The mystery of angiographically silent macular oedema due to taxanes

Ocular adverse events of perioperative adjuvant docetaxel vs paclitaxel for breast cancer: propensity-score overlap-weighted analysis

BACKGROUND

Taxanes are known to be associated with several ocular adverse events; however, large-scale data comparing the risk of ocular adverse events between the two commonly used taxanes, docetaxel (DTX) and paclitaxel (PTX), remain limited. Therefore, we aimed to compare the risks of epiphora, cystoid macular edema, and optic neuropathy between DTX- and PTX-based chemotherapy regimens.

METHODS

Using a nationwide claims database in Japan, we identified 6038 patients who initiated neoadjuvant or adjuvant taxane-based chemotherapy for breast cancer between April 2014 and November 2022. Data analysis was conducted in 2024. This study was conducted across multiple referral centers and community hospitals in Japan, providing a comprehensive view of taxane-based chemotherapy practices in diverse healthcare settings. Participants included 6038 patients diagnosed with breast cancer who initiated neoadjuvant or adjuvant taxane-based chemotherapy. Eligibility criteria included female patients aged 18 years or older. Participants were selected from a nationwide claims database using a consecutive sampling method. Patients who received DTX-based chemotherapy (DTX group) were compared with those who received PTX-based chemotherapy (PTX group). After adjusting for potential confounders using a propensity score-overlap weighting method, we estimated the incidence of the three ocular adverse events and hazard ratios (HRs) using Cox proportional hazards regression models.

RESULTS

Among the 6038 eligible patients, 3829 were in the DTX group and 2209 in the PTX group. The adjusted HR for epiphora in the DTX group was 1.69 [95% confidence interval (CI), 1.17 to 2.45] compared with the PTX group. For cystoid macular edema and optic neuropathy, the adjusted HRs were 0.74 (95% CI, 0.52 to 1.04) and 0.72 (0.47 to 1.11), respectively. The composite incidence of epiphora, cystoid macular edema, and optic neuropathy did not differ significantly between the DTX and PTX groups.

CONCLUSION

Among patients receiving taxane-based chemotherapy for breast cancer, DTX was associated with a higher risk of epiphora compared with PTX. However, the incidence rates of cystoid macular edema and optic neuropathy did not differ significantly between the two groups. These findings offer valuable insights into the ocular adverse event profile of taxane-based chemotherapy in patients with breast cancer.

Efficacy of topical carbonic anhydrase inhibitors in treating taxane drug-induced cystoid macular edema: A case report

RATIONALE

Taxanes, derived from Taxus chinesnsis, stabilize microtubules and include drugs like Paclitaxel, Docetaxel, and Nab-paclitaxel. These are commonly used to treat various malignant tumors. However, Taxane-drug-induced cystoid macular edema (TDICME) is a rare and often under-recognized complication.

PATIENT CONCERNS

A male patient, aged sixty-three, who was diagnosed with poorly differentiated gastric adenocarcinoma, experienced a progressive decline in visual acuity in both eyes after a 4-month course of nab-paclitaxel therapy.

DIAGNOSES

Upon Fundus examination, bilateral cystoid macular edema (CME) was seen.

INTERVENTIONS

Undergo treatment with carbonic anhydrase inhibitors and discontinue the use of nab-paclitaxel.

OUTCOMES

After eleven days of treatment with carbonic anhydrase inhibitors, the patient reported significant improvement in visual acuity. Furthermore, CME was completely resolved in both eyes 8 weeks after stopping nab-paclitaxel.

LESSONS

This case highlights the potential therapeutic effectiveness of topical carbonic anhydrase inhibitors in treating TDICME. Our findings underscore the importance of monitoring and addressing ocular side effects in patients undergoing Taxane therapy, ultimately contributing to enhanced patient quality of life and treatment outcomes.

Unraveling the Mystery of Taxol-Induced Cystoid Macular Oedema: Case Report and Literature Review

Objectives

The primary aim of this article is to present cystoid macular oedema as one of the side effects of Paclitaxel (Taxol) chemotherapy. Paclitaxel is used as a treatment option in patients with different types of solid carcinomas. The potential loss of vision, already altered by the disease, further compromises their quality of life, a contributing factor to overall psychological and mental decline.

Case presentation

A 69-year-old woman developed a drop in visual acuity that was painless, bilateral, and accompanied by wavy lines. This occurred six months after starting Paclitaxel chemotherapy for metastatic breast cancer. The diagnosis of cystoid macular oedema caused by Paclitaxel was made. The visual acuity significantly improved after Paclitaxel was discontinued, and the symptoms subsided.

Discussion

Paclitaxel is a chemotherapy drug used to treat various types of cancers and has been associated with cystoid macular oedema (CMO) in rare cases. CMO is thought to result from the disruption of the normal blood-retinal barrier. The specific mechanism remains incompletely understood, and multiple mechanisms have been postulated. In typical CMO, leakage from parafoveal capillaries is demonstrated on fluorescein angiograms in a classic petaloid pattern. However, in Taxane-Drug Induced CMO (TDICMO), there is no evidence of fluorescein leakage on angiography. TDICMO is a rare drug side effect of breast cancer treatment, described just 14 times in the English literature.

Conclusion

It is crucial to reiterate that if a patient undergoing Paclitaxel treatment experiences any vision changes, it is imperative to consult an ophthalmologist for a thorough evaluation and appropriate management. This step is essential for the patient's well-being and to ensure the best possible outcome.

Ixabepilone related angiographically silent macular edema

INTRODUCTION

We present a single-eyed case with a previous diagnosis of breast cancer who had intraretinal cystoid changes associated with the systemic administration of ixabepilone in her only seeing eye. To our best knowledge, this is the first reported case describing this phenomenon related to the ixabepilone administration.

