Drug-induced uveitis or dry eye?

by Juan Ding, OD, PhD

I will try to write about one interesting eye case that I see each day. The purpose is to provide education of eye diseases, vision function and eye care to the public, and maybe to students who study optometry. This is the 2nd of the series.


Woman in her 30s referred by her cancer doctor for red eye. The symptoms were irritation, itchiness, pain, redness, and some crusting, but hardly any photophobia. Cancer doctor informed me that the patient was on two cancer medications, dabrafenib and trametinib, which are known to cause uveitis (inflammation of the middle layer of the eye). Just from the symptoms, it sounded like conjunctivitis or dry eye rather than uveitis. Unexpectedly though, there was indeed inflammation of the iris; the vitreous and retinal were normal, so the inflammation was restricted to the fronter part of the eye, termed iritis. Interestingly, almost all her complaints were actually from the mild dry eye she also had. In contrast, usually iritis would produce a dramatic complaint of pain and photophobia.


My patient had malignant melanoma. She started with chemotherapy with dabrafenib and trametinib for 2 months, followed by surgery, then continued with chemo. About 5 months into the chemo she presented with inflammation of both eyes. Below are the eye side effects of these two medications listed by manufacturer:


“Ocular Toxicities. Retinal vein occlusion (RVO) may lead to macular edema, decreased visual function, neovascularization, and glaucoma. Urgently (within 24 hours) perform ophthalmologic evaluation periodically and at any time for a patient-reported loss of vision or other visual disturbances. Permanently discontinue MEKINIST in patients with documented RVO.

Retinal pigment epithelial detachment (RPED) can occur with MEKINIST administration. Withhold MEKINIST if RPED is diagnosed. If resolution of the RPED is documented on repeat ophthalmologic evaluation within 3 weeks, resume MEKINIST. Reduce the dose or discontinue MEKINIST if no improvement after 3 weeks.

Uveitis (including iritis and iridocyclitis) can occur with TAFINLAR. Perform ophthalmologic evaluation for any visual disturbances. Monitor patients for visual signs and symptoms of uveitis (eg, change in vision, photophobia, and eye pain). Permanently discontinue TAFINLAR for persistent grade 2 or greater uveitis of more than 6 weeks duration.”


Her iritis responded well to prednisolone acetate 1% drops 4 times a day in both eyes, and tapered without incident.


Two months later, she came complaining of bad dry eyes; no uveitis. She got relief with preservative free artificial tears. About the same time, her cancer doctor found sarcoid-like reaction in her lungs.


Another two months later, in a routine follow up eye exam, I found iritis in both of her eyes again, though she had no compliant. It went away again with prednisolone drops.


It is not clear if her two episodes of iritis are due to sarcoidosis, or to drug toxicity; or if her sarcoid is in anyway related to the drugs. It does appear that her symptoms are mostly related to dry eye rather than uveitis. Prior to this she did not have a history of dry eye. Hopefully she can be off of these medications soon and hopefully she will then not suffer from dry eye again.

Accommodative insufficiency and convergence insufficiency

by Juan Ding, OD, PhD

I will try to write about one interesting eye case that I see each day. This is the first of the series.

A pretty woman with meticulous makeup (at least for me) in her early 40s complained about difficulty reading and seeing distance. Also had bouts of double vision a few months ago. She has a history of bipolar disorder, hypothyroidism and alcohol use, and goes in and out of rehab for alcohol problem.


This is the second time I see her. I saw her 3 weeks ago for the first time. As in any comprehensive eye exam, when I saw her, she’s already been worked up by the technician with her pupils dilated. Unable to make her see 20/20 with refraction, yet with a complete normal eye exam otherwise, I suspected a functional problem. So here she is again today, sitting in my chair, only able to see 20/60 letters for distance, and 20/100 letters at close up. Looking at her auto-refractor reading, I know right away that she will not respond to phoropter refraction. So I did the good old trial frame. With +0.25 D of astigmatism correction and +0.25 of sphere, she’s seeing the 20/20 line. Makes no sense even for a 70 year old to see so poorly with such a minor prescription. For near, she requires a +2.00 add, which people usually don’t need until 55 years and older.


I then did other tests to find out that her accommodation is indeed non-existent, and the ability of her two eyes to converge and diverge is also minimal.


I tried two pairs of glasses on for her, one for distance and one for near, and she’s comfortably seeing everything clearly. So I gave her the glass prescription, and ask her to come back if her vision is not improved with glasses.


My diagnosis for her is accommodative insufficiency and convergence insufficiency. These are functions of the eyes to focus and to look at objects at the same point, respectively. I have seen quite a few young women with these issues, and many of them with a psychiatric disorder such as bipolar, depression or anxiety. However, the visual functional deficit is not a psychological one, their eyes truly cannot perform, and glasses can usually help.


It has been shown that certain psychiatric medications such as ritalin can lead to accommodative insufficiency which makes convergence insufficiency worse (http://www.pressvision.com/pdf/hong_press.pdf). It is not known whether the medications that these patients are usually on, or their psychological issues, contribute to their accommodative and vergence dysfunction. Maybe both. Maybe another underlying cause results in their psychological and eye issues.


Common symptoms of accommodative insufficiency include:

  • difficult to focus,
  • blurry vision (especially when reading, using computer or phone)
  • eye strain

Common symptoms of convergence insufficiency include

  • double vision (especially when reading, using computer or phone)
  • eye strain.


Treatment for both:

  • Wear glasses: sometimes bifocals or progressive addition lenses are needed, and sometimes prism may help further.
  • Vision therapy: this is a set of individualized eye exercises that an optometrist prescribes and trains with motivated patients.