This article was originally published in a sponsored newsletter.

I am positive I have written about this patient before, but his case remains salient today even though it was some time ago. At the time, my patient was a firefighter in his early 30s who had received chemotherapy for testicular cancer. He recovered, but complained of horrible dry eye disease (DED) that was extremely sensitive to smoke. Even though he wore an airtight mask, smoke on his clothes and in the environment while he was at work severely impacted his ability to do his job. I distinctly remember his description: “I have battled some of the worst home fires and have walked into infernos. I can’t believe my eyes are bringing me to my knees.” We started him on topical cyclosporine and a routine of day and night artificial tears and gels.

Back then, limited information was available regarding the impact of chemotherapy on the ocular surface. The exact mechanisms and the prognosis of DED following chemotherapy remain unclear, but case reports and published research can provide some insight. We explore some of the recent literature in this issue.

The tough patients really stick with you. All clinicians have memories of patients we couldn’t “cure,” but today’s treatment options provide additional choices that could make a difference. There are many treatments I would consider with this cancer survivor, firefighter and hero in addition to immunomodulators, such as varenicline, steroids, amnionic membranes or scleral lenses. His meibomian glands would be evaluated, and thermal pulsation or intense pulsed light might be considered, possibly with perfluorohexyloctane (Miebo). Unfortunately, I don’t know what happened to my patient. I hope he is currently being successfully managed with today’s technology by a dry eye specialist and is experiencing the relief he deserves.

Kelly K. Nichols, OD, MPH, PhD
Editor

Managing Patients with Dry Eye Disease from Cancer-Related Treatments

An optometric colleague recently sent a patient to me (Thanks, Josh!) for co-management of ocular surface disease, which was a side effect of tisotumab vedotin-tftv (Tivdak) that she was taking for cancer treatment. According to the package insert and treatment protocols, patients are prescribed prednisolone acetate during the infusion day but need regular monitoring of other ocular surface issues that may arise.

During the examination, we found mild punctate staining in the inferior cornea and a decreased tear prism/ meniscus height. The meibomian glands were clogged, and thickened meibum was easily expressed manually. Overall, this patient had mild ocular surface disease, but with her history of cancer and the treatment she was on, we decided to start her on topical cyclosporine to help with ocular surface immunomodulation, increased tear volume and goblet cell production.

Patients who are undergoing treatment for cancer generally ask many questions regarding their journey. One that’s not necessarily on their radar is, “How will my treatment affect my eyes?” Their primary, secondary and tertiary concerns are often centered around improving survival rates, getting to remission and, in the best of cases, becoming cancer-free with as few side effects from their medications as possible. Like our patients managing other systemic diseases, medications can and will affect the ocular surface.

My staff and I are never shocked when patients question why we ask about medical history and medications, and we continually educate them on the risks to their eyes and vision from their other treatments. In this case, we knew the patient was being referred for an ocular surface evaluation due to her medications, but if you are not asking these questions, your patients won’t know how important disclosing that information can be.

These patients are already going through a difficult time, so we must do our best to manage their signs and symptoms. The OSD workup for patients on cancer treatment looks no different than the process for other patients, although we may be more likely to prescribe a therapy rather than rely on over-the-counter treatments due to their altered immune systems. The conversation between patient and provider should always be open because some patients–even cancer patients–do not want to add another medication to their long list of therapies. Follow-up may be more frequent with systemic medicine changes.

We all are well-trained in how interconnected the eyes are to the whole body. Our patients, however, are not. Being proactive and intentional in screening cancer patients and their medications that can affect the ocular surface further enhances what we do in our exam lanes every day. We should use every opportunity to educate our patients and elevate their experience so they can start to understand how important an eye exam can be, and how ocular surface health can be related to cancer treatments.

The incidence of cancer is expected to increase and become one of the main causes of mortality in the future. However, anti-cancer treatments, new screening protocols and earlier identification of cancer have resulted in an increased overall survival rate over the past few decades.

The development of novel medications that help slow or even reverse the course of the disease is among the main areas of cancer treatment driving improved rates of cancer survival. Despite their success, these novel chemotherapeutic agents also have the potential for ocular side effects like dry eye disease (DED) and blepharoconjunctivitis. The aim of this review was to examine possible ocular surface and adnexal side effects of newly introduced anti-cancer drugs in order to better understand the pharmacological mechanisms underlying the occurrence of these complications and provide useful insights on their correct management.¹

The researchers searched the PubMed medical database using “ocular surface” and “ocular adnexa” as keywords in conjunction with other words that pertained to anti-cancer medications and possible ocular side effects including “blepharoconjunctivitis,” “keratitis,” “blurred vision,” “itchy eye,” “corneal edema,” “conjunctivitis,” “keratoconjunctivitis,” “conjunctival hyperemia” and “ocular pain.”¹

The most common ocular surface adverse effects identified by this search were DED, conjunctivitis, corneal damage, blepharitis and meibomian gland dysfunction (MGD). Blepharitis and MGD appeared to be associated only with a few novel treatments, while DED, conjunctivitis and corneal damage were associated with almost all the newer treatments. Most of the novel anti-cancer drug-associated ocular surface side effects can be managed easily with observation, topical treatments and, at most, a reduction in the anti-cancer drug dosage. Drug discontinuation may be required only in a minority of cases.¹

For example, conjunctivitis usually does not require treatment and observation, given its tendency to resolve quickly without intervention. However, a careful examination to rule out an infectious or allergic cause for the conjunctivitis should be completed.

