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Vyas A, Subramanyam A, Phatak S, Tiwari S. Ethambutol and its ophthalmic effects; is screening and collaboration the new way forward? Indian J Tuberc 2024; 71:30-34. [PMID: 38296388 DOI: 10.1016/j.ijtb.2023.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 03/21/2023] [Indexed: 02/08/2024]
Abstract
AIM To screen patients on ethambutol and evaluate its role on visual functions and toxic optic neuropathy. SETTING AND DESIGN Retrospective, observational single tertiary centre cohort of 80 patients. METHODS AND MATERIAL A total of 69 from the initial 80 patients with visual complaints were categorised into two groups A and B; ongoing anti-tubercular therapy with ethambutol and having stopped ethambutol for greater than six months respectively. All patients underwent vision (V) testing on ETDRS chart and anterior and posterior segment evaluation. Additionally, patients in group A recorded color vision (CV) on Ishihara chart and visual evoked potential (VEP). STATISTICAL ANALYSIS USED P value was calculated using Chi square test (SPSS ver. 20). RESULTS Out of 69 patients in our study, 58 (84.05%) patients recorded reduced visual acuity. The mean visual acuity was 0.58 logMAR units. 33 out of our 58 (57%) patients with reduced visual acuity showed normal optic discs while 25 out of 58 (43%) showed altered optic discs. In group B, 14 out of 32 patients with vision of less than 20/20 also had optic disc pallor (p = 0.02). 12 out of 15 patients in group A recorded an altered color vision and also had a vision of less than 20/20 (p = 0.023). 15 patients who recorded altered VEP also had vision of less than 20/20 (p = 0.037). CONCLUSION Visual acuity, color vision and vep are sensitive and sustainable tools which can be implemented in regular screening. Ethambutol toxicity is a real problem and a collaborative approach is necessary to establish screening protocols and prevent ethambutol induced toxic optic neuropathy.
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Affiliation(s)
- Aneesha Vyas
- Vitreo-retina Department, K B H Bachooali Charitable Ophthalmic & ENT Hospital, Mumbai, Maharashtra, India
| | - Anand Subramanyam
- Vitreo-retina Department, K B H Bachooali Charitable Ophthalmic & ENT Hospital, Mumbai, Maharashtra, India.
| | - Sumita Phatak
- Vitreo-retina Department, K B H Bachooali Charitable Ophthalmic & ENT Hospital, Mumbai, Maharashtra, India
| | - Sarvesh Tiwari
- Vitreo-retina Department, K B H Bachooali Charitable Ophthalmic & ENT Hospital, Mumbai, Maharashtra, India
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Sen S, Mandal S, Banerjee M, Gk R, Saxena A, Aalok SP, Saxena R. Ethambutol-induced optic neuropathy: Functional and structural changes in the retina and optic nerve. Semin Ophthalmol 2022; 37:730-739. [PMID: 35699333 DOI: 10.1080/08820538.2022.2085517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUD Ethambutol hydrochloride (EMB) is used in the treatment of tuberculosis and is used as first line modality in combination with other medications. Ethambutol optic neuropathy (EON) is a rare but well-recognised adverse ocular event in patients who receive ethambutol for the treatment of mycobacterial infections and may be potentially devastating with reversible to irreversible changes in visual acuity. KEY FINDINGS Optical coherence tomography has been used to evaluate the thickness of retinal nerve fibre and ganglion cell layers to look for degenerative changes and early markers. Electrophysiological tests like multifocal electroretinogram, visual evoked potentials and visual fields have been used to understand the functional changes associated with established EON and also whether these can be used to detect subclinical EON and correlate them with the structural changes. In this review, we have summarised evidence published till December 2021 related to evaluation of structural and functional changes in the retina and optic nerve in eyes with EON.
