Association of Uveitis and Macular Edema With Anastrozole Therapy

Partially Reversible Bilateral Papilledema in a Patient Using Anastrozole: A Case Study

Anastrozole is an endocrine-modifying agent used in the treatment of estrogen-sensitive breast cancer in the postmenopausal breast cancer population. Anastrozole is known for its side effect profile which includes an increased risk of osteoporosis. However, emerging evidence in the literature in the form of case studies demonstrates several potential ocular side effects due to the use of the medication. In our study, a 66-year-old female using anastrozole suffered severe bilateral papilledema that resolved after cessation of the medication. There is a growing body of evidence demonstrating the use of anastrozole and its impact on ocular health leading to deleterious side effects, such as papilledema.

Clinical Manifestations, Diagnosis, Treatment and Prognosis of Uveitis Induced by Anticancer Drugs: A Review of Literature

There are increasing reports that anticancer drugs, especially immunotherapy and specific targeted therapy, can cause uveitis, but it is not fully understood whether the clinical features of this drug-induced uveitis differ from those of other types of uveitis and whether there are differences between these drugs. We retrospectively reviewed the published cases and case series in PubMed, Embase, Web of Science, and Cochrane from January 2011 to October 2020. We analysed the data, including patients’ basic information, medications used, duration of use, time to onset, clinical manifestations, diagnosis, treatment, and prognosis of uveitis. We focused on the differences in uveitis caused by immunotherapy and specific targeted therapy. Altogether 93 cases (43 men, 48 women, and 2 cases whose gender was not mentioned) reported in 55 articles were included in this study. The average age was 59.6 ± 13.5 years. Eighty percent of the patients had bilateral involvement. Sixty cases were caused by immunotherapy (64.5%), and twenty-six were caused by specific targeted therapy (27.9%). No significant difference was found in the mean time from treatment to onset between the two groups. Anticancer drug-induced uveitis can involve all parts of the uvea from anterior to posterior, manifested as anterior chamber flare, anterior chamber cells, papillitis, macular oedema, subretinal fluid, and choroidal effusion. Anterior uveitis (24 cases, 40.0%) was more common in immunotherapy, and intermediate uveitis (8 cases, 30.8%) was more common in specific targeted therapy. The mean LogMAR visual acuity in specific targeted therapy at presentation was lower than in immunotherapy, but it was not statistically significant. Corticosteroid therapy can effectively control uveitis induced by anticancer drugs. However, the survival prognosis was poor. Among the 19 patients with reported cancer prognosis, seven (36.8%) had no cancer progression, eight (42.1%) had further metastases, and four (21.0%) died of cancer. In conclusion, uveitis caused by anticancer drugs involves both eyes and manifests as various types of uveitis. Patients with specific targeted therapy are more likely to have intermediate uveitis and low vision, and immunotherapy patients are more likely to have anterior uveitis. Corticosteroids are effective against uveitis caused by anticancer drugs.

The effects of systemic aromatase inhibitors on meibomian glands and corneal structure

OBJECTIVES

To evaluate the ocular surface, meibomian glands and corneal structural changes using in vivo confocal microscopy (IVCM) in patients receiving aromatase inhibitor (AI) therapy due to the breast cancer.

METHODS

This prospective observational study included 13 patients undergoing AI therapy. The patients were evaluated before the treatment, at 3- and 6-month timepoints of AI therapy. To examine the ocular surface and tear film, corneal sensitivity (CS) measurement with Cochet-Bonnet Aesthesiometer, tear film break-up time (TBUT), lissamine green (LG) staining, Schirmer I test with anaesthesia (ST) and the ocular-surface disease index (OSDI) questionnaire were performed consecutively. Corneal cell densities and sub-basal nerve plexus were evaluated with IVCM (ConfoScan 4, Nidek, Japan). Finally, quantitative MG drop-out assessment was made using infrared meibography. Shapiro Wilk, Friedman's and Post-hoc Dunn tests were used for the statistical analysis.

RESULTS

TBUT, ST scores, basal epithelium, anterior and posterior keratocytes and endothelial cell densities, long and total sub-basal nerve densities were found to be decreased (p < 0.001, p = 0.023, p < 0.001, p = 0.01, p = 0.002, p = 0.004, p < 0.001, p < 0.001), and meiboscore, CS, OSDI scores and sub-basal nerve tortuosity values were increased (p < 0.001, p = 0.015, p = 0.001, p = 0.004) during the treatment. Endothelial pleomorphism rates were lower at the 3- and 6-month timepoints compared to before the treatment (p = 0.04).