CASE DESCRIPTION

A 54-year-old woman with a history of breast cancer was examined due to visual deterioration in her only good left eye. The patient had undergone cataract surgery and lens implantation in her right eye following a childhood accident, but subsequently had developed a refractory glaucoma and lost her right vision. Six cycles of 40 mg/m2 systemic ixabepilone (3-hly intravenous infusion once every 3 weeks) had been administered within the past six months. Her visual decline started two weeks following the last treatment session. She was offered intravitreal anti-vascular endothelial growth factor injection elsewhere. Fluorescein angiogram showed no dye leakage whereas spectral-domain optical coherence tomography demonstrated parafoveal intraretinal cystoid changes. En-face optical coherence tomography revealed petaloid type roundish hyporeflective areas at the level of superficial and deep vascular plexus. Ixabepilone-associated cystoid maculopathy was suspected as she received only ixabepilone for the chemotherapy in the last six months. We thus recommended her not to continue ixabepilone therapy. Ten weeks after the ixabepilone cessation, intraretinal cystoid changes had resolved completely.

CONCLUSION

Angiographically silent intraretinal cystoid changes may develop in association with the use of ixabepilone. Referral to an ophthalmologist should be considered for the patients experiencing visual complaints as ixabepilone cessation may lead to visual improvement and avoid unnecessary treatment.

Retinal phototoxicity after macular hole surgery in a patient under paclitaxel

BACKGROUND

The purpose is to report the second case, to our knowledge, of suspected paclitaxel-induced phototoxic maculopathy following pars plana vitrectomy surgery.

CASE PRESENTATION

63-year-old phakic female who underwent an uneventful phaco-vitrectomy to treat a complete macular hole, developing macular phototoxicity in the post-operatively period that could not be explained by the surgery itself and could only be attributed to a possible photosensitization induced by the previous use of paclitaxel.

CONCLUSIONS

The use of paclitaxel has been widely extended as a chemotherapy drug to treat breast cancer. It works by altering the intracellular microtubular reorganization and, based on this mechanism of action, photosensitivity has been previously described. We report a case of suspected paclitaxel-induced macular phototoxicity following ocular endoillumination during vitrectomy surgery.

Evaluation of Retinal Nerve Fiber Layer and Macular Thickness Pre- and Post-Chemotherapy With Carboplatin and Paclitaxel in Patients With Endometrial and Ovarian Cancer

Background Carboplatin and paclitaxel are two standard chemotherapeutic agents known to cause neurotoxicity. In this study, we aim to evaluate the toxicity of these agents by measuring the peripapillary retinal nerve fiber layer (RNFL) and macular thickness in patients with endometrial and ovarian cancers who are receiving them. Methods A one-year prospective cohort study involving 28 patients who were treated intravenously with carboplatin (200-400 mg/m2) and paclitaxel (175 mg/m2) three-weekly for six cycles was conducted. RNFL and macula thickness were measured using optical coherence tomography (OCT) before the commencement of chemotherapy, after the third cycle, and one month after the sixth cycle. The main outcome measurements were the average RNFL thickness and central subfield thickness of the macula. Results The mean age of the 28 participants was 54.68 years old (standard deviation [SD] 9.03). Eleven had endometrial cancer, while 17 had ovarian cancer. The mean of the average RNFL thickness during baseline pre-chemotherapy was 96.43 µm (SD 11.39). One month after cessation of treatment, the mean RNFL thickness increased to 101.57 µm (SD 13.54). Statistical analysis showed a significant increment in the mean RNFL thickness (p ≤ 0.001), from baseline to after three cycles, and baseline to one month after six cycles of chemotherapy, except the nasal quadrant. The increment of all macular quadrants was statistically significant (p < 0.05) except for central subfield thickness. Conclusion Systemic administration of carboplatin and paclitaxel affected both the peripapillary RNFL and macula thickness. This represents early evidence of subacute subclinical retinal toxicity. OCT can be used as a screening tool to assess peri-chemotherapeutic retinal alterations.

Data mining for signal detection of adverse events for taxanes based on the food and drug administration adverse drug events reporting system database

BACKGROUND

This study aimed to mine and compare the positive signals of adverse drug events (ADE) in paclitaxel, docetaxel, and nab-paclitaxel to evaluate the accuracy of current drug package information inserts and enable clinicians to select the appropriate treatment.

RESEARCH DESIGN AND METHODS

ADE data reported from January 2006 to December 2020 were extracted from the Food and Drug Adverse Drug Events Reporting System (FAERS) database, and the reporting odds ratio (ROR) was used to detect the risk signals of the 3 taxanes. The definition relied on system organ class (SOCs) and preferred terms (PTs) by the Medical Dictionary for Regulatory Activities (MedDRA).

RESULTS

A total of 39,163 case reports on paclitaxel, docetaxel and nab-paclitaxel involving 25 different system organ classes (SOCs) were retrieved from the database. The ADE paclitaxel and nab-paclitaxel reports mainly focused on 'general disorders and administration site conditions' and the docetaxel ADE reports focused on 'skin and subcutaneous tissue diseases.' Among the three taxanes, nab-paclitaxel had the highest positive signal for serious adverse events.

CONCLUSIONS

Overall, the most common ADE signals and ADE mapping systems obtained in this study were consistent with the package inserts. However, some inconsistencies were noted. Further research is recommended to confirm some of the strong risk signals for ADEs for taxanes before updating the drug package information inserts.

Cystoid macular oedema without leakage in fluorescein angiography: a literature review

Cystoid macular oedema (CMO), which is defined as a macular thickening and cystic changes due to accumulation of fluid, could be asymptomatic and only diagnosed using paraclinical techniques. Fluorescein angiography (FA) and optical coherence tomography (OCT) are useful in detecting CMO in clinical practice. Non-leaking CMO, also known as angiographically silent CMO, is referred to as cases of CMO without leakage in fluorescein angiography. This type of CMO has been reported in some retinal dystrophies, in cases of maculopathy as a side effect of certain drugs, and also in some systemic disorders. The exact mechanism and treatment options for this type of CMO are still not clear. This literature review aims to discuss different causes of non-leaking CMO, proposed mechanisms, and management options. Three sections including drugs, retinal dystrophies, and systemic disorders are discussed in this review.