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Affiliation(s)
- Sagnik Sen
- Dr Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
| | - Sohini Mandal
- Dr Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
| | - Mousumi Banerjee
- Dr Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
| | - Ranjitha Gk
- Dr Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
| | | | | | - Rohit Saxena
- Dr Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
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Taffner BMP, da Cruz LGI, de Ávila Fowler F, Nawa CC, Savioli MT, Rodrigues DS, Magalhães Junior O, Belfort Junior R. Campimetry and visual changes after RHZE treatment for tuberculosis. Int J Retina Vitreous 2022; 8:16. [PMID: 35256005 PMCID: PMC8900402 DOI: 10.1186/s40942-022-00367-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 02/20/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Tuberculosis (TB) caused by Mycobacterium tuberculosis has a high prevalence in Brazil (Global tuberculosis report 2020. Geneva: World Health Organization; 2020). The ethambutol-induced optic neuropathy damage is partly reversible, making its early diagnosis essential to reduce permanent visual damage.
Purpose
To observe alterations in the computerized campimetry, Ishihara test and visual acuity secondary to rifampicin, isoniazid, pyrimethamine, ethambutol (RHZE) treatment.
Methods
Patients undergoing treatment with RHZE at the tuberculosis service of the Federal University of São Paulo were recruited from March 2019 to December 2020. The best-corrected visual acuity (VA) measurements, Ishihara test and visual fields were performed at baseline, monthly, until 2 weeks after treatment.
Results
Twenty-five patients were included. The VA decreased significantly (P = 0.0129) post-treatment compared to month 1. The mean deviation (MD) did not decrease significantly (P > 0.05); the pattern standard deviation (PSD) decreased post-treatment compared to month 1 (P = 0.0371). Changes in the Ishihara test increased significantly (P < 0.0001) in the second month.
Conclusion
The VA and PSD decreased significantly after RHZE treatment. Changes in the Ishihara test were observed in the second month.
Trial registration: The Research Ethics Committee of Federal University of São Paulo, Paulista School of Medicine approved the study in March 2019. CAAE 04297018.4.0000.5505.
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Sheng WY, Wu SQ, Su LY, Zhu LW. Ethambutol-induced optic neuropathy with rare bilateral asymmetry onset: A case report. World J Clin Cases 2022; 10:663-670. [PMID: 35097092 PMCID: PMC8771374 DOI: 10.12998/wjcc.v10.i2.663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/12/2021] [Accepted: 12/08/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Ethambutol-induced optic neuropathy (EON) most commonly manifests as bilateral symmetrical loss of vision and often cause serious and irreversible visual impairment because of the lack of early detection and effective treatment. We followed a case of EON with rare binocular asymmetric clinical manifestations and observed the changes of visual function and retinal structure after drug withdrawal, so as to further understand the clinical characteristics of this disease.
CASE SUMMARY A 54-year-old man complained of gradual visual decline in the left eye. The patient presented with best-corrected visual acuity of 20/20 in the right eye and 20/50 in the left eye. Color vision examination revealed difficulty in reading green color plates in the left eye. The visual field manifested as concentric contraction in the left eye. After nearly a month of drug withdrawal, the right eye had a similar decline in visual function. At the last visit, 19 mo after drug withdrawal, the visual function significantly recovered in both eyes. During follow-up optical coherence tomography (OCT) examination, both eyes manifested the thickness of the retinal nerve fiber layer from mild thickening to thinning and finally temporal atrophy, and the ganglion cell-inner plexiform layer showed significant thinning. The difference was that a reversible structural disorder in the outer retina of the nasal macula was detected in the left eye by macular high-definition OCT.
CONCLUSION Nephropathy and high blood pressure, which damage the retinal microcirculation, may cause damage to the outer layer of the retina. Ethambutol may influence photoreceptor as well as retinal ganglion cells.
