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

A major review of punctal stenosis: Updated anatomy, epidemiology, etiology, and clinical presentation

We aim to provide a detailed and updated literature review on the epidemiology, etiology, clinical presentations, histopathology, and ultrastructural features of punctal stenosis. There are inconsistencies in the definition and staging of punctal stenosis. While advanced optical coherence tomography imaging techniques have revolutionized the way the punctum and vertical canaliculi are assessed or monitored following treatment, the planes of measurement to characterize punctum anatomy need to evolve further. The current criteria for diagnosing and grading punctal stenosis are inadequate and based on empirical clinical findings. There is increasing evidence of the role of lymphocytes and myofibroblasts in the pathogenesis of punctal stenosis. There is a need for a uniform assessment of punctal stenosis and a uniform reporting of severity that would help standardize the several management options available in the lacrimal armamentarium.

Punctal and Canalicular Stenosis Following Topical 1% 5-Fluorouracil Eye Drop Therapy for Ocular Surface Squamous Neoplasia

PURPOSE

To present the first known cases of punctal and canalicular stenosis following topical 5-fluorouracil (5-FU) eye drops for ocular surface squamous neoplasia (OSSN).

METHODS

A retrospective chart review of patients with OSSN receiving topical 1% 5-FU eye drops as a primary or adjuvant treatment between 2013 and 2021 was performed. Individuals diagnosed with punctal or canalicular stenosis during or after topical 5-FU use were included in this study. Four individuals met these criteria; we report clinical findings and treatment course for each patient.

RESULTS

We reviewed 303 patients (316 eyes) with OSSN. All patients were treated with topical 1% 5-FU eye drops in cycles, given 4 times daily for 1 week with 3 weeks off. Four patients (5 eyes) developed punctal stenosis, for a frequency of 1.3%. The mean age at 5-FU initiation in the 4 individuals was 61 years (range 53-69). Most individuals were male (75%), White (75%), and non-Hispanic (100%). The most common presenting symptom of stenosis was epiphora, noted 4.6 ± 3 months after initiating topical 5-FU (after 4.9 ± 2.0 cycles). This occurred in 4 eyes while on therapy (3, 2, 4, and 4 months since 5-FU initiation) and in 1 eye after stopping therapy (10.3 months since 5-FU initiation). In 1 eye, punctal stenosis and epiphora resolved spontaneously after stopping 5-FU. Punctal dilation led to symptom resolution in 2 eyes. Surgical intervention (punctoplasty and external dacryocystorhinostomy) was needed in 2 eyes for punctal and canalicular stenosis, respectively.

CONCLUSIONS

Punctal or canalicular stenosis is a rare and previously unreported adverse effect of topical 5-FU that may require surgical treatment.

Uncommon Blepharitis

Blepharitis is a common chronic inflammatory condition affecting the eyelid margins; the pathophysiology of blepharitis is complex and not fully understood. The disease is anatomically divided into anterior (inflammation of eyelashes) and posterior (meibomian gland dysfunction) types. Diagnosis relies on clinical examination, revealing characteristic features like scurf, vascular changes, and meibomian gland dysfunction. The main goals of blepharitis treatment are symptom relief, recurrence prevention, and complication risk minimization. Treatment options include lid hygiene, topical and systemic antibiotics, topical corticosteroids, and omega-3 supplements. However, it is important to highlight reported cases of blepharitis as side effects of systemic therapies, particularly in the context of chemotherapy, bortezomib, cetuximab, TNFα inhibitors, and dupilumab. It is crucial to monitor patients undergoing such treatments regularly and attentively in order to promptly set up adequate supportive therapy. Of even more importance is future research on the pathophysiological mechanisms responsible for the occurrence of these ocular side effects in order to find a nosological cure for the issue.

Ocular complications of antineoplastic therapies

Ocular complications of antineoplastic agents can have a profound effect on the quality of life of cancer patients. New oncologic treatments like monoclonal antibodies, immunotherapies, antibody-drug conjugates, checkpoint inhibitors and growth factor receptors have resulted in increased ocular complications. These ocular complications differs in respect to distinct mechanisms of actions and lead to significant challenges in the management of cancer patients. In this review, we reviewed literature, clinical studies and cases detailing ocular complications due to administration of antineoplastic agents and emphasized the need for communication between oncologists and ophthalmologists toward early detection and management of ocular complications.

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.