Taxane-Induced Neuropathy and Its Ocular Effects-A Longitudinal Follow-up Study in Breast Cancer Patients

A common severe neurotoxic side effect of breast cancer (BC) therapy is chemotherapy-induced peripheral neuropathy (CIPN) and intervention is highly needed for the detection, prevention, and treatment of CIPN at an early stage. As the eye is susceptible to neurotoxic stimuli, the present study aims to determine whether CIPN signs in paclitaxel-treated BC patients correlate with ocular changes by applying advanced non-invasive biophotonic in vivo imaging. Patients (n = 14, 10 controls) underwent monitoring sessions after diagnosis, during, and after therapy (T0-T3). Monitoring sessions included general anamnesis, assessment of their quality of life, neurological scores, ophthalmological status, macular optical coherence tomography (OCT), and imaging of their subbasal nerve plexus (SNP) by large-area confocal laser-scanning microscopy (CLSM). At T0, no significant differences were detected between patients and controls. During treatment, patients' scores significantly changed while the greatest differences were found between T0 and T3. None of the patients developed severe CIPN but retinal thickenings could be detected. CLSM revealed large SNP mosaics with identical areas while corneal nerves remained stable. The study represents the first longitudinal study combining oncological examinations with advanced biophotonic imaging techniques, demonstrating a powerful tool for the objective assessment of the severity of neurotoxic events with ocular structures acting as potential biomarkers.

Bilateral intermediate uveitis following treatment with paclitaxel in a patient with invasive ductal carcinoma of the breast

BACKGROUND

To report a case of bilateral intermediate uveitis without cystoid macular edema secondary to paclitaxel therapy, and its successful management with oral corticosteroids.

CASE PRESENTATION

A 66-year-old female developed bilateral intermediate uveitis with reduced best corrected visual acuity to 20/40 right and 20/200 left, following 12 cycles of paclitaxel therapy for breast carcinoma. Optical coherence tomography demonstrated no cystoid macular edema in either eye, and fundus fluorescein angiography showed localized retinal vascular leakage. Resolution of uveitis and improvement of visual acuity followed treatment with oral prednisolone for two months. Fourteen months after presentation, right and left visual acuities had returned to 20/32 and 20/40, respectively, and there was no recurrence of the uveitis.

CONCLUSIONS

This is the first reported case of bilateral intermediate uveitis in a patient treated with paclitaxel. Drug-induced uveitis should be considered in patients with visual symptoms in the setting of taxane chemotherapy, and oral corticosteroids are a safe and effective treatment.

Non-vasogenic cystoid maculopathies

Besides cystoid macular edema due to a blood-retinal barrier breakdown, another type of macular cystoid spaces referred to as non-vasogenic cystoid maculopathies (NVCM) may be detected on optical coherence tomography but not on fluorescein angiography. Various causes may disrupt retinal cell cohesion or impair retinal pigment epithelium (RPE) and Müller cell functions in the maintenance of retinal dehydration, resulting in cystoid spaces formation. Tractional causes include vitreomacular traction, epiretinal membranes and myopic foveoschisis. Surgical treatment does not always allow cystoid space resorption. In inherited retinal dystrophies, cystoid spaces may be part of the disease as in X-linked retinoschisis or enhanced S-cone syndrome, or occur occasionally as in bestrophinopathies, retinitis pigmentosa and allied diseases, congenital microphthalmia, choroideremia, gyrate atrophy and Bietti crystalline dystrophy. In macular telangiectasia type 2, cystoid spaces and cavitations do not depend on the fluid leakage from telangiectasia. Various causes affecting RPE function may result in NVCM such as chronic central serous chorioretinopathy and paraneoplastic syndromes. Non-exudative age macular degeneration may also be complicated by intraretinal cystoid spaces in the absence of fluorescein leakage. In these diseases, cystoid spaces occur in a context of retinal cell loss. Various causes of optic atrophy, including open-angle glaucoma, result in microcystoid spaces in the inner nuclear layer due to a retrograde transsynaptic degeneration. Lastly, drug toxicity may also induce cystoid maculopathy. Identifying NVCM on multimodal imaging, including fluorescein angiography if needed, allows guiding the diagnosis of the causative disease and choosing adequate treatment when available.

[Effects of systemic drugs on the development of drug-induced retinopathy]

This article reviews information on possible adverse events occurring in the organ of vision - in particular, the retina - after using systemic drugs, discusses the drugs that lead to drug-induced retinopathy most often, and describes histomorphological changes and modern understanding of the pathogenesis of damage to retinal structures.

Paclitaxel may be a risk factor for retinal phototoxicity

PURPOSE

To report the first case, to our knowledge, of suspected paclitaxel induced phototoxic maculopathy following vitrectomy surgery.

OBSERVATIONS

A 62-year-old phakic female receiving paclitaxel therapy for ovarian carcinoma presented with a best corrected visual acuity (BCVA) of 20/40 OD with an epiretinal membrane (ERM) and lamellar macular hole on spectral domain optical coherence tomography (SD-OCT). The patient underwent an uneventful pars plana vitrectomy with ERM peel using standard illumination and vitrectomy settings. Membrane Blue Dual (DORC, Netherlands) was used to stain the ERM. Two weeks post-operatively, the patient presented with a reduced BCVA of 20/200 in the operated eye. Fluorescein and indocyanine green angiography revealed right sided patchy hypofluorescence and hyperfluorescence secondary to retinal pigment epithelium changes with intact choroidal and retinal vasculature. SD-OCT and fundoscopy showed right sided loss of ellipsoid layer, increased reflectivity within the retinal pigmented epithelium and subretinal fibrosis without cystoid macular edema. Four months post-operatively her vision had stabilized to 20/160; unfortunately, the patient was palliated a month later due to ovarian carcinoma progression.

CONCLUSIONS

A number of drugs are known to increase photosensitivity to solar and artificial forms of radiation. Paclitaxel use has been widely reported to cause dermatological photosensitivity. We report a case of suspected paclitaxel induced phototoxic maculopathy following endoillumination during vitrectomy surgery.

