Punctal-canalicular stenosis related to systemic fluorouracil therapy

Effect of Topical 5-Fluorouracil on Lacrimal Drainage System: Histopathological Evidence From Animal Experiments and Potential Clinical Implications

PURPOSE

The purpose of this study is to investigate the histopathological changes in the lacrimal drainage system of rabbits following the application of 1% topical 5-fluorouracil (5-FU) for 4 weeks.

METHODS

Ten eyes of 10 healthy New Zealand white rabbits were subjected to topical instillation of 1% (10 mg/mL) 5-FU, 1 drop 4 times a day for 4 weeks. Rabbits underwent a detailed ocular examination including eyelids, ocular surface, punctal, peri-punctal changes, and nasolacrimal duct patency at baseline and after 4 weeks of 5-FU. The rabbits were then sacrificed, and the eyelid, conjunctiva, lacrimal gland, and the entire lacrimal drainage system were retrieved for histopathological analysis as per standard protocols.

RESULTS

Clinically demonstrable peripunctal changes and canalicular stenosis were noted in 6 (60%, 6/10) rabbits. Two of these (20%, 2/10) had additional complete regurgitation of clear fluid, indicating a nasolacrimal duct obstruction. The remaining 4 (40%, 4/10) clinically did not demonstrate lacrimal drainage changes and were patent on irrigation. The conjunctiva showed focal loss of goblet cells in several areas. Significant changes were noted in the canalicular, lacrimal sac, and the nasolacrimal duct tissues in the form of epithelial hyperplasia, subepithelial inflammation, edema, dilated and congested vessels, and fibrosis. The lacrimal gland, eyelid tissue (excluding tarsal conjunctiva), and cornea showed no significant histopathological changes.

CONCLUSIONS

Clinical and histopathological changes were noted in the lacrimal drainage system of rabbits subjected to topical 5-FU application. These findings can have potential clinical implications for patients receiving 5-FU therapy.

The Management of Ocular Surface Squamous Neoplasia (OSSN)

The rise of primary topical monotherapy with chemotherapeutic drugs and immunomodulatory agents represents an increasing recognition of the medical management of ocular surface squamous neoplasia (OSSN), which may replace surgery as the standard of care in the future. Currently, there is no consensus regarding the best way to manage OSSN with no existing guidelines to date. This paper seeks to evaluate evidence surrounding available treatment modalities and proposes an approach to management. The approach will guide ophthalmologists in selecting the most appropriate treatment regime based on patient and disease factors to minimize treatment related morbidity and improve OSSN control. Further work can be done to validate this algorithm and to develop formal guidelines to direct the management of OSSN.

Clinical features and treatment outcomes of patients with tearing after chemotherapy

PURPOSE

To evaluate the clinical features and treatment outcomes of patients complaining of tearing after receiving chemotherapy.

METHODS

The clinical records of patients who complained of tearing between August 2014 and February 2016, and underwent or were undergoing chemotherapy were retrospectively reviewed. Clinical measurements were as follows: LipiView^® interferometer (lipid layer thickness and meibography), lacrimal drainage examinations (syringing), and outcomes at 6 months after treatment.

RESULTS

This study included 34 eyes of 17 patients with a mean age of 62.4 ± 14.82 years. The mean follow-up period was 9.6 months. On syringing, 10 eyes (29.4%) showed total regurgitation, 19 eyes (55.9%) showed partial regurgitation, and 5 eyes (14.7%) showed no regurgitation. On LipiView^®, mean lipid layer thickness was 34.5 nm (range, 20-89 nm). Mean meiboscore was 2.15 ± 0.86 in upper eyelid and 2.53 ± 0.79 in lower eyelid. Patients were treated with silicon tube intubation (STI) (10 eyes, 29.4%), dacryocystorhinostomy (DCR) (4 eyes, 17.6%), conjunctivodacryocystorhinostomy (CDCR) (8 eyes, 11.8%), DCR combined with CDCR (1 eyes, 8.8%), and conservative care (11 eyes, 32.4%). Mean time interval from onset of tearing to first clinic visit was 1.4 months in the conservative care group, 2.9 months in the STI and DCR groups, and 6.0 months in the CDCR group.

CONCLUSION

Because of the high incidence of accompanying meibomian gland loss in cases of lacrimal drainage system (LDS) obstruction, reflex tearing by mebibomian gland dysfunction should also be considered for proper management of tearing. Early recognition and management of LDS stenosis could result in patients undergoing surgery with a lower burden.