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Affiliation(s)
- Wen-Yan Sheng
- Department of Ophthalmology, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Shuang-Qing Wu
- Department of Ophthalmology, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Ling-Ya Su
- Department of Ophthalmology, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Li-Wei Zhu
- Department of Ophthalmology, Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
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Dhiman R, Lakra S, Panda PK, Hemachandran N, Sharma S, Saxena R. Neuro-ophthalmic manifestations of tuberculosis. Eye (Lond) 2022; 36:15-28. [PMID: 34127839 PMCID: PMC8727585 DOI: 10.1038/s41433-021-01619-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 05/04/2021] [Accepted: 05/25/2021] [Indexed: 02/06/2023] Open
Abstract
Neuro-ophthalmic features are a known association in tuberculosis, especially common in central nervous system tuberculosis (CNS-TB). They are mostly the result of the visual pathway and/or ocular motor and other cranial nerve involvement. Furthermore, toxic optic neuropathy and paradoxical response to anti-tubercular drugs (ATT) are also not uncommon. The etiopathogenesis is by the complex interplay of various factors like exudates, vasculitis, arachnoiditis, presence of tuberculomas, hydrocephalus, brain infarcts and/or immune-mediated reaction. The entity often poses a diagnostic dilemma for the ophthalmologists/neuro-ophthalmologists and may lead to irreversible vision loss. The presence of neuro-ophthalmic features not only affect the visual outcome but are also predictors of systemic morbidity of the disease. Therefore, understanding and knowledge about this entity are necessary for the comprehensive management of the disease. While various forms of TB including CNS-TB have been well-dealt with in literature, little is discussed specifically about the neuro-ophthalmic manifestations of tuberculosis. Therefore, the purpose of this review is to highlight current understanding of the types of neuro-ophthalmic involvement in tuberculosis, its etiopathogenesis, diagnosis and management.
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Affiliation(s)
- Rebika Dhiman
- Neuro-Ophthalmology Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.
| | - Subodh Lakra
- Neuro-Ophthalmology Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Prateek Kumar Panda
- Pediatric Neurology Services, Department of Paediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Naren Hemachandran
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjay Sharma
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Rohit Saxena
- Neuro-Ophthalmology Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
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Konar KD, Pillay S. A case and literature review of intraocular echinococcus causing bilateral visual loss in a HIV-infected patient. SAGE Open Med Case Rep 2022; 10:2050313X221113699. [PMID: 36051405 PMCID: PMC9425879 DOI: 10.1177/2050313x221113699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 06/28/2022] [Indexed: 11/16/2022] Open
Abstract
Although echinococcosis is a common parasitic disease endemic to Africa, ocular echinococcosis is rare. We present a case of intraocular echinococcosis in a HIV-infected patient. A 38-year-old South African HIV-infected woman presented to a district-level hospital in Kwa-Zulu Natal on 10 March 2020. Her main presenting complaint was that of progressive, painless, bilateral visual loss. A B-ultrasonography scan revealed tractional retinal detachment on the right eye, while the left eye had tractional bands with a ‘double-walled’ cystic cavity causing retinal traction. A systemic work-up revealed a positive Echinococcus ELISA IgG with a value of 1.3, eosinophilia of 5.70% (0.41 × 109), and elevated C-reactive protein and erythrocyte sedimentation rate of 47 mg/L and 93 mm/hr, respectively. Based on the above clinical, biochemical and ultrasonographical evidence, a diagnosis of ocular echinococcosis was made. Our differential diagnosis includes toxic optic neuropathy, Jarisch-Herxheimer-like reaction secondary to immune reconstitution and necrotizing herpetic retinitis. She was initiated on topical and intravitreal steroids which led to decreased intraocular inflammation and dry maculae. Five months after presentation, her visual acuity remained unchanged with no light perception in both eyes. We conclude that ocular echinococcosis, although rare, can lead to severe visual impairment as there are no known definite treatment modalities for intraocular hydatid disease. Reports on co-infections with HIV and Echinococcus are limited with a potential scope for research.