Causes of Tearing in Patients With Chemotherapy: Meibomian Gland Dysfunction Versus Lacrimal Drainage Obstruction

Numerous ocular toxicities that have been associated with the use of chemotherapeutic agents present as problems with the ocular surface, ocular adnexa, and lacrimal system, and many chemotherapeutic agents have tearing as a side effect. In this study, 34 eyes from 17 patients with a mean age of 62.4±14.8 years were analyzed. Chemotherapy was administered for a mean of 13.8±7.6 months. Chemotherapeutic agents of the following types were included: titanium silicate-1 (58.8%), Docetaxel (23.5%), Paclitaxel (11.8%), and 5-fluorouracil (5.9%). Tearing began 9.1 to 10.9 months after chemotherapy treatment. Within 3 months of beginning chemotherapy, tearing occurred in 9 patients (52.9%), and within 6 months, it occurred in 11 patients (64.7%). Mean tear break-up time was 5.4±2.6 sec. Ten eyes (29.4%) had normal fluorescein dye disappearance test findings (within grade 1), and the mean fluorescein dye disappearance test was 1.91±0.87. Among the 34 eyes, 24 (70.6%) had normal puncta and 9 (26.5%) and 1 (2.9%) had stenosis and blockage, respectively. Ten eyes (29.4%) showed total regurgitation, 19 eyes (55.9%) showed partial regurgitation, and 5 eyes (14.7%) showed no regurgitation upon syringing. Four eyes (11.8%) and 30 eyes (88.2%), respectively, showed soft and hard stops upon probing. Dacryoscintigraphy confirmed that 6 eyes (17.6%) were normal, 8 eyes (23.5%) showed post-sac delay or obstruction, and 20 eyes (58.8%) showed pre-sac delay or obstruction. The mean meiboscores for the upper and lower eyelids on LipiView were 2.15±0.86 and 2.53±0.79, respectively. The difference in meiboscores between the upper and lower eyelids was significant (P=0.004). Obstruction of the lacrimal drainage system is a significant contributing factor to tearing in chemotherapy patients. However, reflex tearing because of meibomian gland dysfunction should also be fully considered to effectively manage the tearing because of the high incidence of accompanying meibomian glands loss when the lacrimal drainage system is obstructed.

Dacryoendoscopic Findings of Patients with Lacrimal Drainage Obstruction Associated with Cancer Treatment

PURPOSE

To compare the diagnosis and treatment outcome of lacrimal drainage obstruction of patients who underwent systemic chemotherapy (CTx) or radioactive iodine treatment (RAI) by using dacryoendoscopy and at the same time performing dacryoendoscopy-guided silicone tube insertion (STI) to treat epiphora.

METHODS

From July 2017 to December 2020, the medical records of 11 patients (16 eyes) were diagnosed with lacrimal drainage obstruction after CTx or RAI and underwent dacryoendoscopy-guided STI were reviewed retrospectively. We tried to count the number of obstructive sites in total patients using slit-lamp examination and dacryoendoscopic findings.

RESULTS

A total of 11 patients, 16 eyes, were enrolled in this study. The onset of epiphora in the CTx group (3.0 ± 4.0 months) was significantly shorter than that in the RAI group (52.6 ± 36.5 months, p = 0.001). There were total 32 obstructive sites including 28 obstructive sites of dacryoendoscopic findings and four sites of punctual stenosis in total 16 cases. Using dacryoendoscopy, granulation findings was dominant in RAI patients (p = 0.038) and mucus finding was frequent mostly in lacrimal sac and canaliculus. In the CTx group, mucosal edema finding was dominant (p = 0.038) and fibrotic membrane finding was frequent in all levels of lacrimal drainage system. Regarding the obstructive location, lacrimal sac was the most frequently obstructed site in the two groups (p = 0.038).

CONCLUSIONS

The onset of epiphora in the CTx group was significantly earlier than in the RAI group. In the CTx group, mucosal edema finding was frequent in all levels of lacrimal drainage system. In the RAI group, granulation finding was frequent mostly in lacrimal sac and canaliculus. Since the clinical outcome was satisfactory, intervention with dacryoendoscopy-guided STI could be a treatment of choice in patients with epiphora after CTx or RAI.

Potential Ophthalmological Side Effects Induced by Anti-Neoplastic Regimens for the Treatment of Genitourinary Cancers: A Review

The outcomes of patients with genitourinary (GU) cancers have been steadily improving in recent years. Novel therapies have entered our armamentarium, while several other regimens are currently being studied in clinical trials. This recent explosion of new agents has improved patient survival and the quality of life for patients, but has also significantly increased the frequency of several side effects. The current review will focus on the potential ocular adverse reactions of GU neoplastic treatments. The broad spectrum of manifestations of ocular toxicity underscores the uniqueness and complexity of the anatomic, physiologic, and metabolic features of the human eye. Most side effects are mild in severity and transient, but some can be severe, disabling, and irreversible. Clinicians should be aware of complications that might be vision threatening and impact the patient's quality of life. In this review, we focused on the ocular toxicity of the antineoplastic regimens that are currently used for the treatment of GU, including prostate cancer, bladder cancer, renal cell carcinoma, testicular cancer, pheochromocytoma, adrenocortical carcinoma, and penile cancer.