Nepafenac for cystoid macular oedema secondary to paclitaxel

Paclitaxel is used to treat a wide range of malignant tumours. This type of drug is known to cause ocular adverse effects, with cystoid macular oedema being a known, but rare complication, of this therapy. Although most cases resolve after discontinuation of the drug, several authors have attempted various treatments to accelerate resolution, or when paclitaxel therapy cannot be discontinued. A case is presented of a 62 year-old man who presented with decreased visual acuity due to bilateral cystoid macular oedema after administration of paclitaxel for oesophageal cancer. As part of the study, optical coherence tomography angiography (OCTA) was performed at the time of diagnosis, and later when the symptoms subsided. Nepafenac eye drops were prescribed as treatment.

Regression of taxane-related cystoid macular edema after topical dorzolamide treatment: two case reports

Background

Cystoid macular edema is a rare, vision-threatening side effect of the taxane family of anticancer agents. There is no established treatment or standard treatment protocol for taxane-related cystoid macular edema. Here, we report two cases of taxane-related cystoid macular edema that were treated with topical dorzolamide.

Case presentation

In case 1, a 72-year-old Japanese woman with bilateral geographic choroiditis reported for a follow-up visit with a complaint of blurred vision in both eyes for 2 months after starting nanoparticle albumin-bound paclitaxel chemotherapy for multiple metastases of her breast cancer. Her best-corrected visual acuity had dropped from 1.2 to 0.9 in the right eye and from 1.0 to 0.4 in the left eye. Fundus examination showed no newly active geographic choroiditis lesion, but optical coherence tomography exhibited cystoid macular edema. We suspected taxane-related cystoid macular edema and terminated nanoparticle albumin-bound paclitaxel, and started topical dorzolamide treatment. Cystoid macular edema nearly resolved within 6 weeks in the right eye and within 10 weeks in the left eye after starting topical dorzolamide treatment. The resolution of cystoid macular edema without leaving a chorioretinal scar after discontinuation of paclitaxel confirmed our initial diagnosis of taxane-related cystoid macular edema. A few inconspicuous cystoid spaces persisted at the parafovea for a year after dorzolamide treatment ended, but regressed after restarting dorzolamide treatment without any side effects. Best-corrected visual acuity improved to 1.2 in the right eye and 1.0 in the left eye. In case 2, a 70-year-old Japanese man, who received nanoparticle albumin-bound paclitaxel for pancreatic cancer with multiple metastases, developed bilateral cystoid macular edema. Best-corrected visual acuity was 0.3 bilaterally. Cystoid macular edema resolved within 5 weeks after stopping nanoparticle albumin-bound paclitaxel and starting topical dorzolamide treatment confirming the diagnosis of taxane-related cystoid macular edema. Nine weeks later, best-corrected visual acuity improved to 0.8 in the right eye and 1.0 in the left eye.

Conclusions

Cystoid macular edema in each case resolved within a few months without any side effects using topical dorzolamide and terminating taxane-based chemotherapy. Topical dorzolamide appears to be a safe and effective treatment option for patients with taxane-related cystoid macular edema whose quality of life is threatened by visual disturbances.

Retinal toxicities of systemic anticancer drugs

Newer anticancer drugs have revolutionized cancer treatment in the last decade, but conventional chemotherapy still occupies a central position in many cancers, with combination therapy and newer methods of delivery increasing their efficacy while minimizing toxicities. We discuss the retinal toxicities of anticancer drugs with an emphasis on the mechanism of toxicity. Uveitis is seen with the use of v-raf murine sarcoma viral oncogene homolog B editing anticancer inhibitors as well as immunotherapy. Most of the cases are mild with only anterior uveitis, but severe cases of posterior uveitis, panuveitis, and Vogt-Koyanagi-Harada-like disease may also occur. In the retina, a transient neurosensory detachment is observed in almost all patients on mitogen-activated protein kinase kinase (MEK) inhibitors. Microvasculopathy is often seen with interferon α, but vascular occlusion is a more serious toxicity caused by interferon α and MEK inhibitors. Crystalline retinopathy with or without macular edema may occur with tamoxifen; however, even asymptomatic patients may develop cavitatory spaces seen on optical coherence tomography. A unique macular edema with angiographic silence is characteristic of taxanes. Delayed dark adaptation has been observed with fenretinide. Interestingly, this drug is finding potential application in Stargardt disease and age-related macular degeneration.

Ophthalmic adverse effects of taxanes: The Mayo Clinic experience

PURPOSE

To investigate ophthalmic side effects of taxanes and compare side effect frequency, requirement for cessation of taxane therapy, visual acuity outcome, and concurrent systemic effects between paclitaxel and docetaxel.

METHODS

Patients taking taxanes at a single center from 1/1/2010 to 2/29/2020 were retrospectively reviewed for clinical characteristics, treatments, and concurrent systemic adverse effects.

RESULTS

Of 1918 patients, 22 (1.1%) experienced an ophthalmic side effect that came to the attention of an eye care provider. Mean age at presentation of the side effect was 62 years (median 66, range 23-82). The most common side effect was meibomian gland dysfunction in 5 (23%) patients, followed by cystoid macular edema in 4 (18%) patients and canalicular obstruction in 4 (18%) patients, followed by diplopia in 2 (9%) patients, and singular cases of lash alopecia, and blepharitis, among others. Lids/lashes as well as nasolacrimal duct adverse effects occurred more frequently with docetaxel therapy than with paclitaxel therapy. Follow-up was available in 10 (45%) patients, with mean duration of 5 months (median 4, range 0-12 months). Of these patients, the ophthalmic side effects were resolved or controlled without discontinuing therapy in 8 (80%) patients. Taxane cessation was required in one patient with docetaxel-related canalicular obstruction and one patient with paclitaxel-related cystoid macular edema.

