A Case of Tamoxifen Keratopathy

Raloxifene induced keratopathy: A case report

Purpose

We report a case of corneal verticillata in a patient who had been taking raloxifene for a prolonged period. To our knowledge, this is the first case report of an ocular side effect of raloxifene.

Observations

A 69-year-old female patient presented to our clinic for her routine eye check-up. On slit-lamp examination, whorl-like subepithelial deposits were observed in the bilateral corneas. She was diagnosed with corneal verticillata (vortex keratopathy) caused by raloxifene. A follow-up evaluation was conducted after discontinuation of the drug; however, the corneal opacity did not improve.

Conclusions and importance

Patients with corneal verticillata should be asked regarding any intake of raloxifene for osteoporosis, as it may cause corneal verticillata.

Evaluation of Optic Nerve Head Parameters and Electro-Physiology Among Breast Cancer Patients on Tamoxifen

Introduction

To evaluate if early tamoxifen toxicity can be detected by comparing pre-and post-treatment optic nerve head parameters and visual function using Heidelberg Retinal Tomograph III (HRT III) and Pattern Visual Evoked Potential (Pattern VEP).

Method

This is a prospective study involving 76 eyes of 38 breast cancer patients treated with tamoxifen in Hospital Universiti Sains Malaysia, Kelantan, Malaysia. These patients were examined by a single doctor and the investigations were done by a single technician. The visual acuity, optic nerve function, visual field, optic nerve head parameters on HRT III and Pattern VEP were assessed. The examination was performed before and three months after treatment initiation.

Results

There was no tamoxifen ocular toxicity found three months post-treatment with tamoxifen. There was no change in visual acuity and optic nerve function post-treatment initiation. There were no statistically significant changes found in optic nerve head parameters on HRT III and P 100 peak latency and amplitude on Pattern VEP.

Conclusion

Ocular toxicity is a recognized complication of tamoxifen treatment. Tamoxifen optic neuropathy is a potentially irreversible, visually disabling complication. Tamoxifen ocular toxicity was not found three months after tamoxifen treatment initiation among estrogen receptor (ER)-positive breast cancer patients. No early changes in optic nerve head parameters and P 100 peak latency and amplitude changes were found after three months of treatment. A longer duration of monitoring with HRT III and Pattern VEP may be needed to adequately observe for early, subclinical changes in optic nerve head parameters and visual function among tamoxifen users.

Corneal endothelial cell density in patients receiving chemotherapy

PURPOSE

This study aimed to determine if the corneal endothelium was affected by chemotherapy.

METHODS

Chemotherapy patients were recruited to undergo specular microscopy before treatment and again at 1- and 2-year follow-up visits. One eye per patient, per follow-up, was selected for comparison to baseline.

RESULTS

Forty-six volunteers completed baseline and at least one follow-up assessment. From 51 eyes, there was no significant change in endothelial cell density for 41 eyes assessed at one year (M_D = 0.73%, 95% CI -1.33 to 2.78%) and 18 eyes at two years (M_D = 0.31%, 95% CI -3.53 to 4.15%).

CONCLUSION

Although other studies have shown that chemotherapy can adversely affect the corneal epithelium, this study showed no measurable change in endothelial cell density.

Ocular Toxicity of Targeted Anticancer Agents

The proliferation of targeted anticancer agents over the last two decades has revolutionized cancer treatment and improved survival in many previously refractory malignancies. However, many agents are associated with characteristic ophthalmic adverse effects. It is important that ophthalmologists recognize and maintain a high index of suspicion for these side effects in patients on targeted therapy. Most ophthalmic adverse effects can be treated with specific ocular therapy without discontinuation of cancer treatment, although it is important to be aware of the life-threatening and vision-threatening circumstances that would require therapy cessation in conjunction with the patient's oncologist. This review aims to summarize the ophthalmic adverse effects of targeted and hormonal anticancer agents and briefly describe their management.

The impact of anticancer drugs on the ocular surface

Cancer is a global health problem and is one of the leading causes of death worldwide. Pleasingly, the rate of survival has improved and continues in an upward trend mainly due to better diagnosis and treatment modalities. In particular, the development of anticancer drugs including cytotoxic chemotherapy, hormonal agents and targeted therapies have provided the most effective treatment options in combatting cancerous cells. However, the antineoplastic mechanisms of these drugs can also lead to undesirable systemic and ocular side effects resulting from cytotoxicity, inflammation and neurotoxicity. While survival rates are projected to increase with time, the number of patients presenting with these side effects that can substantially impact quality of life will also rise. The current paper reviews the ocular surface and adnexal side effects of anticancer drugs, the appropriate management and possible interactions between drugs for ocular surface pathology treatment and the anticancer drugs.

Refractory Tamoxifen-Induced Keratopathy Despite Drug Withdrawal

PURPOSE

To report a case with refractory tamoxifen-induced keratopathy despite drug withdrawal.

METHODS

Case report.

RESULTS

A 50-year-old woman, diagnosed with bilateral breast cancer underwent mastectomy in 2005. She was treated with tamoxifen citrate from 2005 to 2012. According to her medical history, no corneal abnormalities had been documented during past ophthalmological examinations except low myopia, before initiation of tamoxifen treatment. In 2009, 4 years after start of treatment, she was diagnosed with subepithelium deposits compatible with drug-induced keratopathy. The patient was examined again in 2016, 4 years after withdrawal of the drug with persistent tamoxifen-induced keratopathy.