Supportive care for toxicities in children undergoing radiation therapy

Radiation therapy (RT) is an integral part of the management of many pediatric tumors; however, it is associated with both acute and permanent adverse events that can significantly impact a child's quality of life, lead to treatment delays, and potentially affect outcomes of cancer therapy. Prevention, early detection, and optimal management of these adverse effects will help reduce their impact on the patients' quality of life and overall well-being. Unfortunately, there has not been a coordinated effort to study the etiology, evaluate risk factors, and explore novel treatments for these conditions. Studies of supportive care for children undergoing RT are often small and uncontrolled. This review will focus on the impact of irradiation on the different organ systems and their current management. Further studies are required to improve our understanding of the contributing factors and explore novel treatment options for these adverse effects and to enable children and their families to better cope with some of the unavoidable toxicities following multimodality therapy.

Cicatricial ectropion and madarosis associated with panitumumab treatment of metastatic colorectal cancer

Purpose

To report a case of cicatricial ectropion and madarosis with the use of anti-epidermal growth factor receptor medication panitumumab.

Observations

An 82-year-old man with metastatic colorectal cancer presented with cicatricial ectropion and madarosis after starting panitumumab, an anti-epidermal growth factor receptor medication used to treat metastatic colorectal cancer. His findings resolved several weeks after discontinuation of panitumumab and treatment with lubrication and antibiotic/steroid ointment.

Conclusion

This case demonstrates the importance to consider potential medication side effects when treating periocular conditions in patients taking anti-epidermal growth factor receptor (anti-EGFR) agents.

Prevalence of symptomatic dry eye in breast cancer patients undergoing systemic adjuvant treatment: A cross-sectional study

Objectives

To investigate the prevalence of symptomatic dry eye (SDE) on women undergoing systemic adjuvant therapy for breast cancer and its association with treatment settings.

Methods

Woman undergoing breast cancer systemic adjuvant therapy were included in exposure group. An age-matched non-treatment control group was recruited. This cross-sectional questionnaire-based study utilised validated Ocular Surface Disease Index (OSDI) and NCCN-FACT-Breast Cancer Symptom Index (NFBSI-16) questionnaires to determine the presence of SDE and investigate other breast cancer treatment complications. Additionally, demographic data and medical histories were collected.

Results

Of 423 eligible participants, 200 in each of the control group and the exposure group were included in the final analysis. The prevalence of SDE was 59.0% in breast cancer patients with adjuvant treatment, statistically significantly higher than 25.5% in the control group (P < 0.01). Additionally, exposure group experienced higher prevalence of moderate and severe SDE, which were 20.0% and 19.5% respectively compared with 9.0% and 4.0% in the control group (P = 0.002, P < 0.001). There was a significantly high prevalence of SDE among patients who had received over four cycles of systemic therapy (71.0%, P < 0.001) and the application of targeted therapy (71.2%, P = 0.014). The severity of SDE positively correlated with the cycles of treatment administered.

Conclusion

SDE was significantly predominant in women with breast cancer undergoing systemic adjuvant treatment. Our findings suggest dry eye assessments among patients receiving more than four cycles of chemotherapy or targeted therapy, thus early revealing possible dry eye conditions to both patients and clinicians for further specialized examination and treatment.

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Breast cancer patients undergoing systemic treatment have fairly high prevalence of symptomatic dry eye.

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Around 40% of them experienced from moderate to severe degree of dry eye.

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The severity of symptomatic dry eye in exposure group showed cycle-dependency.

The impact of anticancer drugs on the ocular surface

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

Unilateral visual impairment in a patient undergoing chemotherapy: a case report and clinical findings

Background

Visual impairment occurred as an infrequent form of chemotherapeutic toxicity and was often underestimated despite of several reports. We described a case of acute unilateral visual impairment after one cycle of intravenous chemotherapy of a normal dose, aiming at raising attention to chemotherapy-induced ocular toxicity.

Case presentation

The patient developed a progressive vision loss in the right eye during the chemotherapy. After one cycle of intravenous chemotherapy, her visual acuity decreased by 0.6 in the right eye (VOD = 0.4) compared to the previous value of 1.0 (VOD = 1.0). No evidence of ocular infiltration was observed from the cerebral magnetic resonance imaging (MRI). During her follow-up period, we documented the ophthalmologic examinations including visual acuity, visual field (VF), visual evoked potential (VEP), electroretinogram (ERG), fundus photograph (FP), fundus fluorescein angiography (FFA) and optical coherence tomography (OCT). Ophthalmoscope examination and fundus photograph showed optic disc edema, fuzzy boundary and linear hemorrhages in her right eye. Fundus fluorescein angiography (FFA) revealed capillary underdevelopment at the nasal and superior temporal area of the optic disc in the early phase and capillary fluorescein leakage in the late phase. The result of VEP test suggested the impaired function of the optic nerve. Thus, a diagnosis of nonarteritic anterior ischemic optic neuropathy (NAION) was made by the ophthalmologist according to these results. The patient was prescribed prednisone combined with neuroprotective drugs, which did not work. After the cessation of chemotherapy, her impaired vision gradually recovered.

