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Zoledronate-induced anterior , scleritis and : a case report Laura E Wolpert, Andrew R Watts

isphosphonates, such as zoledronate, with proptosis, periorbital oedema, conjunc- are used by approximately 55,000 tival chemosis and injection and cells and Bpeople per year in New Zealand1 to flare in the anterior chamber (Figure 1A). prevent the loss of bone density in a range There was no evidence of vitritis, and fundal of conditions such as osteoporosis, Paget’s examination was normal. 2 of the bone and bone metastases. A B-scan of the right eye showed scleral Although ocular side effects are rare, bis- thickening (Figure 2). The patient underwent phosphonates have been associated with a CT scan of her orbits, which revealed right- 3,4 4,5 acute anterior uveitis (AAU) and scleritis. sided proptosis with intraconal fat stranding There have also been case reports of optic and surrounding the 6–8 neuritis following bisphosphonate use. and , consistent with scleritis and Here we report a case of a patient who pro- retrobulbar optic neuritis (Figure 3). Inves- gressively developed AAU, scleritis and optic tigations, including serum ACE, treponemal neuritis following a zoledronate infusion. serology, ANA and QuantiFERON-TB Gold, were unremarkable. Case report A diagnosis of zoledronate-induced uveitis, A 61-year-old woman with a past medical scleritis and optic neuritis was made. The history of previous morbid obesity with patient received 1g intravenous methyl- sleeve gastrectomy, severe reflux and , which resulted in a rapid ileostomy secondary to hemicolectomy for improvement of her symptoms and signs by severe diverticular disease presented to the following day (Figure 1B). The patient the eye clinic with a three-day history of was then discharged on a weaning course right eye pain, and blurred of oral prednisone, topical prednisolone 1% vision. These symptoms commenced one eye drops and cyclopentolate 1% eye drops. day following her first zoledronate infusion At one week follow-up the inflammation had for osteoporosis. She had no significant past resolved. ophthalmic history. Right eye was 6/15 and Discussion left eye visual acuity was 6/9. Intraocular Orbital inflammation is an uncommon pressures were normal. She had right side effect of zoledronate infusion. The circumlimbal injection with cells and flare incidence of zoledronate-associated AAU in the anterior chamber. Fundal exam- has been reported at around 1.1%.3 To our ination was normal. An initial diagnosis of knowledge, there are only two case reports AAU was made and treatment with prednis- of zoledronate-associated optic neuritis,7,8 olone 1% eye drops and cyclopentolate 1% although optic neuritis has been seen with eye drops was commenced. other bisphosphonates in a few cases.6 Two days later the patient presented There is little information on bisphos- with worsening pain and vision and pain phonate rechallenge following adverse on eye movements. Right visual acuity had ocular events. Adverse ocular events have decreased to 6/24. She had red desaturation been reported following bisphosphonate

NZMJ 25 June 2021, Vol 134 No 1537 ISSN 1175-8716 © NZMA 91 www.nzma.org.nz/journal clinical correspondence

Figure 1: (A) The patient’s right eye five days following a zoledronate infusion, showing proptosis, lid oedema and conjunctival chemosis. (B) The patient’s right eye after treatment with intravenous methyl- prednisolone, which resulted in reduced peri-ocular swelling and chemosis. The is dilated due to cyclopentolate drops.

Figure 2: A B-scan of the patient’s right eye showing scleral thickening (white arrow).

NZMJ 25 June 2021, Vol 134 No 1537 ISSN 1175-8716 © NZMA 92 www.nzma.org.nz/journal clinical correspondence

rechallenge but do not occur in all cases.9,5–7 Recognition of drug-induced ocular Although inflammation associated with inflammation is critical to allow for prompt bisphosphonate use is usually mild and referral to an ophthalmologist and with- shows complete resolution after cessation drawal of the drug in question. Patients of the precipitating agent and treatment of receiving bisphosphonate treatment should the ocular inflammation, in the context of be counselled to seek medical attention if potentially sight-threatening conditions such they develop symptoms of visual loss, eye as scleritis and optic neuritis, rechallenge pain or eye redness. may not be advisable.

Figure 3: CT scan showing right eye proptosis (blue arrow), intraconal fat stranding (yellow arrow) and optic nerve thickening (red arrow).

NZMJ 25 June 2021, Vol 134 No 1537 ISSN 1175-8716 © NZMA 93 www.nzma.org.nz/journal clinical correspondence

Competing interests: Nil. Author information: Laura E Wolpert: Registrar, Department of Ophthalmology, Whangarei Hospital, Northland District Health Board, Maunu Road, Whangārei 0148, New Zealand. Andrew R Watts: Consultant Ophthalmologist, Department of Ophthalmology, Whangarei Hospital, Northland District Health Board, Maunu Road, Whangārei 0148, New Zealand. Corresponding author: Dr Laura Wolpert, Department of Ophthalmology, Whangarei Hospital, Northland District Health Board, Maunu Road, Whangārei 0148, New Zealand, 09 430 4100 [email protected] URL: www.nzma.org.nz/journal-articles/zoledronate-induced-anterior-uveitis-scleritis-and-op- tic-neuritis-a-case-report

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NZMJ 25 June 2021, Vol 134 No 1537 ISSN 1175-8716 © NZMA 94 www.nzma.org.nz/journal