CONCLUSION

Ophthalmic taxane-related adverse events are rare with estimated frequency of ophthalmic side effects of about 1%. Nevertheless, it is important that ophthalmologists recognize the range of side effects for optimal management. Most ophthalmic events can be treated with targeted therapy without discontinuation of life-prolonging taxane therapy.

Drug-induced maculopathy

PURPOSE OF REVIEW

The purpose of this article is to provide an overview of drug-induced maculopathies including their clinical presentations, diagnostic findings, and treatment options. With the increasing pace of development and arrival of drugs to the market, this review aims to inform retina specialists of relevant side effects that may be encountered in a clinical practice setting.

RECENT FINDINGS

The major themes visited in this article focus on relevant findings of drugs that cause pigmentary and crystalline maculopathy, photoreceptor dysfunction, cystoid macular edema, central serous choroidopathy, uveitis, and vascular damage.

SUMMARY

The current review reports updated findings and discusses the pathophysiologic mechanisms, presentations, and treatments of drug-induced maculopathies.

Macular oedema associated with taxanes: A case report and literature review

BACKGROUND AND PURPOSE

Although taxanes are a frequently used group of chemotherapy agents, they can, rarely, lead to macular oedema. The purpose of this article is to review and communicate, in an integrated way, the data of the cases previously reported in the literature, as well as to present a new case.

MATERIAL AND METHODS

Narrative review of reports of cases of macular oedema associated with taxanes, and communication of the clinical case of a 73-year-old woman who, after treatment with paclitaxel for metastatic breast cancer, developed macular oedema that disappeared after discontinuing the drug.

RESULTS

The review included 57 cases with data from 109 eyes collected in 52 articles. The large majority (76.79%) of the cases were women, and the mean age was 58.75 years. The cancer that most frequently motivated the treatment was breast cancer (60.72%), and 92.5% of cases had metastases. The most frequently associated drug was paclitaxel (52.63%). The median time to symptom development was 4.25 months. At the initial examination, 92.86% of the cases had bilateral oedema and the mean visual acuity was 0.4 (decimal scale). The mean macular thickness was 509.63 microns, and 97.83% of the eyes had no or minimal angiographic findings. In 90.57% of the cases, the treatment with taxanes was interrupted, and some other treatment was used in 43.86% of the cases, with the most widely used being acetazolamide. The outcome was favourable, to a greater or lesser extent, in 96.23% of cases.

CONCLUSIONS

Despite being a rare entity, macular oedema associated with the use of taxanes is a disorder that every oncologist and ophthalmologist should be aware of, taking into account the good outcome of the condition that usually occurs when treatment is suspended.

Dexamethasone intravitreal implant in cystoid macular edema secondary to paclitaxel therapy

Purpose

To report the first case of cystoid macular edema (CME) induced by nabpaclitaxel treated with intravitreal dexamethasone implant.

Observations

A 67 year-old man diagnosed with unresectable pancreatic cancer presented with decreased vision in both eyes while receiving nab-paclitaxel. He was diagnosed with CME and intravitreal dexamethasone implants were administered in both eyes. Central retinal thickness (CRT) of both eye decreased 1 month after the implant but CME persisted. 2 months after Ozurdex implant nabpaclitaxel was discontinued, improving central macular thickness and the CME significantly in both eyes.

Conclusion and importance

Cessation of nab-paclitaxel could lead to resolution of CME more than intravitreal dexamethasone implant, although intravitreal dexamethasone implant achieved some reduction in central macular thickness.

Docetaxel-induced maculopathy possibly potentiated by concurrent hydroxychloroquine use

Purpose

To report a case of bilateral non-leaking cystoid macular degeneration induced by docetaxel, possibly potentiated by hydroxychloroquine.

Observations

A 63-year-old female patient with a long-term history of rheumatoid arthritis controlled on hydroxychloroquine for 33 years with no evidence of retinopathy developed bilateral loss of vision after having been on docetaxel chemotherapy for breast cancer. Optical coherence tomography showed bilateral cystic maculopathy with no angiographic evidence of leakage on fluorescein angiography. The patient was treated conservatively with no further interventions. Marked improvement of the macular degeneration occurred over the subsequent 9 months, but without visual improvement, although a cataract likely confounded final visual acuity measurement.

Conclusions and importance

Docetaxel-induced maculopathy has been previously reported, but with only four case reports in literature, and most often in conjunction with concurrent therapies or conditions also known to cause macular edema. This is the first case report of docetaxel-induced maculopathy in a setting of hydroxychloroquine therapy which may possibly has potentiated the effect of docetaxel to induce maculopathy. Impaired transcellular retinal pigment epithelial transport might be the cause of non-leaking cystic maculopathy.

Current status of eye disorders caused by docetaxel administration every 3 weeks: A case-control study in Japanese patients

PURPOSE

Docetaxel is known to cause eye disorders. In this study, current status of eye disorders caused by docetaxel administration every 3 weeks in Japanese patients was examined.

METHODS

This case-control study targeted patients who were newly administered docetaxel at the Kyoto Okamoto Memorial Hospital between 1 July 2015 and 30 June 2018. Eye disorder occurrence was defined as an event in which the pharmacist confirmed the symptoms in a patient interview and the ophthalmologist diagnosed the disorder.

RESULTS

Of the 89 subjects, 7 (7.9%) had eye disorders. The symptoms were watering eyes (7.9%), a stye and eye discharge (2.2% each), corneal and conjunctival disorder, visual acuity reduction, and blepharedema (1.1% each). Four patients who presented with watering eyes, eye discharge, or corneal and conjunctival disorder showed improvement with the use of eye drops such as artificial tears. Two patients who presented with a stye showed improvement with the use of oral cefcapene. One patient with mild symptoms showed spontaneous improvement. However, one patient had irreversible visual acuity reduction. The multivariate logistic regression analysis revealed that a cumulative docetaxel dose of ≥300 mg/m² (odds ratio: 15.50, 95% confidence interval: 1.37-175.00, p = 0.027) and concomitant cyclophosphamide use (odds ratio: 13.20, 95% confidence interval: 1.13-153.00, p = 0.039) were significant risk factors associated with eye disorders.

