Madeline Arzbecker, MD; Ryan D. Larochelle, MD; Cat N. Burkat, MD; Elaine M. Downie, MD; Jackson Korger, MD; Mihai Mititelu, MD, MPH; Suzanne W. van Landingham, MD
WMJ. 2026;125(4):542-546. Published November 1, 2026.
ABSTRACT
Introduction: Bisphosphonates are known to cause acute systemic inflammation through stimulation of proinflammatory cytokines. This reaction can include conjunctivitis, anterior uveitis, episcleritis, scleritis, and, rarely, orbital inflammation. We present 2 cases of zoledronate-associated orbital inflammation and a literature review highlighting treatment challenges.
Case Presentation: The first case was managed with intravenous (IV) methylprednisolone, 1 mg/kg, followed by a short steroid taper. Symptoms recurred after completion of the taper. The second case presented with optic perineuritis and preseptal and postseptal inflammation. Initial treatment with IV methylprednisolone, 1 mg/kg, resulted in incomplete response, necessitating escalation to high-dose corticosteroid therapy.
Discussion: A literature review identified 19 additional cases of zoledronate-associated orbital inflammation. There was no clear consensus regarding treatment and only 1 reported case of relapse was identified.
Conclusions: We recommend initial treatment with IV methylprednisolone, 1 mg/kg, followed by a prolonged taper. If symptoms do not improve within the first day of treatment or if the optic nerve sheath is involved, escalation to IV methylprednisolone, 1 g daily, may be warranted.