How to minimize pterygium recurrence rates: clinical perspectives

The main treatment for pterygium is surgical removal. However, pterygium surgery is concerned with high rates of postoperative recurrence. Predicting factors of recurrence are not fully understood, yet, but they probably depend on a multitude of patient-related, clinical, and/or surgical factors. Several adjuvant treatments have been proposed to reduce postoperative pterygium recurrence, including different antimetabolites, antiangiogenetic factors, and radiation therapy. The purpose of this review is to collect the current evidence regarding application and limits of different therapeutic approaches for preventing postoperative recurrence of pterygium, giving insights and perspectives for better management of this disease. In the light of the current evidence, pterygium surgery cannot disregard wound coverage with conjunctival autografting or rotational flap combined with adjuvant treatments. The rotational flap technique is associated with shorter surgical time rates and prevents graft displacement and necrosis, given its vascular pedicle. Amniotic membrane may still be reserved in case of great conjunctival defects or insufficient conjunctiva. Repeated subconjunctival antivascular endothelial growth factor injections can be considered as an effective and safe adjuvant treatment. Moreover, management of postoperative pain is crucial. Innovative treatment strategies will probably target different molecular pathways, considering recent findings regarding pterygium pathogenesis, to improve better understanding and develop universally shared guidelines. Great importance shall be dedicated to the identification of novel molecular biomarkers and favoring factors of recurrence, in order to achieve a customized surgical treatment for each patient and obtain maximal reduction of postoperative recurrence.

Classification of Lacrimal Punctal Stenosis and Its Related Histopathological Feature in Patients with Epiphora

Purpose

To evaluate the classification of punctal stenosis based on the shape of the external punctum, clinical characteristics and histopathologic features.

Methods

Patients who experienced tearing and were diagnosed with punctal stenosis were evaluated in this study. Punctal stenosis was classified according to the shape of the lower external punctum, which included membranous type, slit type, horseshoe type, and pinpoint type. Tear meniscus height, 2% fluorescein dye disappearance test and lacrimal pathway irrigation were measured or performed. For treatment, a punctal snip operation and silicone tube placement were performed, and the peripunctal histopathological findings were evaluated.

Results

Punctal stenosis was classified into four types: membranous type (17 eyes, 21.5%), slit type (11 eyes, 13.9%), horseshoe type (25 eyes, 31.6%), and pinpoint type (26 eyes, 32.9%). The tear meniscus was significantly higher, and the 2% fluorescein dye disappeared significantly more slowly in the punctal stenosis group. However, correlation of the tear meniscus height and 2% fluorescein dye disappearance test with the punctum shape was not statistically significant. A history of previous chemotherapy was significantly associated with the occurrence of punctal stenosis, especially the membranous type (p < 0.05). Histopathologic evaluation of the punctum showed differences between the punctum types. Pinpoint puncta exhibited a high density of muscle fibers, while they were faintly visible in the membranous type.

Conclusions

Acquired punctal stenosis has various shapes, and the major types of stenotic puncta exhibited unique histopathologic features. Punctal stenosis and its pathophysiology may be related to multiple factors, such as age and systemic 5-fluorouracil chemotherapy history.

Diagnosis and Medical Management of Ocular Surface Squamous Neoplasia

INTRODUCTION

Topical chemotherapy has gained popularity among clinicians for the treatment of ocular surface squamous neoplasia (OSSN). The principal topical chemotherapy agents used in the management of OSSN are interferon-α2b, 5-fluorouracil, and mitomycin C. High-resolution optical coherence tomography (HR-OCT) is a non-invasive technique that can differentiate OSSN from other ocular surface lesions.

AREAS COVERED

This review highlights the current regimens and diagnostic modalities used in managing OSSN. A review of the literature was performed using the keywords "conjunctival intraepithelial neoplasia", "ocular surface squamous neoplasia", "optical coherence tomography", "interferon-α2b", "5-fluorouracil" and "mitomycin C".

EXPERT COMMENTARY

Topical chemotherapy for OSSN can be used as primary therapy, for chemoreduction prior to surgical excision, and postoperatively to prevent tumor recurrence. It has the advantage of treating microscopic disease as well as large tumors. HR-OCT provides an "optical biopsy" that can assist in diagnosis and guide management of OSSN lesions.

Outcomes of dacryocystorhinostomy in patients with head and neck cancer treated with high-dose radiation therapy

PURPOSE

To evaluate the outcomes of dacryocystorhinostomy (DCR) in patients with head and neck cancer treated with high-dose radiation therapy.