CONCLUSIONS

Contrary to current literature, it seems that tamoxifen-induced corneal abnormalities may persist for years after drug withdrawal.

Tamoxifen retinopathy: a case report

Purpose

To present a case of tamoxifen retinopathy on a 57-year-old woman.

Design

An observational case.

Methods

A review of history, clinical examination, and findings on Spectral-domain Optical Coherence Tomography (SD-OCT), fluorescein angiogram (FA) and electro-oculogram (EOG) was conducted.

Results

A 57-year old female patient, who had been treated with oral tamoxifen after mastectomy due to breast cancer, had profound visual impairment in both eyes. Disruption of the ellipsoid zone and interdigitation zone which represent photoreceptor damage as well as macular thinning was revealed on SD-OCT in both eyes. Bilateral retinal pigmented epithelium (RPE) function compromised was indicated by reduced Arden ratio in EOG.

Conclusion

Tamoxifen-induced retinopathy could be detected by SD-OCT and EOG. As it is irreversible, patients who are given tamoxifen need regular ophthalmic consultation, including SD-OCT and EOG before and during the treatment in order to early detect and avoid further retinal damage.

Di-22:6-bis(monoacylglycerol)phosphate: A clinical biomarker of drug-induced phospholipidosis for drug development and safety assessment

The inability to routinely monitor drug-induced phospholipidosis (DIPL) presents a challenge in pharmaceutical drug development and in the clinic. Several nonclinical studies have shown di-docosahexaenoyl (22:6) bis(monoacylglycerol) phosphate (di-22:6-BMP) to be a reliable biomarker of tissue DIPL that can be monitored in the plasma/serum and urine. The aim of this study was to show the relevance of di-22:6-BMP as a DIPL biomarker for drug development and safety assessment in humans. DIPL shares many similarities with the inherited lysosomal storage disorder Niemann-Pick type C (NPC) disease. DIPL and NPC result in similar changes in lysosomal function and cholesterol status that lead to the accumulation of multi-lamellar bodies (myeloid bodies) in cells and tissues. To validate di-22:6-BMP as a biomarker of DIPL for clinical studies, NPC patients and healthy donors were classified by receiver operator curve analysis based on urinary di-22:6-BMP concentrations. By showing 96.7-specificity and 100-sensitivity to identify NPC disease, di-22:6-BMP can be used to assess DIPL in human studies. The mean concentration of di-22:6-BMP in the urine of NPC patients was 51.4-fold (p ≤ 0.05) above the healthy baseline range. Additionally, baseline levels of di-22:6-BMP were assessed in healthy non-medicated laboratory animals (rats, mice, dogs, and monkeys) and human subjects to define normal reference ranges for nonclinical/clinical studies. The baseline ranges of di-22:6-BMP in the plasma, serum, and urine of humans and laboratory animals were species dependent. The results of this study support the role of di-22:6-BMP as a biomarker of DIPL for pharmaceutical drug development and health care settings.

Macular oedema due to letrozole: a first case report

A 72-year-old woman presented with unexplained, progressive, painless visual loss in the right eye during the past six months. At presentation visual acuity (VA) was 3/60 in the right eye and 6/6 in the left eye. Anterior segment examination and intraocular pressures were normal. Dilated fundoscopy revealed significant macular oedema in the right eye and a normal fundus appearance in the left eye. Her medical history was noteworthy for breast ductal carcinoma in situ, for which she had undergone right mastectomy three years earlier. She had not received chemotherapy or radiotherapy but she had been under treatment with letrozole 2.5 mg/day over the past three years. She did not receive any other medication. Optical coherence tomography showed intraretinal fluid and a significant increase in retinal thickness in the foveal and parafoveal areas, while fluorescein angiography detected foveal hyperfluorescence and leakage of the dye in the late phase. Multifocal electroretinogram showed a decreased response in both eyes. In suspicion of letrozole-related retinopathy, the patient was advised to stop the medication. The patient agreed to receive an intravitreal injection of 0.05 ml/0.5 mg ranibizumab. One month later, VA in the right eye was 6/9 and macular oedema had apparently improved. This is the first reported case of letrozole-associated macular oedema treated with intravitreal ranibizumab.

Peripheral retinopathy and maculopathy in high-dose tamoxifen therapy

PURPOSE

To describe the clinical, angiographic, and optical coherence tomography (OCT) features of high-dose tamoxifen retinopathy in three male patients.

DESIGN

Observational case series.

METHODS

A review of history, clinical examination, and findings on fluorescein angiography (FA) and optical coherence tomography (OCT) was conducted.

RESULTS

Three male patients receiving high-dose tamoxifen therapy sought treatment for vision loss and a crystalline maculopathy. Crystalline deposits were noted in the peripheral retina of two patients. All the patients showed macular leakage by FA, but cystoid macular edema (CME) on OCT was detected in two patients. Inner retinal hyperreflective deposits were identified by OCT in all the patients.

CONCLUSIONS

High-dose tamoxifen therapy may result in peripheral crystalline retinopathy in addition to perifoveal opacities. Angiographic evidence of macular edema may not unanimously correlate with presence of CME on OCT in these cases.