Bilateral blindness and lumbosacral myelopathy associated with high-dose carmustine and cisplatin therapy

The Impact of Systemic Medications on Retinal Function

This study will provide a thorough review of systemic (and select intravitreal) medications, along with illicit drugs that are capable of causing various patterns of retinal toxicity. The diagnosis is established by taking a thorough medication and drug history, and then by pattern recognition of the clinical retinal changes and multimodal imaging features. Examples of all of these types of toxicity will be thoroughly reviewed, including agents that cause retinal pigment epithelial disruption (hydroxychloroquine, thioridazine, pentosan polysulfate sodium, dideoxyinosine), retinal vascular occlusion (quinine, oral contraceptives), cystoid macular edema/retinal edema (nicotinic acid, sulfa-containing medications, taxels, glitazones), crystalline deposition (tamoxifen, canthaxanthin, methoxyflurane), uveitis, miscellaneous, and subjective visual symptoms (digoxin, sildenafil). The impact of newer chemotherapeutics and immunotherapeutics (tyrosine kinase inhibitor, mitogen-activated protein kinase kinase, checkpoint, anaplastic lymphoma kinase, extracellular signal-regulated kinase inhibitors, and others), will also be thoroughly reviewed. The mechanism of action will be explored in detail when known. When applicable, preventive measures will be discussed, and treatment will be reviewed. Illicit drugs (cannabinoids, cocaine, heroin, methamphetamine, alkyl nitrite), will also be reviewed in terms of the potential impact on retinal function.

Use of Visual Electrophysiology to Monitor Retinal and Optic Nerve Toxicity of Medications

It is important for clinicians to consider exposure to toxic substances and nutritional deficiencies when diagnosing and managing cases of vision loss. In these cases, physiologic damage can alter the function of key components of the visual pathway before morphologic changes can be detected by traditional imaging methods. Electrophysiologic tests can aid in the early detection of such functional changes to visual pathway components, including the retina or optic nerve. This review provides an overview of various electrophysiologic techniques, including multifocal electroretinogram (mfERG), full-field ERG (ffERG), electrooculogram (EOG), pattern electroretinogram (PERG), and visual evoked potential (VEP) in monitoring the retinal and optic nerve toxicities of alcohol, amiodarone, cefuroxime, cisplatin, deferoxamine, digoxin, ethambutol, hydroxychloroquine, isotretinoin, ocular siderosis, pentosane, PDE5 inhibitors, phenothiazines (chlorpromazine and thioridazine), quinine, tamoxifen, topiramate, vigabatrin, and vitamin A deficiency.

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.

Cilioretinal artery occlusion associated with cisplatin

Introduction

Cancer is an important risk factor for venous and arterial thromboembolic events. Treatment with chemotherapy was associated with a 6.5-fold increase in the risk of thromboembolic events. Here, we present a patient with cilioretinal artery emboli during cisplatin-based therapy.

Case report

A 54-year-old male patient with a diagnosis of metastatic small cell carcinoma was under cisplatin-based regimen. He presented with visual disturbance. Retinal fluorescein angiography showed multiple plaques located in cilioretinal artery and cilioretinal artery occlusion. After excluding other potential etiological factors, patient was diagnosed with cilioretinal artery occlusion associated with cisplatin.

Discussion

In oncology practice, patients are prone to thromboembolic events due to primary disease, underlying comorbidities and treatment modalities. In addition to numerous toxicities, cisplatin is an important risk factor for thromboembolic events. Clinicians caring patients with a diagnosis of cancer should be aware of this rare complication of cisplatin-based therapies.

Uveoretinal Adverse Effects Presented during Systemic Anticancer Chemotherapy: a 10-Year Single Center Experience

BACKGROUND

The present study describes our 10-year experience with uveoretinal adverse events that manifest because of chemotherapy.

METHODS

A retrospective chart review was performed for all patients who presented to the ophthalmologic department while undergoing systemic chemotherapy between July 2005 and June 2015.