CONCLUSION

In conclusion, it was determined that docetaxel-related eye disorders might be influenced by the cumulative dose of docetaxel and concomitant cyclophosphamide use. In addition, relatively mild symptoms improved with medication.

SEROUS RETINOPATHY ASSOCIATED WITH CISPLATIN TREATMENT

BACKGROUND/PURPOSE

To describe a case of serous retinopathy and associated photoreceptor atrophy after intravenous cisplatin therapy.

METHODS

Evaluation was performed using electroretinogram, optical coherence tomography, fundus autofluorescence, and funduscopic examinations to assess the extent of retinal disease, toxicity, and eventual atrophy.

RESULTS

A 56 year-old man with metastatic small cell carcinoma with vision changes after initiation of cisplatin therapy. The patient developed loss of vision to 20/400. A serous retinopathy was found on spectral domain optical coherence tomography with associated outer retinal atrophy and subretinal fibrosis. He developed outer ellipsoid layer atrophy after discontinuation of cisplatin therapy. He had patchy hypoautofluorescent areas in his macula on fundus autofluorescence and decreased cone response and slowed b-wave on electroretinogram. The serous retinopathy resolved with discontinuation of cisplatin and the malignancy was further managed with etoposide without recurrence of subretinal serous fluid or further vision loss.

CONCLUSION

Commonly used to treat various solid tumors, cisplatin is not without significant neurologic, ocular, and retinal toxicities. Multimodal imaging may further the authors' understanding of toxicity and this case highlights the benefits of optical coherence tomography, especially with color vision deviation or visual acuity change.

Taxane Induced Cystoid Macular Edema: Case Report and Integrated Pathogenic Theory

PURPOSE

To report a case of a 73-year-old man who presented with decreased visual acuity due to bilateral macular edema after paclitaxel administration for prostate cancer.

METHODS

The ophthalmic evaluation consisted of medical and ocular history, Best Corrected Visual Acuity, slit-lamp biomicroscopy and Spectral-domain optical coherence tomography / Fluorescein Angiography.

RESULTS

Optical Coherence Tomography and Fluorescein Angiography revealed silent cystoid macular edema. After consulting with the oncologist, the cessation of paclitaxel therapy was decided. The patient presented a gradual but steady resumption of the retinal edema, with complete restoration of normal retinal morphology and function within two months. The pathogenesis of the silent Cystoid Macular Edema (CME) is still unclear. Based on our case and a critical review of the previous observations and published data, we propose that the underlying cause of Taxane induced CME is the functional failure of Aquaporin mediated water transport at the level of retinal Intermediate and Deep capillary plexuses, and at lesser extent at the level of the Retinal Pigment Epithelium.

CONCLUSION

Taxane induced silent CME should be attributed to the action of Taxanes on the microtubule guided aquaporin vesicles transport to the cell membrane. In our case of Taxane induced silent CME, withdrawal of the taxane was enough for complete recovery, and no additional treatment was needed.

Risk Factors for Eye Disorders Caused by Paclitaxel: A Retrospective Study

Paclitaxel and nanoparticle albumin-bound paclitaxel are known to cause adverse events of eye disorders, such as cystoid macular edema. However, at present, the risk factors remain unclear. Therefore, risk factors for eye disorders caused by paclitaxel and nanoparticle albumin-bound paclitaxel were studied. This retrospective study targeted patients who were newly administered paclitaxel or nanoparticle albumin-bound paclitaxel at Kyoto Okamoto Memorial Hospital between April 1, 2012, and March 31, 2017. Eye disorder occurrence was defined as an event in which the pharmacist confirmed the symptoms in a patient interview and the ophthalmologist diagnosed the disorder. To analyze the risk factors, logistic regression analysis using 41 factors was performed. Of 128 subjects, 13 (10.2%) had eye disorders with symptom degrees of Grades 1 and 2. The symptoms were conjunctivitis or subconjunctival hemorrhage (3.1%), visual acuity reduction (2.3%), blurred vision and eye pain (1.6% each), eye mucus, blepharitis, stye, watering eyes, photopsia, and muscae volitantes (0.8% each). In eight patients, the conditions patients improved with spontaneously or with medication use; no improvements were observed the cases of visual acuity reduction, blurred vision, or muscae volitantes. Multivariate logistic regression analysis revealed that a cumulative dose of ≥819 mg/m² (odds ratio: 5.34, 95% confidence interval: 1.32-21.60, p=0.019) and baseline alkaline phosphatase ≥256 U/L (odds ratio: 3.74, 95% confidence interval: 1.02-13.70, p=0.046) were significant risk factors associated with eye disorders. In conclusion, it was determined that paclitaxel- and nanoparticle albumin-bound paclitaxel-related eye disorders might be influenced by cumulative dose and baseline alkaline phosphatase.

Impaired retinal pigment epithelium in paclitaxel-induced macular edema: A case report

RATIONALE

Cystoid macular edema (CME) is a rare complication of the paclitaxel. However, the pathophysiology was unknown.

PATIENT CONCERNS

A 60-year-old female presented with bilateral blurred vision due to cystoid macular edema after taking 12-course paclitaxel for her breast cancer. Optical coherence tomography (OCT), fluorescein angiography (FAG), indocyanine green angiography (ICGA), electroretinogram (ERG) and electrooculogram (EOG) were performed.

DIAGNOSES

Paclitaxel-induced macular edema.

INTERVENTIONS

Paclitaxel was discontinued and supportive treatment with pentoxifylline was given.

OUTCOMES

The OCT showed bilateral cystoid macular edema. Impaired filling of choriocapillaries was noted on the ICGA; while EOG revealed decreased Arden ratio. The visual acuity, cystoid macular edema and decreased Arden ratio improved slowly over six months.

LESSONS

Paclitaxel rarely causes cystoid macular edema. The damage of choriocapillaries and retinal pigment epithelium might be the underlying cause. Immediate discontinuation of the drug helps visual recovery.