METHODS

The clinical records of 43 consecutive patients with head and neck cancer who underwent DCR after high-dose external beam radiation therapy plus ablative surgery and/or chemotherapy between December 2001 and April 2011 were retrospectively reviewed.

RESULTS

There were 23 men and 20 women. The median age was 56 years (range, 2-92 years). Thirty-one patients were Caucasian, 6 Hispanic, 4 Asian, and 2 African American. Thirty patients (70%) presented with epiphora, 3 (7%) with dacryocystitis, and 10 (23%) with both epiphora and dacryocystitis. Symptoms were unilateral in 34 patients (79%) and bilateral in 9 patients (21%). The most common primary cancer diagnoses were squamous cell carcinoma (n = 14), sarcoma (n = 8), adenoid cystic carcinoma (n = 4), and basal cell carcinoma (n = 4). The most common primary tumor locations were the sinonasal cavity (n = 16), maxillary sinus (n = 9), palate (n = 3), and ethmoid sinus (n = 3). Thirty-seven patients (43 eyes) had DCR with silicone tube placement, and 6 patients (7 eyes) had DCR with Pyrex glass tube placement. Following DCR, 31 patients (72%) had resolution of their symptoms, and 12 patients (28%), 9 with silicone tubes and 3 with Pyrex glass tubes, had persistent or recurrent epiphora (DCR failure). The most common reason for failure was significant residual canalicular and nasal mucosal scar tissue. Eight of these 12 patients underwent additional surgery, most commonly with placement of a Pyrex glass tube. Seven (35%) of the 20 patients who underwent DCR less than 12 months after radiation therapy and 5 (21%) of the 23 patients who underwent DCR at least 12 months after radiation therapy had recurrent symptoms.

CONCLUSIONS

Dacryocystorhinostomy in patients with head and neck cancer previously treated with high-dose radiation therapy is generally successful, especially when delayed until at least 12 months after the completion of radiation therapy. A common reason for DCR failure after high-dose radiation therapy is severe canalicular and nasal mucosal scarring.

Punctal stenosis: definition, diagnosis, and treatment

Acquired punctal stenosis is a condition in which the external opening of the lacrimal canaliculus is narrowed or occluded. This condition is a rare cause of symptomatic epiphora, but its incidence may be higher in patients with chronic blepharitis, in those treated with various topical medications, including antihypertensive agents, and especially in patients treated with taxanes for cancer. The purpose of this review is to cover the medical literature, focusing in particular on definition, incidence, risk factors, etiology and treatment options.

Dacryoendoscopic observation and incidence of canalicular obstruction/stenosis associated with S-1, an oral anticancer drug

PURPOSE

To report dacryoendoscopic observations and the incidence of lacrimal obstruction/stenosis associated with S-1, an oral anticancer drug.

DESIGN

Retrospective, nonrandomized clinical trial.

METHODS

A total of 52 patients (41 men, 11 women; age 42-93 years) who were prescribed the anticancer drug S-1 were studied. Patients who suffered eye complaints following S-1 treatment underwent ophthalmic examination, probing and lacrimal irrigation. Patients whose tear meniscus was high or had abnormal lacrimal irrigation were evaluated by dacryoendoscopy.

RESULTS

Overall, 5 of 52 S-1-treated patients (9.6%) experienced lacrimal passage stenosis/obstruction. One patient had punctal stenosis, and four patients had canalicular obstruction/stenosis. The onset of epiphora ranged from 2 to 8 months (4.4 ± 2.2 months, mean ± SD) after the initiation of chemotherapy.

CONCLUSIONS

Patients receiving S-1 treatment should be evaluated for potential lacrimal disorders, particularly canalicular obstruction/stenosis. Dacryoendoscopic observation is effective for the diagnosis of this side effect.

Ocular presentations of breast cancer

CONTEXT

Breast cancer is the most common malignancy in women, with increasing incidence in Europe and North America. The frequency of involvement of the eye and visual pathways is reported to be as high as 30% in patients with known metastatic disease. In some cases, ophthalmic involvement can be the first sign of metastatic spread. Metastasis occurs via the haematogenous route and predominantly involves the choroid. Metastases to other ocular structures, the orbit and the visual pathways have also been described. Paraneoplastic effects are rare but significant.

