A 75-year-old Japanese male ex-smoker underwent four different video-assisted thoracoscopic surgeries for EGFR-mutated NSCLC and a pancreaticoduodenectomy for metastatic pancreatic tumor in 2006. In September 2014, he was diagnosed with metastatic thyroid tumor and received afatinib therapy in November 2014. Afatinib was the only chemotherapy administered to the patient. Two weeks after the initiation of an oral 40-mg afatinib dose, the patient developed bilateral conjunctival injection without discharge and was referred to ophthalmologists. The best-corrected visual acuity (BCVA) measurements showed there was a decimal visual acuity of 0.9 in the right eye and 1.0 in the left eye. Slit-lamp examination revealed there was bulbar conjunctival injection and incipient senile cataract in both eyes. During these examinations, there were no clinical signs that suggested the presence of uveitis. The conjunctivitis resolved shortly after the instillation of bromfenac 0.1% eye drops twice a day and a 1-week afatinib washout period.
On the 3rd day after the patient resumed taking afatinib, he developed blurred vision in his right eye and once again visited his ophthalmologists. BCVA had decreased to a decimal acuity of 0.2 in his right eye, while it remained at 1.0 in his left eye. Slit-lamp examination revealed keratic precipitates, cells (1+) in the anterior chamber, two small Koeppe nodules on the nasal iris, posterior synechiae and mild vitreous haze in the right eye (fig. 1a). There was no inflammation observed in the left eye. Fundus examination revealed no remarkable findings, including metastatic choroidal tumor. Intraocular pressure elevation, dendritic or pseudo-dendritic corneal epithelial lesion, iris atrophy, or histories of recurrent HSV infection or skin eruption were absent. The results of a serologic test including full blood counts, liver enzymes, kidney function, electrolytes, fasting plasma glucose and hemoglobin A1C revealed only mild anemia. Serologic tests for syphilis were negative. A chest X-ray and CT scan showed no hilar or mediastinal lymphadenopathy, and no signs of tuberculosis. Human leukocyte antigen (HLA) typing revealed that the patient was HLA-B27 negative. Since the unexplained uveitis that developed after the administration of afatinib was similar to that which has been observed for erlotinib, we considered the possibility of afatinib-induced uveitis. Based on these findings, we stopped the general afatinib treatment and then restarted topical betamethasone 0.1% four times per day and mydriatics once per day. After the inflammation gradually subsided, the topical betamethasone 0.1% was then tapered to twice per day and the mydriatics were discontinued. Although oral afatinib at a dose of 30 mg was resumed after a 3-week washout period, the anterior uveitis in the right eye did not recur. The BCVA finally recovered to a decimal acuity of 1.0 after 6 months. However, the posterior synechiae remained (fig. 1b). There were no other structural complications observed.