Indocyanine green angiography findings of cystoid macular edema secondary to paclitaxel therapy

PURPOSE

To report 2 cases of paclitaxel-related maculopathy manifesting as cystoid macular edema (CME) with late petaloid hyperfluorescence on indocyanine green angiography (IA).

CASES

A 74-year-old man (patient 1) undergoing paclitaxel chemotherapy for gastric and metastatic liver cancer and a 69-year-old man (patient 2) receiving paclitaxel for hypopharyngeal cancer presented with anorthopia in both eyes. Spectral domain-optical coherence tomography (SD-OCT) revealed macular edema in both eyes of each patient. Fluorescein angiography showed weak petaloid pooling around the fovea in the late phase. IA revealed CME with petaloid hyperfluorescence that matched the region of macular edema detected by SD-OCT. The CME was attenuated in the right eye but not in the left eye of patient 1 at 2 weeks after discontinuation of paclitaxel treatment, whereas it was no longer apparent in either eye at 3 months. The CME was no longer detected in either eye of patient 2 at 3 months after discontinuation of paclitaxel.

CONCLUSION

These cases suggest that paclitaxel-induced CME may result from intraretinal accumulation of intracellular fluid and minimal impairment of the blood retinal barrier.

Cystoid Macular Edema during Treatment with Paclitaxel and Bevacizumab in a Patient with Metastatic Breast Cancer: A Case Report and Literature Review

We present a case of a metastatic breast cancer patient with cystoid macular edema (CME) occurring during treatment with paclitaxel and bevacizumab. She had a history of neoadjuvant chemotherapy and partial mastectomy plus axillary lymph node dissection for stage IIB left-breast cancer. Twenty-four months later, she was diagnosed with multiple bone metastases and underwent chemotherapy with paclitaxel and bevacizumab. Thirty-three months after the initiation of the chemotherapy, she noticed bilateral blurred vision. The retinal thickening with macular edema was observed by optical coherence tomography, resulting in a diagnosis of CME. With cessation of paclitaxel and administrating ocular instillation of a nonsteroidal anti-inflammatory drug, her macular edema gradually reduced and disappeared in a month. While CME caused by chemotherapy is very rare, taxane may cause ocular adverse events such as CME. It is important to urge patients to consult an ophthalmologist promptly when they have visual complaints during taxane chemotherapy.

Central Macular Thickness Monitoring after a Taxane-Based Therapy in Visually Asymptomatic Patients

BACKGROUND

Taxanes are drugs used in various chemotherapeutical protocols to treat solid tumors. They have multiple systemic adverse effects, such as bone marrow suppression, alopecia, nausea, and vomiting, and may rarely cause ocular symptoms. In the past decade, a few reported cases have shown the occurrence of a cystoid macular edema with significant visual loss after the use of a taxane-based chemotherapy. The aim of this study was to compare the central macular thickness (CMT) before and after the initiation of a taxane-based therapy in visually asymptomatic patients and to elucidate the possible impact of these drugs on the vision of cancer patients.

METHODS

Patients with a confirmed diagnosis of a solid tumor were screened for any ophthalmic disease before inclusion and had a baseline macular spectral domain optical coherence tomography (OCT; RTVue-100; Optovue Inc., Fremont, CA, USA) before the initiation of a taxane-based chemotherapy according to different protocols, such as 4EC-4T, 3FEC/3T, or 4TC. OCT was repeated after 4 cycles (or 3 months) of treatment, and CMT was compared to baseline. Patients presenting diabetic retinopathy, age-related macular degeneration or any condition that causes macular edema confirmed by ophthalmic examination were excluded.

RESULTS

Fifty eyes of 25 patients were included; 92% of the subjects were female with a mean age of 48.52 years, 88% were diagnosed with breast cancer, 8% with esophageal cancer, and 4% with ovarian cancer. Docetaxel was the taxane administered to 92% of the patients. The received dose of docetaxel ranged between 110 and 160 mg. The other patients had paclitaxel in their protocols. No significant macular edema or drop in visual acuity were noted in any patient. Nevertheless, the mean CMT was found to be increased, particularly in the parafoveal and perifoveal areas (mean difference of +2.22 μm; p = 0.001).

CONCLUSION

Taxane-based chemotherapy regimens seem to increase macular thickness, with a relative sparing of the fovea, in patients without significant macular edema. Further research is required to better explain the pathophysiology and possible impact of this phenomenon.

Docetaxel Retinopathy: A Case Report

Background

To report the use of En-face optical coherence tomography (OCT) in a patient treated with docetaxel and tamoxifen for breast cancer for the detection of macular edema (ME) without evidence of leakage on fluorescein angiography (FA).

Case Presentation

A 52-year-old woman treated for breast cancer presented with bilateral visual loss for 2 months. FA showed no significant leakage while spectral-domain OCT scans of both eyes showed foveolar and parafoveolar cystic spaces in a moderately thickened macula. En-face OCT segmented at the inner retina showed the petaloid arrangement of cystic cavities, comparable to a cystoid ME.

Conclusions

The combined use of tamoxifen could have potentiated the toxic effect of docetaxel on the macula. En-face OCT images may reveal a petaloid aspect of the macula due to cysts in the inner retina segmentation, when FA shows no leakage.

Single-eye trial of a topical carbonic anhydrase inhibitor versus intravitreal bevacizumab for the treatment of taxane drug-induced cystoid macula oedema

Taxanes are a class of microtubule stabilising agents used to treat a wide range of malignancies. Taxane drug-induced cystoid macula oedema (TDICMO) is a known but rare complication of therapy. First reported with Docetaxel in 2003 and Paclitaxel in 2007, there are currently less than 20 cases of TDICMO in the literature. Although most cases resolve following taxane cessation, several authors have tried using carbonic anhydrase inhibitors or intravitreal bevacizumab to accelerate resolution or when taxane therapy cannot be discontinued. We report the first published case of TDICMO treated with a single-eye trial of topical dorzolamide versus intravitreal bevacizumab.