Conclusions

This is the first reported case of acute visual impairment in a patient who underwent chemotherapy of a normal dose. It is indicated that while receiving benefits from chemotherapy, cancer patients simultaneously suffer from the risk of vision loss.

Pharmacokinetics of S-1 monotherapy in plasma and in tears for gastric cancer patients

BACKGROUND

S-1 is an oral anticancer drug composed of tegafur (FT), which is a prodrug of 5-FU, 5-chloro-2,4-dihydroxypyridine (CDHP), and potassium oxonate. Recently, some studies have been reported on watering eyes caused by S-1. However, the mechanism of watering eyes caused by S-1 is still unclear. The aim of this study was to investigate the correlation between tears and plasma concentrations of FT, 5-FU, and CDHP, which are components and active modulator of S-1.

METHODS

We prospectively investigated the pharmacokinetics (PK) of FT, 5-FU, and CDHP in plasma and in tears of gastric cancer patients who were treated with S-1 monotherapy at the dose of 80 mg/m²/day. Plasma and tears from both eyes were obtained 1, 2, 4, and 8 h after S-1 administration on day 1 and 14 of the first cycle.

RESULTS

Total of eight patients were enrolled. All the FT, 5-FU and CDHP were detected both in plasma and in tears, and their PK parameters were measured. There was a positive correlation between the concentrations of FT, 5-FU and CDHP in the plasma and those in the tears on day 1 and day 14 (correlation coefficients r, right eye/left eye: r = 0.882/0.878, 0.877/0.890, and 0.885/0.878, respectively).

CONCLUSION

There was a positive correlation between the concentrations of FT, 5-FU and CDHP in the plasma and those in the tears. The result is expected to facilitate the further investigation into the causes of watering eyes and the establishment of the effective methods for the prevention and the treatment.

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.

Capecitabine-Induced Bilateral Ectropion: A Rare Ocular Manifestation Requiring Surgical Intervention

It has been established that many chemotherapeutic agents are associated with a variety of ocular side effects. As an antineoplastic agent, 5-fluorouracil (5-FU) is the chemotherapeutic agent that is frequently linked with cicatricial ectropion. Capecitabine is a prodrug of 5-FU and has a more favorable side effect profile than 5-FU. Frequent side effects of capecitabine include gastrointestinal events and hand-foot-mouth syndrome; cicatricial ectropion is rather uncommon. Enzyme deficiencies affecting the capecitabine metabolism have been reported to be associated with exaggerated generalized systemic and cutaneous side effects; however, there are no cases in the literature reporting capecitabine-induced isolated bilateral-progressive ectropion. Although cessation of the agent is frequently sufficient for the treatment of ectropion, close follow-up is indicated in such patients as permanent damage may occur if the problem is left untreated. We report a case of capecitabine-induced bilateral cicatricial ectropion refractory to treatment cessation, ultimately requiring surgical treatment.

Meibomian Gland Dysfunction in Patients With Chemotherapy-Induced Lacrimal Drainage Obstruction

PURPOSE

To investigate the relationship between chemotherapy-induced lacrimal drainage (LD) obstruction and obstructive meibomian gland dysfunction.

METHODS

Twenty patients who had received chemotherapy were divided into 2 groups, according to the presence of LD obstruction: the LD obstruction group (n = 10) and control group (n = 10). Upper and lower meibomian gland loss was evaluated using noncontact meibography, and tear film lipid layer thickness was measured using an interferometer. The mean values of the right and left eyes of each patient were used to compare parameters between both groups.

RESULTS

The LD obstruction group had higher levels of meibomian gland loss in both upper (42.9% ± 16.4%) and lower meibomian glands (80.1% ± 16.7%) than did the control group (17.3% ± 6.7% and 22.8% ± 13.0%, respectively) (P < 0.001 and P < 0.001, respectively). In the LD obstruction group, meibomian gland loss in the lower eyelid was significantly higher than that in the upper eyelid (P < 0.001). The lipid layer was significantly thinner in the LD obstruction group (28.4 ± 9.7 nm) than it was in the control group (72.9 ± 22.5 nm) (P < 0.001).

CONCLUSIONS

Patients with chemotherapy-induced LD obstruction had greater meibomian gland loss and thinner lipid layers than did patients without LD obstruction. Chemotherapeutic agents that induce LD obstruction can also block the meibomian gland orifice, resulting in obstructive meibomian gland dysfunction through the same mechanism.

Retrospective Comparative Study of Topical Interferon α2b Versus Mitomycin C for Primary Ocular Surface Squamous Neoplasia

PURPOSE

To compare the efficacy and safety of topical interferon alpha 2b (IFNα2b) and mitomycin C (MMC) for ocular surface squamous neoplasia.