TREATMENTS

Different modalities are employed in the treatment of breast cancer and its metastases. These include chemotherapy and radiotherapy. The ocular adverse effects of these have been well described, but recently developed new treatment modalities, such as monoclonal antibodies, may have different side-effects. With the increasing incidence of breast cancer and the advent of new treatment strategies, the complications of the disease and the sequelae of therapy are highly relevant to both oncologists and ophthalmologists.

Epiphora as a side effect of topical mitomycin C

AIM

To report symptoms and findings of lacrimal duct malfunction after topical mitomycin C (MMC) for conjunctival neoplasia.

METHODS

14 consecutive patients treated with 1-6 cycles of topical 0.04% MMC four times daily for periods of 2 weeks were interviewed about symptoms of lacrimal duct malfunction. Patients who complained of tearing had examination of the puncta and canaliculi including probing and lacrimal duct irrigation.

RESULTS

Nine patients complained of epiphora after topical MMC. Three of these patients had normal puncta and canaliculi, patent to irrigation. In these patients epiphora ceased spontaneously after probing and irrigation. The additional six patients had stenosis of the punctum (n = 3), the common canaliculus (n = 1), both puncta and both canaliculi (n = 1) and complete occlusion of the lower canaliculus (n = 1).

CONCLUSION

Obstruction of the puncta or canaliculi is not an infrequent event after topical 0.04% MMC.

Punctal-canalicular stenosis associated with mitomycin-C for corneal epithelial dysplasia

PURPOSE

To report a case of punctal-canalicular stenosis after topical mitomycin C use for corneal dysplasia. To the authors' knowledge, this association has not previously been described.

DESIGN

Observational case report.

METHOD

A 62-year-old woman was noted to have a right inferotemporal corneal dysplastic lesion. She received a topical course of mitomycin-C 0.04% four times a day, which subsequently invoked a toxoallergic reaction. One month later, the patient developed right-sided epiphora.

RESULTS

Probing demonstrated complete stenosis of the right lower canaliculus, 5 mm from the punctum.

CONCLUSION

Mitomycin-C use may lead to lacrimal apparatus fibrosis and symptomatic epiphora when inciting a toxoallergic reaction.

Ocular surface, ocular adnexal, and lacrimal complications associated with the use of systemic 5-fluorouracil

PURPOSE

To determine the prevalence rates and associated characteristics of patients who have ocular surface, ocular adnexal, and lacrimal complications associated with the systemic use of the cancer chemotherapeutic agent 5-Fluorouracil (5-FU).

METHODS

An exposure-based cohort study was designed. Adult patients who had completed at least 3 months of systemic 5-FU therapy within the past 5 years were eligible for enrollment. Study subjects had a detailed medical history taken with emphasis on preexisting conditions known to be associated with the development of ocular surface, ocular adnexal, and lacrimal complications. An ocular examination was then performed. A complete nasolacrimal system evaluation was performed if symptoms or findings were identified. The prevalence was then determined for each ocular symptom and each ocular finding identified that was not present pretreatment. An exploratory analysis was then performed to identify patient characteristics that might influence the likelihood of developing any of the above complications.

RESULTS

Fifty-two patients were enrolled in the study. The prevalence rates of the following ocular abnormalities were calculated: ocular irritation, 5.8%; blepharitis, 3.8%; conjunctivitis, 3.8%; keratitis, 3.8%; eyelid dermatitis, 5.8%; cicatricial ectropion, 1.9%; tearing, 26.9%; punctal-canalicular stenosis, 5.8%; and blurred vision, 11.5%. Blacks had tearing at a significantly higher rate when compared with whites (P = 0.022, 2-sided Fisher exact test). Three patients had permanent complications that will require surgery for correction. Of the 7 patients who had a single abnormality, 6 had tearing and one had eyelid dermatitis. All of the 8 patients who had multiple findings had tearing as one of their abnormalities.

CONCLUSIONS

Ninety-three percent of the patients who had an ocular abnormality had tearing as one of the complications. Patients who are receiving systemic 5-FU and begin to tear should have an ocular examination, looking for ocular surface, ocular adnexal, and lacrimal complications.

Squamous metaplasia of the canaliculi associated with 5-fluorouracil: a clinicopathologic case report

OBJECTIVE

To illustrate a newly recognized histopathologic change in a patient with canalicular obstruction after weekly administration of 5-fluorouracil for colon cancer.

DESIGN

Interventional case report.

METHODS

A full-thickness section of canaliculus was obtained during surgical repair.