Sub-Tenon Injections of Triamcinolone Acetonide Had Limited Effect on Cystoid Macular Edema Secondary to Nanoparticle Albumin-Bound-Paclitaxel (Abraxane)

Purpose. To report the first case of cystoid macular edema (CME) induced by nanoparticle albumin-bound- (nab-) paclitaxel treated with sub-Tenon injections of triamcinolone acetonide (STTA) with detailed long-term follow-up. Case. A 39-year-old Japanese woman with breast cancer presents with decreased vision in both eyes while receiving nab-paclitaxel. Two STTA treatments were administered for persistent CME in her right eye. Central retinal thickness (CRT) of the treated eye decreased after the first STTA, but there was no change after the second STTA. CRT of the other eye and bilateral visual acuity (VA) showed no change after each treatment. However, this patient experienced gradual recovery of visual function after nab-paclitaxel treatment was completed, 3 months after the second STTA. Improvements in VA and CRT did not overlap in time. Moreover, there was a big improvement time lag in VA between the eyes. Conclusion. Cessation of nab-paclitaxel could lead to resolution of CME more than STTA, although STTA had some effect. Since nab-paclitaxel has been recently approved for treating more types of malignancies, the number of the patients with this CME is expected to increase in the near future. Patients and physicians should understand this side effect and prepare for other treatment options.

Bilateral cystoid macular edema following docetaxel chemotherapy in a patient with retinitis pigmentosa: a case report

Background

Docetaxel is a chemotherapeutic agent of the taxane class of drugs for the treatment of breast cancer. We present a female patient who noted decreased vision after docetaxel treatment.

Case presentation

A 45-year-old female patient received docetaxel treatment after resection of a breast carcinoma. Funduscopy and optical coherence tomography (OCT) showed cystoid macular edema on both eyes. Dilated funduscopy also showed bone spicule-like pigmented deposits, typical for retinitis pigmentosa. Besides the fundus appearance restricted peripheral vision and scotopic electroretinogram confirmed the diagnosis of retinitis pigmentosa. Chemotherapy was discontinued following a consulation with the oncologist of the patient. After five weeks, visual acuity improved significantly along with decrease of retinal thickness measured by OCT.

Conclusion

Docetaxel may cause ocular adverse effects such as cystoid macular edema. Ophthalmological examination is warranted for patients with visual complaints during docetaxel chemotherapy.

Multimodal imaging in paclitaxel-induced macular edema: the microtubule disfunction

Taxanes are a rare cause of macular edema. A 63-year-old female, under paclitaxel treatment, was observed with progressively bilateral visual acuity loss and an apparently normal fundus. Optical coherence tomography revealed a bilateral cystoid macular edema with a late petaloid pooling on fluorescein angiography. Fundus autofluorescence exhibited a foveal hiperautofluorescent pattern. There was a great improvement of visual acuity and macular thickness after 5 months of drug withdrawal. Paclitaxel maculopathy diagnosis requires a high degree of suspicion. The pathophysiology remains unclear.

Paclitaxel- and/or cisplatin-induced ocular neurotoxicity: a case report and literature review

Paclitaxel (PTX) and/or cisplatin (CDDP), as important cytotoxic anti-cancer agents, are widely used to treat various solid tumors. Both may cause moderate or severe neurotoxicity, but ocular neurotoxicity is also occasionally reported. A patient diagnosed with nasopharyngeal cancer suffering acute ocular neurotoxicity 10 days after paclitaxel and CDDP administration at the recommended dose is described in the present case report, and PTX- and/or CDDP-induced ocular neurotoxicity are summarized according to previous reports. Possible mechanisms and the potential diagnostic, therapeutic and predictive strategies of PTX- and/or CDDP-induced ocular neurotoxicity are reviewed, to help the oncologist to take the infrequent toxicity of cytotoxic drugs into account and improve patient safety during anti-cancer therapy.

Transient MEK inhibitor-associated retinopathy in metastatic melanoma

BACKGROUND

Melanoma is one of the most aggressive skin cancers. Recently, selective MEK inhibitors have shown efficacy in patients with advanced BRAF- and NRAS-mutant melanoma. Soon after the initiation of clinical oncology trials with MEK inhibitors, it was observed that some participants developed an eye condition resembling central serous chorioretinopathy. The present article addresses the clinical features and management of these MEK inhibitor-associated retinal syndromes.

PATIENTS AND METHODS

Thirty-two patients with advanced cutaneous melanoma were treated with the selective MEK inhibitor binimetinib (MEK162) in three different Phase 1b or 2 clinical trials. Twenty patients on binimetinib monotherapy and 12 on binimetinib plus RAF inhibitor [pan-kinase RAF inhibitor RAF265 (n = 7) or selective BRAF inhibitor encorafenib (LGX818) (n = 5)] combination therapy underwent ophthalmological examinations at regular intervals, including determination of best corrected visual acuity, perimetry, colour vision testing, dilated fundus examination, and multimodal imaging.

RESULTS

Grade 1-2 bilateral retinopathies with multiple lesions were observed in 13 of 20 patients on binimetinib monotherapy, 4 of 7 patients on binimetinib plus RAF265 combination therapy, and 2 of 5 patients on binimetinib plus encorafenib combination therapy. In this study population, the rate ranged from 40% to 65%. Retinopathy events appeared during the first 4 weeks, and in some cases, during the first few days of treatment. Patients reported mild and only short-lived visual symptoms. Optical coherence tomography revealed neuroretinal elevations. Central retinal thickness and volume showed dose-dependent increases after the start of treatment, followed by a marked decrease despite continued treatment, which was associated with symptom resolution. No vascular abnormalities were found with fluorescein and indocyanine green angiography.

CONCLUSIONS

Treatment with the selective MEK inhibitor binimetinib as a single agent or in combination with RAF inhibitors induced transient retinopathy with multiple bilateral lesions in some patients. Binimetinib-induced retinopathy was usually mild, self-limiting, and tolerable as visual function was not seriously impaired.