Management of Worsening Vision in Patients Receiving Imfinzi (Durvalumab)
Any patient on Imfinzi who develops worsening vision requires urgent ophthalmology referral within 24 hours, and Imfinzi should be held until ophthalmologic evaluation is completed. 1
Immediate Actions Required
- Hold Imfinzi immediately until ophthalmologic assessment is completed, as recommended for all immune checkpoint inhibitor-related ocular toxicities 1
- Arrange urgent ophthalmology referral (within 24 hours if visual acuity is compromised to <20/40, or within 1 month for any visual changes) 1, 2
- Document specific visual symptoms including blurred vision, color vision changes, photophobia, scotomas, visual field defects, double vision, eye pain, or redness 1
Critical Red Flags Requiring Same-Day Ophthalmology Evaluation
The following symptoms indicate potentially vision-threatening complications and require immediate specialist assessment 1, 2:
- Visual acuity worse than 20/40 1
- Ocular pain (beyond mild irritation) 1, 2
- Photophobia (light sensitivity) 1, 2
- Visible corneal opacity or damage 1
Expected Ophthalmologic Workup
The ophthalmologist should perform 1, 2:
- Slit-lamp examination to assess for uveitis, iritis, episcleritis, or keratitis 1, 2
- Visual acuity testing as baseline measurement 1, 2
- Intraocular pressure measurement 2
- Dilated fundus examination to evaluate posterior segment involvement 1, 2
Grading and Treatment Strategy
Mild Ocular Toxicity (Grade 1-2)
- Topical corticosteroids are first-line treatment for most immune-related ocular toxicities 1
- Cycloplegic agents may be added for uveitis management 1
- Artificial tears for symptomatic relief 1
- Imfinzi can often be continued if symptoms are mild and manageable with topical therapy 1
Severe Ocular Toxicity (Grade 3-4)
- Systemic corticosteroids may be required for severe inflammation 1
- Consider infliximab for treatment-refractory cases, though evidence is limited to case reports 1
- Permanent discontinuation of Imfinzi is recommended if vision deteriorates to 20/200 or worse (Grade 4) or with recurrent severe events 1
Epidemiology and Context
Ocular adverse events with PD-1/PD-L1 inhibitors like durvalumab occur in approximately 3.3-7.4% of patients, with median onset at 6-11 weeks after treatment initiation 3. Most events are Grade 1-2 (mild to moderate) and manageable without treatment discontinuation 3. However, vision-threatening complications including uveitis, chorioretinitis, papillitis, and serous retinal detachment have been reported 4, 5, 6.
Common Pitfalls to Avoid
- Do not dismiss mild visual symptoms as they may not correlate with severity of underlying inflammation; slit-lamp examination is essential even for seemingly minor complaints 1
- Do not delay ophthalmology referral while attempting empiric treatment, as conditions like panuveitis can progress to exudative retinal detachment and blindness 1
- Do not assume unilateral symptoms are drug-related; unilateral presentations should follow standard ophthalmology pathways for other etiologies 7
- Do not restart Imfinzi without ophthalmology clearance after a severe ocular event, as rechallenge can cause rapid symptom recurrence 5
Prognosis and Follow-up
Most immune-related ocular toxicities improve with appropriate treatment 1, 3. In one analysis, 34% of patients experienced complete resolution and 30% had at least partial improvement of ocular adverse events 3. However, only 64% of patients received appropriate ophthalmologic evaluation in real-world practice, highlighting the need for systematic referral protocols 3.