MAIN OUTCOME MEASURE

Histopathologic changes in the specimen.

RESULTS

The prominent histologic feature of the canalicular specimen was severe squamous metaplasia with narrowing of the lumen.

CONCLUSION

Canalicular obstruction may follow systemic use of 5-fluorouracil due to squamous metaplasia.

Lacrimal duct stenosis and other ocular toxicity associated with adjuvant cyclophosphamide, methotrexate and 5-fluorouracil combination chemotherapy for early stage breast cancer

Certain side-effects of chemotherapy are well recognized but ocular toxicity is often underestimated. This retrospective study was undertaken after we became aware of a case of irreversible lacrimal duct stenosis in a woman receiving adjuvant chemotherapy for early stage breast cancer. Using the chemotherapy records, 128 patients who received adjuvant cyclophosphamide, methotrexate and 5-fluorouracil combination chemotherapy for early stage breast cancer over a 2 1/2-year period were identified. The case notes of these patients were reviewed and an 18% incidence of ocular side-effects, including four other cases of epiphora, was identified. The epiphora resolved fully on completion of chemotherapy in these four patients but not in the index patient. The optimal management of these side-effects is unclear but it needs to be tailored to the particular toxicity experienced by the patient.

Endoscopic conjunctivodacryocystorhinostomy with Jones tube placement

OBJECTIVE

Conjunctivodacryocystorhinostomy (CDCR) with Jones tube placement as described by Jones has traditionally been performed as an "open" or external procedure by means of medial canthal incision. Application of endoscopic technique for CDCR with Jones tube placement has not been well described in the peer-reviewed literature.

DESIGN

Retrospective nonrandomized comparative trial.

PARTICIPANTS

Ten patients with epiphora secondary to canalicular stenosis.

METHODS

A total of 13 consecutive CDCR with Jones tube procedures were reviewed. Five procedures (performed predominantly in the early study period) were done by means of a traditional external approach with a medial canthal incision. Eight procedures were performed with an intranasal endoscopic approach and instrumentation with Jones tube placement under direct endoscopic visualization.

MAIN OUTCOME MEASURES

Total operative time, estimated blood lost, intraoperative, and postoperative complications and need for secondary surgery were evaluated.

RESULTS

All procedures were successfully completed with no intraoperative complications. Average operative time was 59 minutes in the endoscopic group and 74 minutes in the external group. Average blood loss was 3.5 ml and 4.4 ml in the endoscopic and external groups, respectively. Postoperative adjustment of tube size or position (performed as an office procedure with topical/local anesthesia) was common: five of eight endoscopic and three of five external approach. Two patients in the endoscopic group required secondary surgery for anatomic reasons. Ultimately, all cases in both groups demonstrated patent, retained Jones tubes and relief of epiphora.

CONCLUSION

Endoscopic technique appears to be a reasonable approach for CDCR with Jones tube placement. Operative time and blood loss were comparable in the two groups, with the endoscopic group being slightly lower for each variable. Endoscopic Jones tube placement can be accomplished with readily available instrumentation. In this series, we did not find it necessary to use laser, radiofrequency, or monopolar devices for intranasal hemostasis.

Sclerosing canaliculitis after 5-fluorouracil breast cancer chemotherapy

BACKGROUND

5-Fluorouracil is a pyrimidine analogue that inhibits DNA synthesis and is commonly used in the treatment of carcinomas of the breast, gastrointestinal tract and genitourinary tract. Excessive tearing that resolves on cessation of treatment is commonly described as a side effect of the drug. Permanent stenosis of the punctum and canaliculus is extremely rare, with only 12 cases reported in the world literature. We present three cases of established lacrimal outflow obstruction in patients who were treated with CMF (cyclophosphamide, methotrexate, 5-fluorouracil), a widely used regimen for metastatic breast cancer. Patient 1 had right distal stenosis of her lower canaliculus and was syringed patent during dacryocystography with resolution of epiphora. Patient 2 had proximal blockage of all canaliculi and underwent bilateral canaliculodacryocystorhinostomy with silicone tubes that temporarily relieved symptoms until tube removal. The proximal canalicular blockage recurred due to underlying extensive fibrosis. Patient 3 had right proximal common canalicular stenosis and left distal canalicular blocks but declined surgery.