METHODS

In this retrospective study, medical records of 51 eyes of 50 patients with a diagnosis of primary ocular surface squamous neoplasia were included. All cases were treated with either topical IFNα2b (1 million IU/mL) or MMC (0.4 mg/mL) 4 times a day. The primary outcome measure was frequency of clinical resolution of tumors along with failure and recurrence rates after treatment. Other outcome measures included the duration of treatment and adverse effects associated with both topical therapies.

RESULTS

Twenty-six eyes were treated with topical IFNα2b and 25 eyes were treated with topical MMC. A complete response was achieved in 23 (89%) and 23 (92%) eyes with topical IFNα2b and MMC, respectively (P = 0.67). The median time to lesion resolution was significantly different between the groups (median 3.5 months in the IFNα2b group and 1.5 months in the MMC group) with an average difference of 1.7 months (P < 0.005). Five (10%) of 51 patients showed no or partial response to topical therapy. Subsequently, they underwent surgical excision. Adverse effects occurred in 3 (12%) patients using IFNα2b and 22 (88%) patients using MMC (P < 0.005).

CONCLUSIONS

Both IFNα2b and MMC seemed to be equally effective topical monotherapies. Despite a prolonged time to lesion resolution, IFNα2b-treated eyes had better safety and tolerance in comparison with MMC-treated eyes.

Excessive watering eyes in gastric cancer patients receiving S-1 chemotherapy

BACKGROUND

Watering eyes is a common late adverse event associated with S-1 chemotherapy; however, the frequency and predictive factors are not known.

METHODS

This study included 304 consecutive gastric cancer patients treated with adjuvant S-1 monotherapy for 1 year at Shizuoka Cancer Center. We retrospectively evaluated the frequency of watering eyes, and explored other nonhematological adverse events during the first course of S-1 monotherapy which could become predictive factors for watering eyes.

RESULTS

The severest grade of watering eyes during S-1 monotherapy was grade 2 in 41 patients (13.5 %) and grade 3 in 36 patients (11.8 %). The median time to onset of grade 2 and grade 3 watering eyes was 82 days (range 6-344 days) and 249 days (range 84-653 days), respectively, and the median cumulative S-1 dose at the onset of grade 2 and grade 3 watering eyes was 4174 mg/m(2) (range 491-16,095 mg/m(2)) and 10,243 mg/m(2) (range 4943-16,341 mg/m(2)), respectively. Multivariate analysis showed that anorexia (odds ratio 2.37, P = 0.008), oral mucositis (odds ratio 3.86, P = 0.0003), skin hyperpigmentation (odds ratio 3.84, P = 0.0001), and rash (odds ratio 3.76, P = 0.01) observed during the first course were significantly associated with watering eyes.

CONCLUSION

The risk of watering eyes was higher in patients who also had anorexia, oral mucositis, skin hyperpigmentation, or rash during first course of S-1 monotherapy than in those without them.

Abnormalities in the meibomian glands in patients with oral administration of anticancer combination drug-capsule TS-1(®): a case report

BACKGROUND

The anticancer TS-1(®) combination capsules of tegafur, gimeracil, and oteracil potassium (Taiho Pharmaceutical Co. Ltd, Japan) causes side effects, i. e., corneal epithelial disorder and dacryostenosis. However, its side effect on meibomian gland had not been reported. We observed morphological changes in the meibomian gland in patients taking TS-1(®) who exhibited punctate corneal epithelial defects to examine if dysfunction of meibomian glands is involved in the corneal epitheliopathy.

CASE PRESENTATION

Patients comprised two males and one female (age, 59-81 years). After starting oral TS-1(®) administration, patients developed subjective symptoms such as decreased visual acuity. Corneal epithelial disorder was seen in all six eyes of the three subjects exhibited, and lacrimal duct disorder was seen in one eye. Furthermore, meibomian gland loss and contraction were observed in all six eyes that exhibited meibomian gland disorder upon examination by using the MeiboPen(®).

CONCLUSIONS

Results suggested that oral administration of TS-1(®) may cause meibomian gland disorder which potentially affect corneal epithelial homeostasis.

Erlotinib induced ectropion following papulopustular rash

BACKGROUND

Erlotinib is a targeted anti-cancer drug which acts through the inhibition of epidermal growth factor receptor (EGFR).

MAIN OBSERVATIONS

A 79-year-old developed bilateral ectropion after he received erlotinib treatment for lung adenocarcinoma. The ectropion completely resolved with symptomatic treatment without any modification in erlotinib therapy.

CONCLUSIONS

EGFR inhibitors are frequently associated with a variety of mucocutaneous adverse events. Ocular toxicity associated with these agents has been reported rarely. We present this case to underline the importance of recognition of newly reported cutaneous and ocular adverse events of targeted therapies.

Corneal limbal stem cell deficiency associated with the anticancer drug S-1

Purpose

An oral antineoplastic drug, S-1, is known to be more effective with less toxicity and fewer gastrointestinal side effects than the conventional intravenous 5-fluorouracil. We report a case of limbal stem cell deficiency that occurred in a patient receiving chemotherapy using S-1 alone for gastric cancer.

