Triple Therapy With Rituximab, Intravenous Immunoglobulin, and Intravitreal Corticosteroids for Melanoma-Associated Retinopathy: Ttriic Does the Trick

Abstract

The authors present a case report of melanoma-associated retinopathy that was successfully managed with a combination of rituximab, IV immunoglobulin, and intravitreal corticosteroids. Electroretinographic parameters, which were initially very poor, were tracked throughout the course of treatment, and normalized. Acuity returned to 20/20 in both eyes. Pembrolizumab for metastatic melanoma did not worsen melanoma-associated retinopathy.

Ocular Paraneoplastic Syndromes: A Critical Review of Diffuse Uveal Melanocytic Proliferation and Autoimmune Retinopathy

“…Patients tend to be younger, latency between onset of visual symptoms and cancer diagnosis is longer, and the ERG shows preservation of a-wave. 43-64 The latter finding was the clue that either the bipolar cell or Muller cell rather than photoreceptor was the site of immunologic injury. A number of other anti-retinal antibodies have been identified in patients with MAR, including 35-kDa Muller glial cell protein, 22 kDa neuronal antigen, 135-kDa, 46-kDa, 94-kDa, 30- kDa, 33-kDa, 35-kDa, 23-kDa, and 30-kDa.…”

“…Of the 9 patients with reported vision-related follow-up, 8 demonstrated an improvement in baseline vision, and 1 had stable vision. 43-64…”

“…Since 2012, there have been 17 cases of MAR reported in the English literature (Table, supplement). 43-45,49-64 Nine of those cases reported anti-retinal antibodies, but anti-TRPM1 was present in only 2. Nine of the 17 patients had sufficient documentation to assess visual outcomes clinically.…”

“…A number of other anti-retinal antibodies have been identified in patients with MAR, including 35-kDa Muller glial cell protein, 22 kDa neuronal antigen, 135-kDa, 46-kDa, 94-kDa, 30- kDa, 33-kDa, 35-kDa, 23-kDa, and 30-kDa. 43-64 Since the ERG finding of a preserved a-wave is non-specific and auto-antibodies other than anti-TRPM1 lack specificity, the minimal case-defining features of MAR remain unclear.…”