RESULTS

A total of 55 patients (mean age, 51.2 years, 38 women [69.1%]) suspected of having uveoretinal disease owing to the use of chemotherapeutic agents alone were enrolled. Breast cancer was the predominant disease (36.4%); noninfectious anterior uveitis (21.8%) was the most common condition. Bilateral involvement was observed in 16 patients (29.1%). Although cisplatin (21.8%) was the most commonly used drug, daunorubicin, cytarabine, tamoxifen, toremifene, and imatinib were also frequently used. The median duration until ophthalmologic diagnosis was 208.5 days (range, 19-5,945 days). The proportion of patients with final visual acuity (VA) < 20/40 Snellen VA (0.5 decimal VA) was 32.7%. However, no relationship was observed between final VA < 20/40 and age, sex, therapeutic agents, and metastasis.

CONCLUSION

Uveoretinal complications were mostly mild to moderate and exhibited a favorable response to conservative therapy. A considerable number of patients exhibited significant irreversible loss of vision after cessation of the causative chemotherapeutic agent. Ophthalmological monitoring is required during chemotherapy.

Bilateral blindness with secondary retinitis pigmentosa following postoperative docetaxel and platinum combination chemotherapy in primary small-cell carcinoma of the endometrium: An unusual case report and review of the literature

Ocular toxicity is an uncommon complication of cytotoxic chemotherapy. Bilateral blindness with secondary retinitis pigmentosa (RP) following docetaxel and platinum combination chemotherapy at the recommended dose is extremely rare. The present study reports a case of advanced small-cell carcinoma (SCC) of the endometrium in a patient with diabetes mellitus type 2. The patient suffered from RP with a sharp decline in vision after the fourth course of postoperative docetaxel and platinum combination chemotherapy. Unfortunately, the patient developed bilateral blindness after another course of chemotherapy at a reduced dose. No tumor recurrence was observed during the 33 months of follow-up. A total of 35 cases of docetaxel- and/or platinum-induced retinal toxicity were found in the English literature and reviewed. The ischemic and electrophysiological hypotheses may have been implicated in the pathogenesis of ocular toxicity in the present case, particularly with the history of diabetes. Understanding the ocular side effects of this combination chemotherapy may assist gynecological oncologists and ophthalmologists with early recognition and timely intervention before blindness is established.

Electroretinography and Visual Evoked Potentials in Childhood Brain Tumor Survivors

This population-based cross-sectional study evaluates the clinical value of electroretinography and visual evoked potentials in childhood brain tumor survivors. A flash electroretinography and a checkerboard reversal pattern visual evoked potential (or alternatively a flash visual evoked potential) were done for 51 survivors (age 3.8-28.7 years) after a mean follow-up time of 7.6 (1.5-15.1) years. Abnormal electroretinography was obtained in 1 case, bilaterally delayed abnormal visual evoked potentials in 22/51 (43%) cases. Nine of 25 patients with infratentorial tumor location, and altogether 12 out of 31 (39%) patients who did not have tumors involving the visual pathways, had abnormal visual evoked potentials. Abnormal electroretinographies are rarely observed, but abnormal visual evoked potentials are common even without evident anatomic lesions in the visual pathway. Bilateral changes suggest a general and possibly multifactorial toxic/adverse effect on the visual pathway. Electroretinography and visual evoked potential may have clinical and scientific value while evaluating long-term effects of childhood brain tumors and tumor treatment.

ISCHEMIC RETINOPATHY IN NEUROFIBROMATOSIS TYPE 1

PURPOSE

To describe a patient with severe ischemic retinopathy and maculopathy in the context of neurofibromatosis Type 1.

METHODS

Case report illustrated with multimodal clinical imaging. A 16-year-old female with neurofibromatosis Type 1 presented with visual deterioration over several weeks. Her right eye was amblyopic because of an optic nerve glioma treated in childhood with chemotherapy.