Case Report

A 65-year-old woman with symptoms of grittiness and epiphora in both eyes for several months was referred to the ophthalmology clinic. She had been receiving S-1 orally after total gastrectomy for advanced gastric cancer. Slit lamp examination revealed an irregular hazy corneal epithelium in both eyes that extended to the center of the cornea overlying the pupil and showed late staining with fluorescein dye. Palisades of Vogt at the superior limbus were absent in both eyes. Best-corrected distance vision was 20/50 in both eyes with all other structures of the anterior and posterior segment unremarkable including a patent lacrimal drainage system. There was no change in the corneal lesions of either eye despite 3 months of topical therapy. The lesions did resolve in 4 months after discontinuation of S-1 therapy owing to acute renal failure.

Conclusions

Early detection of this adverse reaction before significant visual loss through regular follow-up appears to be important in patients receiving S-1 therapy.

Bilateral lacrimal drainage obstruction and its association with secondary causes

PURPOSE

Etiologies of lacrimal obstruction requiring a dacryocystorhinostomy (DCR) have been reviewed previously but most commonly are thought to result from "primary acquired" nasolacrimal duct obstruction, a process of chronic inflammation in a narrowed duct. The authors have observed that secondary causes are frequently associated with bilateral lacrimal outflow disease. The purpose of this study is to investigate this relationship to help the clinician prioritize which patients to evaluate for secondary causes.

METHODS

This is a retrospective case-controlled review of patients who underwent bilateral DCR from 1986 to 2012 at this institution. They are compared with an age and gender-matched control group who underwent unilateral DCR. Statistical analysis was undertaken using the Pearson chi-square test for p value, except for age, which used the Wilcoxon rank sum test. Logistic regression was used for comparing prevalence of secondary issues in bilateral disease versus unilateral disease, with age as covariate.

RESULTS

Two hundred thirty-five patients underwent bilateral (91) or unilateral DCR (144). Twice as many patients undergoing bilateral DCR had an underlying secondary cause compared with the patients undergoing unilateral DCR. (38%, 19%, p= 0.001, odds ratio 2.59). In patients <50, the odds ratio of a secondary cause in bilateral disease would be 5.34 compared with patients older than 80. (p = 0.0002) Patients in the bilateral DCR group underwent revisions at more than twice the rate as patients in the unilateral DCR group (26%, 12%, p = 0.007).

CONCLUSIONS

Ophthalmologists should have a high index of suspicion for secondary conditions underlying bilateral lacrimal outflow obstruction, especially in patients <50. These patients should undergo laboratory workup and intraoperative biopsy. They should also be counseled regarding a higher failure rate.

Supportive cryotherapy: a review from head to toe

CONTEXT

Conventional chemotherapy leads to multiple adverse mucocutaneous complications such as oral mucositis, alopecia, ocular toxicity, and onycholysis. Limited pharmacologic interventions are available for preventing these clinical problems.

OBJECTIVES

This study aimed to critically review the role of cryotherapy (regional hypothermia) for alleviating these adverse symptoms.

METHODS

A narrative review was performed, with an emphasis on randomized controlled trials. A comprehensive search using PubMed, Ovid, Embase, and MEDLINE(®) was completed. References of all cited articles also were reviewed. Data from the review were composed of articles published between 1970 and May 2013.

RESULTS

Available evidence suggests that regional hypothermia decreases the burden of chemotherapy-related oral mucositis, alopecia, ocular toxicity, and onycholysis. The major limitations of studies include the absence of blinded control groups and variable clinical end points.

CONCLUSION

Regional hypothermia decreases the burden of these four chemotherapy-induced complications and is well tolerated. More research is needed to determine what subgroups of cancer patients are most likely to respond to different types of regional hypothermia, the ideal duration of cooling needed, and further improve the ease of use of the cooling devices.

Prevalence of Excessive Tearing in Women With Early Breast Cancer Receiving Adjuvant Docetaxel-Based Chemotherapy

Purpose

To define the incidence and impact of tearing in patients receiving adjuvant docetaxel-based chemotherapy and assess for lacrimal duct obstruction (LDO) as a causative factor.

Patients and Methods

Consecutive patients with early breast cancer recommended for docetaxel-based chemotherapy with no prior ocular symptoms were included. Before and after completion of chemotherapy, patients underwent lacrimal drainage evaluation by computed tomographic dacrocystography (CT-DCG) and ophthalmic assessment. Eye symptoms were assessed at baseline, during, and after completion of chemotherapy.

Results

Over a 22-month period, 100 patients were recruited. Asymptomatic LDO was present at baseline in 17% and 18% of patients, as assessed by ophthalmic review and CT-DCG, respectively. Overall, 86% of patients developed tearing, with no significant difference between those who did and did not have LDO (94% v 84%; P = .45). Blepharitis occurred in 37% and minor corneal epitheliopathy in 22% of patients, with neither condition predicting for the development of tearing. Impairment of visual activities was greatest after cycle one (70% of patients) but had decreased to < 5% by 4 months after treatment.

