A 58-year-old man with metastatic melanoma from a primary nasal sinus tumor was referred to ophthalmology for bilateral eye irritation. Around this time, he was undergoing his sixth cycle of nivolumab (3 mg/kg) for treatment of metastatic melanoma. His metastatic lesions had been regressing favorably in response to nivolumab, an immunomodulatory agent that upregulates host immunity. The patient was assessed to have dry eye syndrome for which he was started on preservative-free artificial tears and lubricating ointment at bedtime. For the next two weeks, he continued to experience persistent burning in both eyes and was then referred to a cornea specialist.
On presentation to the Cornea Service, his corrected visual acuity was 20/30 in the right eye and 20/25 in the left. His examination was notable for a low tear meniscus and diffusely distributed punctate epithelial erosions in both eyes. A basic secretion test (Schirmer’s with anesthesia) was performed which yielded values less than 4.0 mm from each eye.