CONCLUSION

With the rise in the incidence of breast carcinoma it is important that the attention of both ophthalmologists and oncologists should be drawn to the potential ocular toxicity of systemic 5-fluorouracil chemotherapy, which may lead to lacrimal canalicular fibrosis with permanent epiphora. The management of these patients is challenging as there is a continuous spectrum of canalicular involvement from focal to diffuse; therefore early referral is recommended. Moreover as no consensus has been reached as how best to manage this unique small group of patients, we review the literature and discuss the implications for treatment.

Lacrimal canalicular obstruction associated with topical ocular medication

PURPOSE

To describe the association between the use of various types of topical ocular medications and acquired lacrimal canalicular obstruction in 14 patients.

METHODS

The records of all patients in the author's practice with either lacrimal canalicular or punctal occlusion associated with the use of topical ocular medication were reviewed.

RESULTS

Fourteen cases were identified. The obstructions occurred at any point from the punctum to the common canaliculus, but most commonly occurred 2-5 mm from the lacrimal punctum. There was an association with various degrees of clinically apparent subconjunctival scarring maximal at the inner canthus, rarely to a severe degree, with symblepharon, medial canthal keratinization and cicatricial medial entropion. In some cases, no subconjunctival scarring could be clinically detected. Topical medications used were often multiple and included prednisolone acetate/phenylephrine hydrochloride (n = 5), timolol maleate (n = 5), pilocarpine (n = 3), dipivefrine hydrochloride or adrenaline (n = 3), chloramphenicol (n = 3), tobramycin (n = 3), indomethacin (n = 2), ecothiopate iodide (n = 1), betaxolol (n = 1), dexamethasone (n = 1), tropicamide (n = 1) and the long-term use of naphazoline and various artificial tear preparations (n = 1). The duration of exposure ranged from 3 weeks to 20 years, with seven patients having used drops for 3-6 weeks. Seven patients had surgical repair, three by dacryocystorhinostomy (DCR) and glass by-pass tube (all successful), three by canalicular repairs (one failed) and one by DCR and canalicular repair that restenosed at the puncta, who then had successful punctoplasty and silicone intubation.

CONCLUSIONS

Lacrimal canalicular obstruction may occur after relatively short-term exposure to topical ocular medications or as part of a more widespread cicatricial reaction in patients on long-term medication. While a direct causal relationship cannot be confirmed, there appears to be a strong association and the site of the obstructions makes other causes unlikely.

Punctal and canalicular stenosis associated with systemic fluorouracil therapy. Report of five cases and review of the literature

Ocular side effects of systemic fluorouracil include excessive lacrimation, due to punctal and canalicular stenosis and fibrosis. Obstruction of the tear ducts after systemic therapy with fluorouracil is more frequent than is assumed. Five patients with breast cancer and punctal or canalicular stenosis are presented. Although complaints of epiphora usually resolve two weeks after cessation of systemic therapy, local antibiotics and steroids may be indicated. In patients with persisting complaints, and patients treated with fluorouracil for a prolonged period of time, prophylactic intubation of the tear ducts with silastic tubes has been advocated. (Conjunctivo)dacryocystorhinostomy may be unavoidable.

Cyclophosphamide, methotrexate, and 5-fluorouracil (CMF)-induced ocular toxicity

Ocular toxicity is a common, but poorly understood, sequela from CMF chemotherapy. We investigated this toxicity in patients receiving CMF therapy. Detailed interviews in 210 patients revealed that new, unpleasant ocular symptoms developed in 42% of patients receiving CMF, in 39% of subjects receiving other regimens containing 5-fluorouracil (5-FU), and only in 18% of subjects receiving a variety of chemotherapy regimens not containing 5-FU. CMF-associated ocular symptoms usually consisted of mild to marked tearing, ocular pruritus, and/or burning. These toxicities usually began 11-17 days after starting a cycle of CMF and lasted for 10-15 days. 5-FU was detected in the tears of 12 tested patients within several minutes after intravenous 5-FU (peak concentrations as high as 60 micrograms/ml). 5-FU tear concentrations did not correlate with the presence or absence of ocular toxicity. There is no established antidote for this toxicity although some patients have reported subjective benefit from cryotherapy, applied around the period of 5-FU injections, or cromolyn sodium eye drops.