Conclusion

Tearing occurs in the majority of patients receiving adjuvant docetaxel-based chemotherapy regimens and occurred similarly in patients with and without LDO. There was poor concordance between CT-DCG and ophthalmic examination in the detection of LDO. Tearing and other eye symptoms impaired visual activities, but in nearly all patients, both symptoms and functional impairment were mild and had resolved by 4 months after chemotherapy. Our study demonstrates docetaxel-related tearing is not caused by LDO, and as such, evaluation or stenting of the duct is not considered necessary.

Lacrimal drainage obstruction in gastric cancer patients receiving S-1 chemotherapy

BACKGROUND

This study was conducted to determine the incidence and clinical characteristics of lacrimal drainage obstruction (LDO) in patients receiving S-1 chemotherapy.

PATIENTS AND METHODS

Consecutive 170 patients with gastric cancer who underwent curative surgery and received adjuvant S-1 chemotherapy were enrolled. S-1 was administered orally (40 mg/m2 b.i.d. on days 1-28 every 6 weeks) for 1 year. Ophthalmologic examinations were carried out on patients complaining of epiphora.

RESULTS

Thirty-one patients (18%) developed epiphora. Among 31 patients, 25 underwent ophthalmologic examinations and 22 (88%) were diagnosed with LDO. The median time to the onset of LDO was 2.9 months. The most common site of obstruction was the nasolacrimal duct [86% (19/22)]; punctal [23% (5/22)] and canalicular obstruction [14% (3/22)] were also noted. In multivariate analysis, total gastrectomy [versus partial gastrectomy: hazard ratio (HR), 2.9; P=0.014] and creatinine clearance<50 ml/min (versus ≥50 ml/min: HR, 2.9; P=0.038) were independent risk factors for the development of LDO.

CONCLUSION

Considering the high incidence of LDO in patients receiving S-1 chemotherapy, oncologists should be alert to epiphora and cooperate with ophthalmologists in the early stages to improve the quality of life of patients and avoid more complicated ophthalmologic procedures.

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.

Breast cancer medications and vision: effects of treatments for early-stage disease

This review concerns the effects on vision and the eye of medications prescribed at three phases of treatment for women with early-stage breast cancer (BC): (1) adjuvant cytotoxic chemotherapy, (2) adjuvant endocrine therapy, and (3) symptomatic relief. The most common side effects of cytotoxic chemotherapy are epiphora and ocular surface irritation, which can be caused by any of several different regimens. Most notably, the taxane docetaxel can lead to epiphora by inducing canalicular stenosis. The selective-estrogen-receptor-modulator (SERM) tamoxifen, long the gold-standard adjuvant-endocrine-therapy for women with hormone-receptor-positive BC, increases the risk of posterior subcapsular cataract. Tamoxifen also affects the optic nerve head more often than previously thought, apparently by causing subclinical swelling within the first 2 years of use for women older than ∼50 years. Tamoxifen retinopathy is rare, but it can cause foveal cystoid spaces that are revealed with spectral-domain optical coherence tomography (OCT) and that may increase the risk for macular holes. Tamoxifen often alters the perceived color of flashed lights detected via short-wavelength-sensitive (SWS) cone response isolated psychophysically; these altered perceptions may reflect a neural-response sluggishness that becomes evident at ∼2 years of use. The aromatase inhibitor (AI) anastrozole affects perception similarly, but in an age-dependent manner suggesting that the change of estrogen activity towards lower levels is more important than the low estrogen activity itself. Based on analysis of OCT retinal thickness data, it is likely that anastrozole increases the tractional force between the vitreous and retina. Consequently, AI users, myopic AI users particularly, might be at increased risk for traction-related vision loss. Because bisphosphonates are sometimes prescribed to redress AI-induced bone loss, clinicians should be aware of their potential to cause scleritis and uveitis occasionally. We conclude by suggesting some avenues for future research into the visual and ocular effects of AIs, particularly as relates to assessment of cognitive function.

Cicatricial entropion following docetaxel (Taxotere) therapy

We report eyelid margin changes in 3 patients after docetaxel treatment for breast cancer. These patients were referred to Cincinnati Eye Institute for eyelash abnormalities and/or epiphora and all had been treated with docetaxel in the near past. The ophthalmic complaints started soon after chemotherapy. All 3 cases showed varying degrees of palpebral mucosal inflammation and cicatricial changes leading to marginal entropion. The first patient exhibited very prominent eyelid margin inflammation and diffuse trichiasis without madarosis. The second patient had extensive madarosis and abnormally curved, thin eyelashes with punctal and canalicular obstruction. Her marginal entropion was most prominent at the medial lower eyelids. The last patient showed significant lash misdirection in a scattered distribution and patchy madarosis along with pseudomembranes blocking the puncta. All of these eyelid abnormalities occurred soon after docetaxel treatment for advanced breast cancer. Such changes in the absence of questioning for previous docetaxel use in history taking.

