscope vision. He received nivolumab (anti–programmed cell death 1 checkpoint inhibitor) 9 months prior, obinutuzumab (B-cell lymphoma 2 inhibitor) 3 months later, and 5-mg oral prednisone daily. On presentation, nivolumab and obinutuzumab treatment was complete.

His visual acuity was 20/125 OD and 20/50 OS. Ophthalmoscopy revealed bilateral panuveitis with diffuse pigmentary abnormalities. Fluorescein angiography showed diffuse retinal pigment epithelium loss and late staining of the retinal lesions. He received 60 mg of oral prednisone daily for 2 weeks with a planned 10-week taper. However, prednisone was discontinued due to positive Lyme disease exposure 6 weeks later. At this time, the active anterior and vitreous cells had resolved.

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Article Information

Corresponding Author: Anuoluwapo Sopeyin, MD, Wilmer Eye Institute, Johns Hopkins School of Medicine, 600 N Wolfe St, Wilmer B29, Baltimore, MD 21287 (sopeyin@jhmi.edu).

Published Online: June 1, 2023. doi:10.1001/jamaophthalmol.2023.2063

Conflict of Interest Disclosures: Dr Wilkins reported personal fees from EyePoint Pharmaceuticals outside the submitted work. No other disclosures were reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References

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Fang T , Maberley DA , Etminan M . Ocular adverse events with immune checkpoint inhibitors. J Curr Ophthalmol. 2019;31(3):319-322. doi:10.1016/j.joco.2019.05.002 PubMed Google Scholar Crossref

Inno A , Metro G , Bironzo P , et al. Pathogenesis, clinical manifestations and management of immune checkpoint inhibitors toxicity. Tumori. 2017;103(5):405-421. doi:10.5301/tj.5000625 PubMed Google Scholar Crossref

Duong SL , Barbiero FJ , Nowak RJ , Baehring JM . Neurotoxicities associated with immune checkpoint inhibitor therapy. J Neurooncol. 2021;152(2):265-277. doi:10.1007/s11060-021-03695-w Google Scholar Crossref

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.