Keratitis, vortex keratopathy, corneal ulcers and other cases of corneal damage represent the most serious adverse effects of these newer anti-cancer drugs. Patients experiencing these effects may require treatment suspension and, in the worst-case scenario, corneal transplant. Patients treated with drugs more frequently associated with severe corneal adverse events should receive regular examinations to monitor for the onset of any adverse ocular complications. Ocular adnexal side effects, such as blepharitis and MGD, can be managed with ocular lubricants, eyelid scrubs, warm compresses and other topical therapies.¹

To guarantee proper management and to reduce potential ocular surface complications, the researchers concluded that it is important to be aware of the prevalence and the characteristics of the possible ocular adverse events that could occur in patients receiving anti-cancer medications, especially newer drugs.¹

Clinical Pearl from Dr. Lonsberry

Optometrists play a crucial role in the management of patients undergoing anti-cancer drug therapy. Ocular adverse events (OAEs) are a common finding with drug therapy, and the optometrist’s role is to not only diagnose and manage any corneal or refractive changes, but also to report them to co-managing oncologists for potential dose modification. Optometrists may feel conflicted in reporting the severity of OAEs, or OAEs in general, for fear that patients may have their cancer treatment discontinued. However, knowing about the presence and severity of OAEs is crucial for oncologists to potentially modify the dosage of the patient’s anti-cancer treatment to allow them to continue therapy.

1. Vitiello L, Lixi F, Coco G, Giannaccare G. Ocular surface side effects of novel anticancer drugs. Cancers. 2024;16(2):344. doi:10.3390/cancers16020344

Ocular Surface Side Effects of Novel Anticancer Drugs

Livio Vitiello, Filippo Lixi, Giulia Coco and Giuseppe Giannaccare
Cancers. 2024;16:344. doi:10.3390/cancers16020344

Surgery, anticancer drugs (chemotherapy, hormonal medicines, and targeted treatments), and/or radiation are common treatment strategies for neoplastic diseases. Anticancer drugs eliminate malignant cells through the inhibition of specific pathways that contribute to the formation and development of cancer. Given the ability of such pharmacological medications to combat cancerous cells, their role in the management of neoplastic diseases has become essential. However, these drugs may also lead to undesirable systemic and ocular adverse effects due to cyto/neuro-toxicity and inflammatory reactions. Ocular surface side effects are recognized to significantly impact patient’s quality of life and quality of vision.Blepharoconjunctivitis is known to be a common side effect caused by oxaliplatin, cyclophosphamide, cytarabine, and docetaxel, while anastrozole, methotrexate, and 5-fluorouracil can all determine dry eye disease. However, the potential processes involved in the development of these alterations are yet not fully understood, especially for novel drugs currently available for cancer treatment.This review aims at analyzing the potential ocular surface and adnexal side effects of novel anticancer medications, trying to provide a better understanding of the underlying pharmacological processes and useful insights on the choice of proper management.

Cancer is characterized by the uncontrolled growth of abnormal cells in the body. These malignant cells can spread anywhere, making cancer one of the leading causes of death. The number of cases is also expected to rise; projections estimate approximately 23.6 million people worldwide will have cancer by 2030.¹ Despite this high number, survival rates have improved over the last few decades due to enhanced cancer screening protocols which lead to earlier diagnosis along with the development of new medications.

Lung cancer remains the leading cause of cancer-related mortality, accounting for approximately 1.8 million deaths each year.² Breast cancer is also a significant health concern. It is the second most common cancer and the second leading cause of cancer death among women.³ As such, new and more targeted medications are continually being developed in hopes that they will effectively reverse the disease or stop it from progressing. However, these therapies can cause ocular side effects, such as dry eye disease (DED), that become significant issues and cause ocular discomfort, reduced visual acuity and overall poorer quality of life for patients. Therefore, more health care professionals must know which cancer drugs cause these side effects and how they occur.

In lung cancer treatment, novel anti-cancer drugs such as gefitinib and erlotinib specifically target the epidermal growth factor receptor (EGFR). While effective in controlling tumor growth, these medications can disrupt normal tear film stability and ocular surface homeostasis, resulting in dryness and discomfort. They are linked to DED in 20 to 25% of patients on EGFR-targeted therapy. Similarly, immune checkpoint inhibitors have been shown to be beneficial in multiple malignancies, but patients have reported ocular discomfort side effects. Specifically, pembrolizumab (Keytruda, Merck)—used for non-small cell lung cancer—has been associated with dry eye symptoms in approximately 30 to 40% of treated patients.¹ Additionally, hormonal therapies for breast cancer such as tamoxifen and aromatase inhibitors have been shown to induce DED in 10 to 15% of patients. The hormonal fluctuations resulting from these therapies can negatively impact tear production and worsen dry eye symptoms. Antibody-drug conjugates such as trastuzumab deruxtecan (Enhertu, Daiichi-Sankyo and AstraZeneca) used for breast cancer also carry risks of dry eye and corneal alterations.¹

With the prevalence of DED in novel anti-cancer medications, health care providers must be aware of the ocular side effects associated with these treatments to provide closer follow-up to patients experiencing these side effects. Managing DED in cancer patients needs to be done in line with guidelines from the Tear Film Ocular Surface Dry Eye Workshop, which are the current gold standard.

Future research also should focus on identifying predictive factors for DED in cancer patients and developing targeted strategies to prevent these side effects. This approach will enhance the overall quality of care and life for those undergoing cancer treatment.

1. Vitiello L, Lixi F, Coco G, Giannaccare G. Ocular surface side effects of novel anticancer drugs. Cancers. 2024;16(2):344. doi:10.3390/cancers16020344
2. Li C, Lei S, Ding L, et al. Global burden and trends of lung cancer incidence and mortality. Chin Med J (Engl). 2023 Jul;136(13):1583-1590. doi:10.1097/CM9.0000000000002529
3. CDC. Breast cancer statistics. Accessed November 4, 2025. https://www.cdc.gov/breast-cancer/statistics/index.html