RESULTS

Corrected visual acuities were counting fingers in the right eye and 20/150 in the left eye. Examination revealed bilateral optic disk pallor. In the left eye, severe and extensive ischemic retinopathy and maculopathy were noted with collateral formation and neovascularization. Proximal arterial occlusion at the level of the internal carotid and ophthalmic arteries was excluded on neuroimaging, including computed tomography angiography.

CONCLUSION

Neurofibromatosis Type 1 may present in the ocular fundus with a variety of lesion types, including vasoproliferative tumors, hamartoma, uveal melanoma, and hemangioma. Vascular occlusions are relatively uncommon. Ocular ischemic syndrome secondary to moyamoya syndrome is well described in neurofibromatosis Type 1 but was excluded in our patient. A spectrum of retinal microvascular abnormalities has also been described, but disease-specific evidence to guide treatment is lacking.

Toxic effects of systemic cisplatin on rat eyes and the protective effect of hesperidin against this toxicity

CONTEXT

In the present study, cisplatin (CP) induced eye toxicity and the beneficial effect of hesperidin (HP) was investigated.

METHODS

Twenty-eight rats were equally divided into four groups; the first group was kept as control. In the second and third group, CP and HP were given at the doses of 7 mg/kg and 50 mg/kg/d, respectively. In the fourth group, CP and HP were given together at the same doses. Tissue samples were collected on day 14 of CP treatment.

RESULTS

The results demonstrated that CP caused a significant increase in thiobarbituric acid reactive substances (TBARS) levels and decrease of glutathione levels and antioxidant enzyme activity (catalase, superoxide dismutase and glutathione peroxidase) in eye tissues compared to other groups, HP prevented these effects of CP. Besides, CP led to histopathological damage in the retina and cornea. On the other hand, HP treatment prevented histopathological effects of CP.

CONCLUSION

CP had severe dose-limiting toxic effects and HP treatment can be beneficial against the toxic ocular effects of CP. Thus, it appears that co-administration of HP with CP may be a useful approach to attenuate the negative effects of CP on the eye.

Retinal toxicities of cancer therapy drugs: biologics, small molecule inhibitors, and chemotherapies

PURPOSE

To review reported retinal side effects from current cancer therapy drugs.

METHODS

Retinal toxicities from ophthalmologic or oncologic case reports, case series, and clinical trials were identified by a systematic literature search using Lexicomp and PubMed.

RESULTS

Four biologics, 8 small molecule inhibitors, and 17 traditional chemotherapy agents had reported retinal side effects. For biologics, interferon alpha 2b was associated with retinopathy, denileukin diftitiox with pigmentary retinopathy, ipilimumab with a Vogt-Koyanagi-Harada-like syndrome, and trastuzumab with retinal ischemia. For small molecule inhibitors, v-raf murine sarcoma viral oncogene homolog B (BRAF) inhibitors were associated with uveitis, mitogen-activated protein kinase/extracellular signal-regulated kinase inhibitors with pigment epithelium detachments, and tyrosine kinase inhibitors with macular edema. Steroid antagonists were associated with crystalline retinopathy and macular edema. Nitrosoureas, platinum analogs, and cytosine arabinoside were associated with retinal vascular occlusions. Antimicrotubular agents were associated with cystoid macular edema but without fluorescein leakage. Retinoic acid derivatives were associated with impaired night vision, and mitotane was associated with a pigmentary retinopathy and papilledema.

CONCLUSION

Certain agents used in the treatment of systemic cancer are associated with ocular complications. Awareness of these complications will allow early detections and maybe reversal of some of the ocular problems.

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.

