PMC9396260_01
PET-CT scan of the patient at baseline and an outlined timeline of his treatment and adverse events. (A, B) Representative images of PET-CT scan of the patient at baseline on 5 May 2021. (C) The schematic timeline for the patient, from diagnosis to resolution of optic neuropathy (not to scale).
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The positron emission tomography-computed tomography (PET-CT) scan showed that irregular soft tissue masses (approximately 8.7 x 6.0 x 7.7 cm) in the dorsal segment of the left upper lobe and lower lobe of the left lung are lobulated, growing across the interlobular fissures, local bronchial occlusion, and abnormally increased standard uptake value (SUV) activity, which is consistent with lung cancer manifestations ( Figures 1A, B ). Ophthalmology ( Figure 1C ). On ophthalmic examination, the best corrected visual acuity (BCVA) was 20/300 in his right eye and finger count (eye front) in his left eye. Magnetic resonance imaging (MRI) of the brain with gadolinium enhancement was negative for metastatic lesions, recent infarcts, or enhancement in the optic nerve ( Figure S1 ) on 31 July 2021.
The ophthalmic examination of the patients with bilateral optic neuropathy after three cycles of sintilimab-containing therapy (A) Fundus photography displayed obvious optic disc edema in both eyes with macular edema in his right eye and parapapillary linear hemorrhage in his left eye after the third cycle of sintilimab plus chemotherapy on 12 August 2021. OD, oculus dexter; OS, oculus sinister. (B) Measurements of the thickness of retinal nerve fiber layer (RNFL) by optical coherence tomography (OCT) on 5 August 2021. (C) Macular OCT showed subretinal fluid in the right eye on 5 August 2021. (D) Visual evoked potential (VEP) was measured on 6 August 2021 and showed prolonged P100 latency and decreased P100 amplitude at 60 and 15 arcmin in both eyes. (E) Fundus fluorescein angiography (FFA) indicated optic disc fluorescence leakage at the late stage and low fluorescence perfusion at the early stage in both eyes on 12 August 2021.
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Fundus photography showed obvious optic disc edema in both eyes, accompanied by macular edema in his right eye and parapapillary linear hemorrhage in his left eye ( Figure 2A ). By optical coherence tomography (OCT), the average retinal nerve fiber layer (RNFL) thickness was 153 mum and 275 mum in right and left eye, respectively ( Figure 2B ). Also, subretinal fluid was noticed in the macular region of the right eye ( Figure 2C ). Visual evoked potential (VEP) showed prolonged P100 latency and decreased P100 amplitude at 60 and 15 arcmin in both eyes ( Figure 2D ). Fundus fluorescein angiography (FFA) showed optic disc fluorescence leakage at the late stage and low fluorescence perfusion at the early stage in both eyes, which suggested anterior ischemic optic neuropathy ( Figure 2E ).
The ophthalmic examination of the patients post steroids against sintilimab-induced optic neuropathy and representative CT images in the follow-up (A) Fundus photography post steroids against optic neuropathy secondary to sintilimab therapy on 28 September 2021. (B) OCT examination of the optic disc post steroids against sintilimab-induced optic neuropathy on 28 September 2021. (C) Representative CT images and (D) the estimated tumor volume during the treatment of the case in the follow-up from 1 May 2021, to 3 December 2021. The horizontal axis represents changes in tumor volume. The vertical axis depicted the time of CT scan and the estimated tumor longitudinal diameter (X) and the greatest transverse diameter (Y) in the axial plane and the maximum thickness in head-to-foot direction (Z). The tumor volume was calculated by using the formula (X*Y*Z)/2.
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Fundus photography showed a slightly pale optic disc with a clear boundary ( Figure 3A ). OCT suggested that the thickness of RNFL in both eyes became thinner than the normal range, exactly 65 mum in his right eye and 74 mum in his left eye ( Figure 3B ). The CT imaging post-sintilimab plus chemotherapy demonstrated a marked reduction of tumor size, consistent with a partial response (PR) to treatment ( Figures 3C, D ).