Ocular complications of systemic cancer chemotherapy

Cancer chemotherapy has changed rapidly in recent years. New agents are constantly being developed. Established agents are being used with increased frequency, in new combinations, at higher dosages, and via new routes of administration. Enhanced survival, as well as increased drug toxicity, has resulted. Ocular toxicity is not uncommon and can greatly impact on quality of life. Practitioners in all fields are increasingly caring for patients who are receiving cancer chemotherapy. The recognition of eye disease resulting from chemotherapy is essential to appropriate patient management. We provide a review of the rapidly growing body of literature on the ocular toxicity of systemic cancer chemotherapy with particular attention to context, clinical course, mechanism, prevention and treatment.

Glaucoma filtering surgery with 5-fluorouracil

A life-table analysis of surgical outcomes was performed on the first eye of 155 patients who were enrolled in a pilot study of glaucoma filtering surgery with postoperative subconjunctival 5-fluorouracil (5-FU) injections. The success rates at 1-, 2-, and 3-year intervals were 68, 63, and 63%, respectively, for 88 patients with non-neovascular glaucoma in aphakia; 82, 75, and 75% for 39 patients with non-neovascular glaucoma after unsuccessful filtering surgery; and 68% at each yearly interval for 28 patients with neovascular glaucoma. Complications which resulted from filtering surgery and the 5-FU injections included corneal epithelial defects (55.5%), conjunctival wound leaks (36.8%), suprachoroidal hemorrhage (5.8%), rhegmatogenous retinal detachment (2.6%), endophthalmitis and phthisis (1.9% each), and corneal scarring, late bleb leak, malignant glaucoma, and traction retinal detachment (1.3% each). A Cox Model regression analysis failed to demonstrate a correlation between surgical success and age, race, type of filtering procedure, or total dose of 5-FU received. Postoperative subconjunctival 5-FU may increase the operative success rate for selected patients with a high risk for failure after glaucoma filtering surgery.

Topical application of 5-fluorouracil in premalignant lesions of cornea, conjunctiva and eyelid

Local application of 5-Fluorouracil was practised on 5 patients. In 3 patients with multiple premalignant oculo-cutaneous lesions, two of whom had also premalignant epibulbar lesions, local 5% 5-Fu cream and/or 1% 5-Fu eyedrops were applied. In 2 other patients who had only premalignant lesions on the cornea and conjunctiva, 1% 5-Fu eyedrops were used only. In animal experiments 1% 5-Fu was not found to cause any damage to normal corneal and conjunctival epithelium. The frequency of the applications and the duration of the treatment were dependent on the location and extent of the lesions. Except for easily treatable lesions, caused by the separation of the tumour epithelium, no complications of local 5-Fu treatment were seen. The visual acuity improved in all 4 patients in whom the cornea was affected. In these premalignant conditions the diagnosis and assessment of the therapy were based on exfoliative cytology and biopsies.

5-Fluorouracil and glaucoma filtering surgery. III. Intermediate follow-up of a pilot study

Ninety-five patients (104 eyes) were enrolled in a pilot study of subconjunctival 5-fluorouracil (5-FU) injections after filtering surgery in eyes with poor surgical prognoses. At least a six-month follow-up was available on 84 patients, of whom four were excluded from the analysis of surgical outcome because they suffered retinal detachments within six months of their filtering surgery. The initial 5-FU procedures on the remaining 80 patients were successful (no further glaucoma surgical procedures were either performed or recommended, and the intraocular pressures [IOPs] were either 21 mmHg or lower with ocular hypotensive medication[s] or 25 mmHg or lower without ocular hypotensive medication) in 33 (68%) of the 48 aphakic eyes with non-neovascular glaucomas, 13 (81%) of the 16 phakic eyes with non-neovascular glaucomas after unsuccessful filtering surgery, and 12 (75%) of the 16 eyes with neovascular glaucoma (NVG). The follow-up on the successful eyes ranged from 6 to 34 months (mean +/- SD = 18.5 +/- 7.5). The visual acuities remained within one line of their preoperative levels or improved in 38 (79%) of the 48 aphakic eyes with non-neovascular glaucoma, 11 (69%) of the 16 phakic eyes with non-neovascular glaucoma after unsuccessful filtering surgery, and 12 (75%) of the 16 eyes with NVG. The initial 5-FU procedures on the 104 eyes were complicated by the following: corneal epithelial defects (50%); conjunctival wound and suture tract leaks (36%; 2% underwent surgical repair); suprachoroidal hemorrhages (9%); retinal detachments (3%); subepithelial corneal scarring (3%); endophthalmitis (2%); and malignant glaucoma (1%). It is the authors' impression that postoperative subconjunctival 5-FU increases the likelihood of achieving IOP control after filtering surgery in eyes with poor surgical prognoses; however, a randomized clinical trial is necessary to confirm this impression.