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Affiliation(s)
| | - Somasundram Pillay
- Department of Internal Medicine, King Edward VIII Hospital (KEH), Durban, South Africa
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Saxena R, Singh D, Phuljhele S, Kalaiselvan V, Karna S, Gandhi R, Prakash A, Lodha R, Mohan A, Menon V, Garg R. Ethambutol toxicity: Expert panel consensus for the primary prevention, diagnosis and management of ethambutol-induced optic neuropathy. Indian J Ophthalmol 2021; 69:3734-3739. [PMID: 34827033 PMCID: PMC8837289 DOI: 10.4103/ijo.ijo_3746_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Ethambutol use may lead to permanent vision loss by inducing a dose- and duration-dependent optic neuropathy. This has been of concern to ophthalmologists and physicians both; however, ethambutol continues to be used because of its anti-mycobacterial action with relative systemic safety. Recently, the guidelines of the Revised National Tuberculosis Control Programme of India have been revised to allow for fixed dose and longer duration of ethambutol use; this is likely to result in an increase in vision-threatening adverse effects. Taking cognizance of this, neuro-ophthalmologists, infectious disease specialists, and scientists met under the aegis of the Indian Neuro-Ophthalmology Society to deliberate on prevention, early diagnosis, and management of ethambutol-related toxic optic neuropathy. The recommendations made by the expert group focus on early suspicion of ethambutol toxicity through screening at the physician’s office and opportunistic screening by the ophthalmologist. Further, they focus on an early diagnosis through identification of specific clinical biomarkers and on management in way of early stoppage of the drug and supportive therapy. This statement also describes the mechanism of reporting a case of toxic optic neuropathy through the Pharmacovigilance Programme of India and emphasizes the need for spreading awareness regarding vision-threatening adverse effects among patients and healthcare workers.
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Affiliation(s)
- Rohit Saxena
- Strabismus and Neuro-Ophthalmology Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
| | | | - Swati Phuljhele
- Strabismus and Neuro-Ophthalmology Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
| | - V Kalaiselvan
- Indian Pharmacopoeia Commission, Ministry of Health and Family Welfare, Government of India, Noida, Uttar Pradesh, India
| | - Satya Karna
- Department of Ophthalmology, Jaypee Hospital, Noida, Uttar Pradesh, India
| | - Rashmin Gandhi
- Neuro-Ophthalmology Services, Centre for Sight, Hyderabad and University of Hyderabad, Telangana, India
| | - Anupam Prakash
- Department of Medicine, Lady Harding Medical College and Affiliated hospitals, New Delhi, India
| | - Rakesh Lodha
- Department of Paediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Anant Mohan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Vimla Menon
- Neuro-Ophthalmology Services, Centre for Sight, Delhi, India
| | - Rajeev Garg
- Directorate General of Health Services, Government of India, New Delhi, India
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10
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Abstract
The purpose of this review is to update clinicians on available literature on the ocular toxicity of ethambutol and the type of eye care to be provided to patients treated with these medications. Ethambutol is a commonly used first-line anti-tuberculosis drug. Since its first use in the 1960s, ocular toxicity is described as related to dose and duration, and it is reversible on therapy discontinuation. However, the reversibility of the toxic optic neuropathy remains controversial. The mechanism of ocular toxicity owing to ethambutol is still under investigation. Other than discontinuing the drug, no specific treatment is available for the optic neuropathy caused by ethambutol. Doctors prescribing ethambutol should be aware of the ocular toxicity, and the drug should be used with proper patient education and ophthalmic monitoring.
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Ethambutol-related impaired visual function in childrens less than 5 years of age treated for a mycobacterial infection: diagnosis and evolution. Pediatr Infect Dis J 2015; 34:346-50. [PMID: 25764095 DOI: 10.1097/inf.0000000000000589] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The effects of ethambutol (EMB) on vision are particularly difficult to detect in children less than 5 years of age because of a lack of complaints and objective clinical signs. The aim of this study was to assess the frequency of visual abnormalities and the utility of visual-evoked potentials (VEPs) recordings in monitoring the visual function of children less than 5 years of age who were exposed to EMB during anti-mycobacterial treatment. METHODS We performed a retrospective study in Robert-Debré University Hospital, Paris, France, including all children less than 5 years of age, who were treated with EMB for a mycobacterial infection from January 2002 to December 2012. RESULTS Fourteen patients were enrolled, including 12 treated for Mycobacterium tuberculosis infection. The sex ratio was 1:1. The median age was 1.65 years (0.3 to 4.7). Five patients had subarachnoid involvement. The median EMB dose was 22 mg/kg/day (15 to 27). Only 11 patients were monitored using VEPs. Three children (27.3%) developed a visual impairment secondary to EMB, with delays of 4, 7 and 36 weeks. One of the 3 patients developed an impairment of the retrochiasmatic visual pathways, and 2 other patients developed classical retrobulbar optic neuritis. In all cases, the discontinuation of EMB resulted in a normalization of these findings. CONCLUSION Alterations in visual function related to the use of EMB are not uncommon in young children and are most likely underestimated. Systematic close monitoring using VEPs recordings is needed in young children treated with EMB.
