Corneal Perforation Associated with Pembrolizumab - A Case Report with Literature Review

To shed light on one of the ocular adverse effects related to pembrolizumab.

Case report and literature review.

A 53-year-old gentleman with underlying Stage III B renal cell carcinoma with lung metastasis and gout presented in June 2021 with bilateral red eyes following Coronavirus disease (COVID-19) vaccination. He had undergone a nephrectomy for renal cell carcinoma and was on Pembrolizumab therapy for 5 years. Examination showed right eye injected conjunctiva with diffuse punctate epithelial erosions over the cornea, which was treated with topical steroids. The left eye is suspected to have infective keratitis, which is treated with topical antibiotics and subsequently steroids for the ocular surface inflammation. However, he developed a left eye paracentral sterile corneal melt which rapidly progressed to perforation measuring 1 mm in size. The perforation was temporarily sealed with tissue glue, but he eventually required a full thickness corneal patch graft. Patient has been doing well post-operatively for the last 3 years.

The diagnosis and management of irAEs are challenging and necessitate continuously updated diagnostic and monitoring tools. As checkpoint inhibitors become more promising in the management of malignancies, it is crucial for both the oncologist and ophthalmologist to be aware of the potential ocular adverse effects of these drugs.