Ocular complications of cancer therapy: a primer for the ophthalmologist treating cancer patients

PURPOSE OF REVIEW

Cancer patients may develop ocular complications secondary to direct or metastatic involvement with cancer, radiation exposure, or chemotherapy. As many as 1.4 million new cancer cases arise in the United States annually.

RECENT FINDINGS

Chemotherapy administration remains a critical aspect of treating many cancers and offers improved prognosis and prolonged survival in many cases; however, these therapies are known to cause a wide range of toxicities.

SUMMARY

Ocular side effects such as photophobia, cataracts, glaucoma, retinopathy, and other ocular toxicities have been reported following chemotherapy administration. To effectively treat cancer patients, oncologists, primary care clinicians, and ophthalmologists should be aware of the potential ophthalmic toxicities certain widely used chemotherapeutic agents and radiation therapy may pose to their patients, particularly in the setting of preexisting ocular conditions.

Docetaxel-associated epiphora

Docetaxel is a semisynthetic taxane indicated for the treatment of advanced breast, prostate, and non-small cell lung cancers; it is also used for the treatment of various other solid tumors. The standard intermittent dosage of docetaxel is 60-100 mg/m2 every 3 weeks. At this dose and schedule, myelosuppression is common and neutropenia is usually the dose-limiting toxicity. Weekly administration of docetaxel 20-42 mg/m2 is being tested in the treatment of advanced solid tumors in order to improve patient tolerance by reducing the interval dose and to maintain therapeutic efficacy by increasing overall dose intensity. Asthenia and peripheral neuropathy can limit continued administration of weekly docetaxel. Epiphora (excess tearing due to narrowing or blockage of the lacrimal outflow passages) is associated with repeated weekly administration of docetaxel. This adverse effect can interfere with activities of daily life and negatively affect quality of life. Epiphora may be an underreported adverse effect of treatment because of underrecognition by clinicians and patient embarrassment with respect to seemingly uncontrolled tearing. The use of weekly docetaxel administration is expanding; therefore, patients should be educated to recognize and report signs and symptoms of epiphora. It is important for clinicians participating in the care of patients undergoing treatment with docetaxel to monitor for excess tearing and signs of eye irritation to ensure timely management of treatment-related epiphora.

Ophthalmic and adnexal complications of radiotherapy

The role of radiotherapy in ophthalmic practice continues to grow. This growth has seen an expansion of indications for radiotherapy, a refinement of the modalities that can be used and a reduction in the ocular and adnexal complications that result from this form of therapy. The compendium of indications for radiotherapy in ophthalmology continues to grow and now includes many conditions such as the treatment of lid and adnexal disease, ocular surface disorders and both benign and malignant disease of the posterior segment and optic pathways. The radiotherapeutic modalities employed to manage these conditions are numerous and include both radioactive plaques (brachytherapy) and external beam radiation techniques. New techniques such as stereotactic radiosurgery are delivering benefits in the management of conditions such as optic nerve sheath meningioma, where the treatment of this blinding and occasionally life-threatening intracranial neoplasm now results in fewer adverse affects. The purpose of this review is to give a brief overview of the indications and treatment modalities, and a more in-depth discussion of the potential side-effects when radiotherapy is used for ocular and periorbital disease.

Complications of mitomycin C therapy in 100 eyes with ocular surface neoplasia

AIM

To determine the complications associated with mitomycin C (MMC) in the treatment of ocular surface neoplasia.

METHODS

A retrospective and consecutive study of 100 eyes in 91 patients with ocular surface neoplasia treated with MMC in a single centre between November 1998 and January 2005. Outcome measures included complications of MMC and the treatment required for these complications.

RESULTS

One to three 7 day cycles of topical MMC 0.04% four times a day were given to 59 eyes with localised corneal-conjunctival intraepithelial neoplasia (CIN), 19 eyes with diffuse CIN, six eyes with recurrent CIN, one eye with ocular surface squamous cell carcinoma, three eyes with primary acquired melanosis (PAM) with atypia, nine eyes with conjunctival malignant melanoma (MM), two eyes with sebaceous carcinoma with pagetoid spread, and one eye with recurrent atypical fibroxanthoma. Nine patients had bilateral CIN. 31 (34%) cases developed an allergic reaction to MMC and 14 (14%) eyes had epiphora secondary to punctal stenosis at a mean follow up period of 26.5 months.

CONCLUSION

In the largest study looking at complications of topical MMC in the treatment of ocular surface neoplasia, allergic reaction and punctal stenosis are relatively common. Serious complications were not observed suggesting the safe use of MMC in mid-term follow up.

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.