Author: Claude (AI), from PubMed abstracts · Reviewed by: Dr Mina Abdelmseih · Reviewed: 2026-11-15 · Review due: 2027-11-15

Educational content only. Not personalised medical advice. Clinical decisions remain the responsibility of the treating clinician.

Ocular adverse events of immune checkpoint inhibitors and targeted cancer drugs

Immune checkpoint inhibitors (ICIs) and targeted cancer drugs, including MEK and BRAF inhibitors and antibody-drug conjugates (ADCs), have improved cancer survival but cause characteristic ocular adverse events [S5] [S11]. These range from dry eye and keratopathy to uveitis, retinopathy and orbital inflammation, and are probably under-reported [S4] [S7]. Early recognition and coordinated care between ophthalmology and oncology protect vision while keeping cancer treatment on track [S9] [S11].

Key points - The commonest ICI ocular toxicities are uveitis, inflammatory orbital disease and ocular surface changes; ocular toxicity is underestimated in ICI trials [S4]. - ICI-associated uveitis began a median of 9 weeks after starting treatment, and 83.6% of cases occurred within 6 months; most patients recovered to within one line of baseline vision with steroids and drug cessation [S3]. - MEK inhibitors cause ocular adverse events in up to 90% of patients, including transient serous retinopathy that is usually mild and self-limited [S1] [S6]. - ADCs such as belantamab mafodotin cause keratopathy and blurred vision; in DREAMM-7, ocular events occurred in 79% vs 29% with the comparator, were managed with dose modification, and worsening acuity mostly resolved [S8]. - ICI-induced sicca may affect 5 to 24% of treated patients [S12].

Evidence last checked: 2026-10-18 (PubMed abstracts).

Red flags

• Reduced vision, red painful eye or floaters on ICI or BRAF/MEK therapy: possible uveitis, which can cause vision loss from macular oedema, subretinal fluid or optic nerve inflammation [S11].
• Vogt-Koyanagi-Harada-like disease or panuveitis on immunotherapy [S6] [S11].
• Retinal vein occlusion or vascular occlusion on MEK inhibitors or interferon α [S1] [S6].
• Orbital inflammation on ICIs [S4].
• Severe keratopathy with vision loss on an ADC [S2] [S8].

Recognise it: patterns by drug class

• Checkpoint inhibitors. Anterior, intermediate, posterior uveitis and panuveitis have all been reported [S3]. Most immunotherapy uveitis manifests as iritis, intermediate uveitis or VKH-like disease [S11]. Sicca (ocular and oral dryness) differs from Sjögren disease in its pathophysiology [S12].
• BRAF inhibitors have the highest percentage of uveitis among these drug classes [S11].
• MEK inhibitors. A transient neurosensory detachment is seen in almost all patients [S6]. Other effects include visual disturbance, dry eye, adnexal changes, field defects, panuveitis and retinal vein occlusion [S1].
• Antibody-drug conjugates. Symptoms include blurred vision and foreign-body sensation; signs include corneal staining, corneal pseudomicrocysts and conjunctivitis [S9]. In DREAMM-2, grade 3 to 4 keratopathy occurred in 27% and 21% of the two dose cohorts [S2].
• Other drugs. Tamoxifen can cause crystalline retinopathy and taxanes a macular oedema with angiographic silence [S6].

Confirm it

• Take a full systemic drug history: diagnosing drug-induced uveitis requires a high index of suspicion and temporal correlation, after excluding infectious and autoimmune causes [S10].
• Use OCT to detect MEK-associated subretinal fluid and tamoxifen-related changes, which may be present in asymptomatic patients [S6].
• Examine the cornea with fluorescein in patients on ADCs [S9].

Manage it

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Tier A (primary care / oncology clinic, no eye specialist)

• Ask patients on ICIs, BRAF/MEK inhibitors or ADCs about blurred vision, pain, redness, dryness and floaters, and teach home symptom monitoring [S11].
• For dry eye symptoms, artificial tears are part of a graded symptomatic approach [S12] [S9].
• Do not stop cancer treatment without the oncologist; most ophthalmic adverse effects can be treated without discontinuing it [S5].

Tier B (general eye clinic)

• Uveitis. Treat with topical, intravitreal or oral corticosteroids according to severity [S11]; prompt recognition and steroid treatment are critical [S3].
• ADC keratopathy. Dose delay or reduction appears beneficial and most events are reversible; the benefit of cool compresses, artificial tears, vasoconstrictors and topical steroids is unclear [S9].
• MEK retinopathy may subside with continued use over weeks or months or after discontinuation, with some exceptions [S1].
• Doses of anticancer drugs and steroids are not covered here: follow oncology protocols and local formularies.

Tier C (specialist centre)

• Agree with the oncologist on dose holds or modifications; cessation of immunotherapy is a last-line measure [S11].
• Identify the vision-threatening and life-threatening situations that require stopping therapy jointly with the oncologist [S5].
• Plan baseline and follow-up examinations with oncology for drugs with frequent ocular toxicity [S11] [S9].

Refer when

Pitfalls

• Missing uveitis that starts weeks to months after starting an ICI [S3].
• Mistaking drug-induced uveitis for autoimmune or infectious disease, or the reverse [S10].
• Stopping cancer treatment for a manageable ocular event [S5] [S9].
• Overtreating mild MEK-associated serous retinopathy, which is usually self-limited [S1].

Evidence notes

• Evidence on ICI eye toxicity is mostly case reports and narrative reviews; incidence is not clearly defined [S4].
• DREAMM-2 and DREAMM-7 were funded by GlaxoSmithKline/GSK [S2] [S8].
• The search returned many oncology trials of ADCs (for example mirvetuximab and tisotumab) that were not used here.
• Not covered by these sources: grading scales for ocular toxicity, steroid regimens, screening intervals for specific drugs, and tebentafusp or bispecific antibodies.

Related articles

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• Drug-induced optic neuropathy: ethambutol, linezolid and amiodarone

References

See the numbered source list below. Each marker [S#] links to its PubMed and DOI record.