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Nursing & Health Sciences Research Journal

Abstract

Case Presentation: We present the case of a 70-year-old male with a history of highgrade urothelial carcinoma who had been treated with multiple cycles of immune checkpoint treatment, pembrolizumab, presenting to the emergency department with worsening bone pain, abdominal discomfort, and hematuria.

Clinical Course: He reported blurry vision and monocular diplopia in the right eye for the past month. Physical examination revealed an inability to fully track with the right eye along with fatigue-induced diplopia, raising concerns for metastatic or immunotherapy-related ocular involvement. Imaging primarily revealed metastatic disease in the right orbital apex involving the rectus muscles, intraconal fat, and optic nerve. A differential diagnosis included metastatic disease, pembrolizumab-induced ocular myositis, and ocular myasthenia gravis. He was diagnosed with a rare presentation of monocular diplopia associated with metastatic urothelial carcinoma and pembrolizumab-induced complications. Radiation Oncology recommended radiation therapy; however, he declined.

Discussion: Early recognition of ocular symptoms in cancer patients is critical for timely intervention and improved care outcomes. This case underscores the complexity of differentiating between metastatic disease and immune-related adverse events (irAEs) in patients on immunotherapy drugs. It highlights the importance of integrating advanced imaging and multidisciplinary consultations to guide diagnosis and management.

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