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Affiliation(s)
- Parvaiz A Koul
- Department of Internal and Pulmonary Medicine, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar -190 011, Jammu and Kashmir, India. E-mail:
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Gümüş A, Öner V. Follow up of retinal nerve fiber layer thickness with optic coherence tomography in patients receiving anti-tubercular treatment may reveal early optic neuropathy. Cutan Ocul Toxicol 2014; 34:212-6. [DOI: 10.3109/15569527.2014.954715] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Kandel H, Adhikari P, Shrestha GS, Ruokonen EL, Shah DN. Visual Function in Patients on Ethambutol Therapy for Tuberculosis. J Ocul Pharmacol Ther 2012; 28:174-8. [DOI: 10.1089/jop.2011.0095] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Himal Kandel
- Eye Care Clinic, S. Hithadhoo, Republic of Maldives
| | - Prakash Adhikari
- BP Koirala Lions Centre for Ophthalmic Studies, Institute of Medicine, Kathmandu, Nepal
| | - Gauri S. Shrestha
- BP Koirala Lions Centre for Ophthalmic Studies, Institute of Medicine, Kathmandu, Nepal
| | - Eeva-Liisa Ruokonen
- Department of Pulmonary Diseases, Turku University Central Hospital, Turku, Finland
| | - Dev Narayan Shah
- BP Koirala Lions Centre for Ophthalmic Studies, Institute of Medicine, Kathmandu, Nepal
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Abstract
Toxic optic neuropathy (TON) is a disease entity which is not only underdiagnosed, but also often diagnosed at a stage when recovery of vision is not possible. This article gives an overview of common causes, clinical features, and management of TON.
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Affiliation(s)
- Pradeep Sharma
- Squint and Neuro-Ophthalmology Unit, R P Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Reena Sharma
- Squint and Neuro-Ophthalmology Unit, R P Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
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Abstract
Ethambutol optic neuropathy is a well-recognised adverse ocular event in patients who receive ethambutol for the treatment of mycobacterial infections. Much has been published on this condition; however, understanding of patient outcomes and the mechanism by which ethambutol optic neuropathy occurs, as well as data published in textbooks and reference books, tend to lag behind what is currently known. The purpose of this article is to update the clinician on what is currently accepted in regards to the clinical presentation of ethambutol optic neuropathy and what type of eye care should be provided to patients treated with this medication. In addition, new treatment recommendations are suggested to assist clinicians in complying with currently accepted standards of care.
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Affiliation(s)
- Frederick W Fraunfelder
- Casey Eye Institute, Oregon Health & Science University, 3375 S.W. Terwilliger Boulevard, Portland, OR 97239-4197, USA.
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Mistr S, Chavis PS. Treatment of neuro-ophthalmologic manifestations of tuberculosis. Curr Treat Options Neurol 2005; 8:53-67. [PMID: 16343361 DOI: 10.1007/s11940-996-0024-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In the absence of obvious pulmonary or disseminated tuberculosis, ocular and central nervous system (CNS) tuberculosis may represent a significant diagnostic challenge. Refinements in polymerase chain reaction techniques and neuroimaging have strengthened the battery of tests used to diagnose CNS and ocular tuberculosis, yet in many cases, the diagnosis remains one of exclusion; it may ultimately be determined through exacerbation by anti-inflammatory therapy with subsequent improvement by antitubercular medication treatment. Because of emerging drug resistance, at least a two-drug regimen is required for therapeutic testing and treatment of isolated ocular tuberculosis. If pulmonary or miliary disease coexists, a 6-month, four-drug regimen with isoniazid, rifampin, pyrazinamide, and ethambutol is required for treatment. Tubercular meningitis is treated with the same four-drug regimen for at least 9 to 12 months. Burden of therapeutic compliance rests on the treating physician and public health sector. Best compliance is realized with directly observed therapy.
