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This previously healthy 34YO female presented with recent bilateral vision loss. She recalled having blood pressure issues during her last pregnancy. Vision was hand motion OD and 20/80 OS.
Optos color RG imaging of her left eye shows disc swelling, scattered inner retinal hemorrhages, cotton wool spots (CWS), and a nasal macular lipid star. Similar findings were noted in her right eye (not shown). Blood pressure was 292/208, and she was immediately referred to the emergency room for malignant hypertension.
She was then lost to follow-up when she presented 4 years later. Vision was 20/20 bilaterally. Optos color RG imaging shows radiating linear areas of pigment loss and clumping, with focal subretinal pigment clumps.
Learning Points:
Malignant hypertension, defined as blood pressure above 180 systolic and/or 120 diastolic, is a life-threatening medical emergency. Eye doctors are often uniquely positioned to diagnose this condition (Shukla et al, Indian J Ophthalmol 2025;73:1552-1555). Patients will often present with bilateral optic nerve swelling, flame-shaped retinal hemorrhages, CWS, and, with more chronic disease, lipid precipitates in the nasal macular outer plexiform layer.
Acute hypertensive choroidopathy outside the setting of pre-eclampsia, in our experience, is quite rare. Independent of the disc and neurosensory retinal findings, patients present with localized multifocal serous retinal detachments (de Venecia and Jampol, Arch Ophthalmol 1984;102:68-73). With blood pressure control, these often resolve with minimal funduscopic changes. Focal (Elschnig spots) or linear (Siegrist streaks) choroidal pigmentary changes, as seen in our patient, may indicate more severe disease.
Am J Ophthalmol. 2026 Sep:289:282-291. doi: 10.1016/j.ajo.2026.05.046.
Immune checkpoint inhibitor-associated uveitis: Melanoma intrinsically higher risk; Renal cell CA largely ipilimumab-nivolumab driven — Retrospective, TriNetX database
Purpose: Understanding how the risk of immune checkpoint inhibitor (ICI)-associated noninfectious uveitis (NIU) differs by malignancy and drug class may help understand its pathophysiology and guide targeted ophthalmic surveillance. This study aims to evaluate the comparative risk of ICI-associated NIU across different malignancies and drug classes.
Design: Retrospective, multicenter clinical cohort study.
Subjects: Adults with metastatic melanoma, lung cancer, renal cell carcinoma (RCC), urothelial carcinoma, hepatocellular carcinoma, Hodgkin lymphoma, or nonmelanoma skin cancer. Propensity score matching was performed for demographics, comorbidities, and socioeconomic factors.
Exposures: Prescription of an ICI agent of any class (anti-PD-1, anti-PD-L1, or anti-cytotoxic T-lymphocyte-associated protein 4 [CTLA-4]).
Main outcome measures: The primary outcome was new-onset NIU within 24 months of first ICI prescription. Relative risks (RR) with 95% confidence intervals (CIs) were calculated. Subgroup analyses compared outcomes across malignancies, with and without ipilimumab or nivolumab exposure, and between ICI subclasses when used in monotherapy.
Results: After matching, 16,834 patients with melanoma and 16,834 with lung cancer were included. Melanoma patients had a higher risk of NIU compared with lung cancer (1.10% vs 0.18%; RR, 6.17; 95% CI, 4.20-9.08). Excluding ipilimumab/nivolumab, melanoma remained associated with increased risk (0.53% vs 0.16%; RR, 3.40; 95% CI, 1.68-6.88). Across malignancies, melanoma consistently demonstrated elevated risk relative to other cohorts. Lung cancer showed borderline decreased risk compared to RCC (0.19% vs 0.36%; RR, 0.53; 95% CI, 0.31-0.90), but this effect was not significant after excluding ipilimumab/nivolumab. In drug-class analyses, anti-PD-1 agents did not demonstrate a significantly different risk of NIU compared with anti-PD-L1 agents (0.26% vs 0.20%; RR, 1.33; 95% CI, 0.89-1.99). Anti-cytotoxic T-lymphocyte-associated protein 4 agents could not be compared due to limited use as monotherapy.
Conclusions: Both malignancy type and ICI subclass influence the risk of ICI-associated uveitis. Melanoma carries an intrinsically higher risk independent of ipilimumab/nivolumab exposure, whereas RCC’s risk appears largely ipilimumab/nivolumab-driven. These findings underscore the need for careful monitoring of melanoma patients initiating ICIs and suggest that the pathophysiology of ICI-related uveitis is driven by both drug- and disease-specific factors.
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