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要約 目的:ペムブロリズマブは免疫チェックポイント阻害薬の一つで,さまざまな副作用が生じることがある。今回,ペムブロリズマブ治療中に片眼の網膜血管炎,網膜中心動脈閉塞症,血管新生緑内障,大動脈瘤の拡大が生じた症例を報告する。
症例:74歳,男性。2年前から前立腺癌に対しペムブロリズマブ治療を受けていた。右視力低下を主訴に静岡済生会総合病院(以下,当院)眼科を紹介され受診した。右過熟白内障を認めたため,右白内障手術を行ったが術中に核落下したため硝子体手術を追加し眼内レンズを囊外固定した。術後,右視力は(1.0)まで改善したが,手術6か月後に右視力低下と右眼痛を訴え当院眼科を再診した。右視力は光覚弁に低下し,右眼圧は51.6mmHgまで上昇,右角膜浮腫と右前房出血,右眼底軟性白斑があり光干渉断層計では右網膜内層浮腫を認めた。D-マンニトール点滴と緑内障薬の点眼・内服を処方したところ眼圧は正常化したが視力は(0.01)までしか改善しなかった。ペムブロリズマブによる右網膜中心動脈閉塞症と右血管新生緑内障と診断しGrade 4の免疫関連有害事象と判定していったん投与を中止した。副腎皮質ステロイドの全身投与は行わなかった。その後,癌のリンパ節転移が発生したためペムブロリズマブ投与を再開したところ以前からあった胸部大動脈瘤が増悪した。
結論:ペムブロリズマブ投与によって,網膜血管炎や既存の動脈瘤が増悪することがあり注意が必要である。さらにペムブロリズマブ以外の免疫チェックポイント阻害薬の適応拡大が望まれる。
Abstract Purpose:Pembrolizumab is an immune checkpoint inhibitor that can cause a variety of side effects. We report a case of retinal vasculitis, central retinal artery occlusion, iris ciliary inflammation in one eye and expanding aortic aneurysm during Pembrolizumab treatment.
Case:A 74-year-old man had been treated with Pembrolizumab for prostate cancer for 2 years. He was referred to our department with a chief complaint of decreased right visual acuity. The patient underwent right cataract surgery due to a right overmature cataract, but the nucleus dropped intraoperatively, so vitrectomy was added and an intraocular lens was fixed in the sulcus. His vision improved to 10/10 after the surgery, but 6 months after the surgery, he came to the outpatient clinic complaining of decreased right visual acuity and right eye pain. The patient was found to have decreased right visual acuity only to light perception, high intraocular pressure on the right, right corneal edema, anterior chamber hemorrhage, and soft exudate of the fundus. Mannitol intravenous infusion and anti-glaucoma eyedrops and oral medicine were administered, and intraocular pressure normalized but right visual acuity only improved to 1/100. Central retinal artery occlusion and neovascular glaucoma were occurred as Grade 4 immune-related adverse events by Pembrolizumab, and treatment was discontinued. Systemic corticosteroids were not administered. Later, when Pembrolizumab administration was resumed due to lymph node metastasis of the cancer, the patient's previous thoracic aortic aneurysm worsened.
Conclusion:Pembrolizumab administration can lead to retinal vasculitis and exacerbate existing aneurysms, therefore caution is required. Further expansion of indications for immune checkpoint inhibitors other than Pembrolizumab is desirable.

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