Current management strategies for intraocular retinoblastoma

Survival rates for retinoblastoma patients have increased dramatically over the last century, with documented 5-year survival figures reaching 87-99% in developed countries. During the last decade, there has been a dramatic paradigm shift in the treatment approach for intraocular retinoblastoma, emphasising chemoreduction protocols and minimising the use of external beam radiation. The recognition of the increased risk for second non-ocular cancers with external beam radiation contributed to the growing emergence of chemotherapy. Although chemoreduction protocols vary slightly between institutions, many centres are currently treating intraocular retinoblastoma with carboplatin, vincristine and etoposide as a three-drug regimen given in two to six cycles. Clinical studies have demonstrated that systemic chemotherapy must be combined with other modalities, such as laser treatment and cryotherapy, for adequate tumour control and many eyes with advanced intraocular disease require salvage therapy with radiation or enucleation. Therefore, modern centres treating retinoblastoma continue to manage patients with a variety of modalities, individualising the therapy according to the patient's presentation and clinical course.

Optic neuritis in evolution

A case of progressive optic neuropathy in a woman with a history of breast cancer is presented. Differential diagnoses including optic neuritis, infiltrative optic neuropathy, carcinomatous meningitis, and toxic optic neuropathies are discussed. Risk factors for metastatic brain lesions are also discussed.

Update on ocular complications of systemic cancer chemotherapy

The constantly growing list of cytotoxic chemotherapeutics requires a new survey of ophthalmic complications, which are often underestimated. Based on the review by Imperia et al (1989), an update on ophthalmic complications of currently used cytotoxic chemotherapeutics in oncology was written. Vision is a quality of life issue, which must be nurtured, especially if loss of vision can be prevented. The broad spectrum of ophthalmic complications induced by cytotoxic chemotherapy includes reversible and irreversible acute and chronic disorders. Mild to moderate ophthalmic complications are very common and reversible after cessation of anti-cancer therapy. Some major ocular toxicities may require a dose reduction or the discontinuation of cytotoxic chemotherapy in order to prevent visual loss. Ocular toxicities can be treated or even prevented, if detected early enough. That is why an ophthalmic baseline examination for patients receiving cytosine arabinoside, 5-fluorourocil, methotrexate, or docetaxel should be taken into consideration, and a consultation with an ophthalmologist has to be done as soon as symptoms are recognized. Oncologists and ophthalmologists must be aware of potential ophthalmic complications during cytotoxic chemotherapy, and should work together.

Retinal ischemia with neovascularization in cisplatin related retinal toxicity

PURPOSE

To report a case of macular ischemia and retinal neovascularization in a patient who received cisplatin related chemotherapy.

DESIGN

Interventional case report.

METHODS

A patient with germ cell testicular tumor received polychemotherapy (bleomycin, etoposide, and cisplatin or BEP) for a recurrence of his tumor. Ten weeks after completion of treatment, he presented with loss of vision in his left eye.

RESULTS

Fluorescein angiography revealed bilateral retinal ischemia and left retinal neovascularization. Panretinal laser photocoagulation was performed. Unfortunately, his vision did not improve.

CONCLUSIONS

Like interferon, cisplatin related chemotherapy could cause considerable ocular morbidity. It can cause marked irreversible visual loss at therapeutic dose, and it is not well recognized. Retinal neovascularization related to cisplatin therapy has not been previously reported. Physicians should be aware and warn patients of the potential ophthalmic side effects of cisplatin related chemotherapy.

Retinal complications of bone marrow and solid organ transplantation

PURPOSE OF REVIEW

A review is presented of the current literature on retinal complications of bone marrow and solid organ transplantation.

RECENT FINDINGS

Retinal complications of bone marrow and solid organ transplantation include microvascular retinopathy, infection, and hemorrhagic findings. Other clinical observations include central serous chorioretinopathy, bilateral optic disc edema, and cyclosporine-related retinal toxicity. The cause of these clinical findings is likely to be multifactorial, resulting from the combined effects of cyclosporine, total body irradiation, infections, high-dose chemotherapy, and recurrent malignancies.

SUMMARY

Understanding of these clinical entities of the posterior segment is important in minimizing the potentially sight-threatening complications from bone marrow and solid organ transplantation.