Surgical treatment of punctal-canalicular fibrosis from 5-fluorouracil therapy

5-Fluorouracil (5-FU) has been reported to cause punctal-canalicular fibrosis with resultant severe epiphora. It is reported that the epiphora will often resolve when treatment ceases or is decreased. However, this report describes a case of punctal-canalicular fibrosis so severe that bilateral conjunctivodacryocystorhinostomies were necessary. This has not been previously reported to the best of the authors' knowledge. It is recommended that ophthalmic consultation be obtained for patients in whom long-term 5-FU therapy is anticipated or who develop tearing while on therapy.

5-fluorouracil and glaucoma filtering surgery. II. A pilot study

5-Fluorouracil (5-FU) was injected subconjunctivally after glaucoma filtering surgery in a pilot study of eyes with poor surgical prognoses. Twenty-seven (79%) of the 34 aphakic eyes with glaucoma achieved an intraocular pressure (IOP) of less than or equal to 21 mmHg (range of follow-up on nonreoperated eyes, 91 -468 days). Nine (69%) of 13 eyes with neovascular glaucoma achieved an IOP of less than or equal to 21 mmHg (range of follow-up on nonreoperated eyes, 120-379 days). Eight (89%) of nine phakic eyes with glaucoma following unsuccessful filtering procedures achieved an IOP of less than or equal to 21 mmHg (range of follow-up on nonreoperated eyes, 134-394 days). Visual acuities remained within one line of their preoperative levels or improved in 32 (94%) of the 34 aphakic eyes with glaucoma, eight (62%) of the 13 eyes with neovascular glaucoma, and six (67%) of the nine phakic eyes with glaucoma following unsuccessful filtering procedures. Postoperative corneal epithelial defects occurred in 45% of the cases. Conjunctival wound and conjunctival needle tract leaks were observed in 41% of the cases, but only one eye required wound revision. No other serious side effects that we attributed to 5-FU were observed. It seems that postoperative subconjunctival 5-FU increases the likelihood of achieving IOP control following filtering surgery in eyes with poor surgical prognoses; however, a randomized clinical trial is necessary to confirm this.

5-fluorouracil: new applications in complicated retinal detachment for an established antimetabolite

Long-term reattachment of the retina following the development of proliferative vitreoretinopathy is often prevented by the occurrence of cellular reproliferation. 5-fluorouracil, a synthetic pyrimidine analog, is a potent inhibitor of fibroblast proliferation in cell culture and an animal model of tractional retinal detachment. Doses of up to 1.0 mg, when administered intravitreally to rabbits, result in no demonstrable retinal toxicity by microscopic and electrophysiologic criteria. The first 22 consecutive patients with advanced forms of proliferative vitreoretinopathy were treated with a combination of periocular and intraocular 5-fluorouracil, in addition to scleral buckling and vitrectomy. Retinal reattachment was achieved in 60% of patients at 6 months postoperatively. No serious systemic or ocular complications were observed although delayed healing of corneal epithelial defects occurred in 18% of cases and subtle subepithelial scarring in 31.8%. In combination with standard vitrectomy techniques, post-operative fluid gas exchange, and photocoagulation, periocular and subconjunctival 5-fluorouracil appears to improve the prognosis for longterm retinal reattachment following the development of proliferative vitreoretinopathy.

Fluorouracil for the treatment of massive periretinal proliferation

A single intravitreal injection of fluorouracil was effective in the treatment of an experimental model of massive periretinal proliferation. When given with an intravitreal injection of 250,000 heterologous fibroblasts, fluorouracil decreased the rate of tractional retinal detachment from 36.8% in controls (seven of 19 eyes) to 5.2% in treated animals (one of 19 eyes) at one week, and from 73.6% in controls (14 of 19 eyes) to 31.5% in treated animals (six of 19 eyes) after four weeks (P less than .05). Intraocular neovascularization was reduced from 52.6% in controls (ten of 19 eyes) to 5.2% in treated animals (one of 19 eyes) after one week and 36.8% in controls (seven of 19 eyes) to 5.2% in treated animals (one of 19 eyes) after four weeks. When supplemented by repeated 10-mg subconjunctival injections of fluorouracil, or in combination with intravitreally administered indomethacin, this effect appeared to be enhanced. Intravitreal and subconjunctival injections of fluorouracil were well tolerated and may prove to be of significant value in the treatment of human disease.