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Affiliation(s)
- Susannah Mistr
- Storm Eye Institute, Department of Ophthalmology, Medical University of South Carolina, 167 Ashley Avenue, Charleston, SC 29425, USA
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Abstract
Ethambutol is an antimicrobial agent used frequently to treat tuberculosis. The most commonly recognized toxic effect of ethambutol is optic neuropathy, which generally is considered uncommon and reversible in medical literature. We describe a 43-year-old man who developed signs and symptoms of bilateral optic neuropathy during treatment with ethambutol. This case and a review of the literature show the severe and unpredictable nature of ethambutol toxicity and its potential for irreversible vision loss despite careful ophthalmologic monitoring.
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Affiliation(s)
- Alex Melamud
- Cole Eye Institute, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Woung LC, Jou JR, Liaw SL. Visual function in recovered ethambutol optic neuropathy. J Ocul Pharmacol Ther 1995; 11:411-9. [PMID: 8590273 DOI: 10.1089/jop.1995.11.411] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
The visual acuity of the patient with ethambutol optic neuropathy will recover within 3 to 4 months after discontinuing the drug. We studied the extent of the recovery of other visual functions. Thirty-six axial type ethambutol optic neuropathy patients, who visited our neuro-ophthalmology clinic from January, 1990, to December, 1993, were included in this study. Fifteen patients (29 eyes) regained their visual acuity to better than 1.0. The average follow-up period following the recovery is 21.7 months. Pattern reversal VEP, Farnsworth-Munsell 100-Hue color vision test, critical flicker frequency (CFF), visual field perimetry, contrast sensitivity and edge-light pupil cycle time were assessed for every affected eye. Latency (P100) of visually evoked potential was delayed in 34.5% (10/29) of eyes. In color vision, 48.3% (14/29) of eyes had deutan or tritan defect. An abnormality of red CFF with value lower than 31 Hz was revealed 51.7% (15/29) eyes. In the visual field, 58.6% (17/29) of eyes had paracentral scotoma, arcuate scotoma, or enlargement of physiologic blind spot. Contrast sensitivity was depressed in 62.1% (18/29) of eyes, mainly at middle and low spatial frequency. Pupil cycle time was prolonged in 72.4% (21/29) of eyes. Aside from visual acuity, other visual functions of the recovered ethambutol optic neuropathy patients were incomplete. The extent of recovery of the visual function is as follows: visual acuity-VEPs-color sense-CFF-visual field-contrast sensitivity-pupil cycle time.
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Affiliation(s)
- L C Woung
- Department of Ophthalmology, National Taiwan University School of Medicine, Taipei, Republic of China
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Nasemann J, Zrenner E, Riedel KG. Recovery after severe ethambutol intoxication--psychophysical and electrophysiological correlations. Doc Ophthalmol 1989; 71:279-92. [PMID: 2776631 DOI: 10.1007/bf00170977] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Six patients with severe ocular side effects caused by therapeutical doses of the tuberculostatic drug ethambutol were investigated during the course of recovery with psychophysical and electrophysiological methods. Three patients developed an optic atrophy with permanently reduced vision as a likely consequence of additional risk factors such as diabetes, alcohol abuse, and reduced kidney function. The severity of the neuritis of the optic nerve was not related to the total intake of ethambutol. The likelihood of a permanent ocular damage increased sharply if the visual acuity had dropped below a value of 1/10. permanently prolonged latency of the P-100 component was found in visual evoked potentials even in cases with good recovery from ethambutol-induced damage. The recovery of color vision could be monitored very well with the Farnsworth-Munsell 100-Hue Test which revealed a diffuse impairment of color discrimination with a slight prevalence of the red-green axis. In addition to the known disturbances of the red-green antagonistic neurons, it could be demonstrated by measuring transient tritanopia and spectral sensitivity functions that ethambutol also affects the blue-yellow antagonism at the retinal level.
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