CONCLUSION

This study showed that aromatase inhibitor therapy causes deteriorations in many of the ocular-surface parameters and corneal structural changes in relation with the duration of treatment. These patients should be observed during the therapy in terms of the ocular-surface side effects.

A case report of cystoid macular edema, uveitis and vitreomacular traction in a patient taking Anastrozole

Purpose

To report a case of cystoid macular edema, uveitis, and vitreomacular traction in a patient with a history of breast cancer and taking anastrozole.

Observations

A 73-year-old female with a history of estrogen receptor-positive breast cancer and treatment with anastrozole presented with bilateral blurry vision, photophobia, and eye soreness. Optical coherence tomography (OCT) of both maculae revealed vitreomacular traction (VMT), an epiretinal membrane, cystoid macular edema (CME) in the right eye, and drusen without subretinal fluid bilaterally. Although later, macular OCT did show evidence of cystoid intraretinal spaces in the left eye as well. Fluorescein angiography showed bilateral petaloid leakage, bilateral slow disc leaking, as well as peripheral leakage in the right eye. Anastrozole was discontinued and, subsequent macular OCT showed release of VMT in the right eye, and eventual resolution of intraretinal cystoid spaces bilaterally.

Conclusions and importance

Stopping of anastrozole was associated in resolution of refractory CME in a patient on aromatase inhibitor therapy for breast cancer. It is therefore important to consider anastrozole and other aromatase inhibitor drugs as possible factors predisposing patients to the development of CME.

Ocular Side Effects of Aromatase Inhibitor Endocrine Therapy in Breast Cancer - A Review

BACKGROUND

Aromatase inhibitor therapy is currently the preferred choice in postmenopausal women with estrogen receptor positive breast cancer. This article reviews the ocular side effects of treatment with aromatase inhibitors (AIs) in patients with breast cancer.

MATERIALS AND METHODS

A comprehensive search was performed on PubMed, Web of Science and Google scholar.

RESULTS

After duplication removal, 14 clinical studies and 5 case reports, published between 2008 and 2021, were identified. Most frequently, AI treatment resulted in minor to moderate dry eye symptoms. "De novo" onset of Sjogren syndrome during AI therapy was also reported. Retinal and optic nerve side effects varied from mild, subclinical anatomic and functional impairment to severe decreased vision, secondary to hemi-central retinal artery occlusion, bilateral optic neuritis or uveitis with bilateral macular edema.

CONCLUSION

Visual disturbances encountered during AI treatment may be underestimated. Ophthalmic screening is important for early detection and appropriate treatment.

Review of the Literature on Ocular Complications Associated With Aromatase Inhibitor Use

Aromatase inhibitors (AIs), such as anastrozole, letrozole, and exemestane, are commonly used as adjuvant endocrine therapy in hormone-receptive breast cancer in postmenopausal women. Their adverse effects are well documented, except for visual disturbances. The purpose of this study was to review the current literature on ocular disease linked to AI use. Due to the scarcity of published data, any suggested ophthalmic adverse events were included to increase awareness of these drugs. The ocular side effects of tamoxifen use are well documented and were not included. Cases of rare side effects such as papilloedema, macular oedema, and uveitis associated with anastrozole and letrozole have been reported. Studies demonstrating retinopathy, in the form of crystalline retinopathy, hemicentral retinal artery occlusion, and retinal haemorrhages, are also noted. All three third-generation AIs can also lead to ocular surface diseases such as corneal epithelial changes, blepharitis, and keratitis. There is slightly more literature available regarding anastrozole-related ocular diseases. Although these are likely rare side effects, we recommend a high level of clinical suspicion when assessing patients with visual symptoms and on AIs. Larger prospective studies are necessary to further investigate these complications.

Ocular Toxicity of Targeted Anticancer Agents

The proliferation of targeted anticancer agents over the last two decades has revolutionized cancer treatment and improved survival in many previously refractory malignancies. However, many agents are associated with characteristic ophthalmic adverse effects. It is important that ophthalmologists recognize and maintain a high index of suspicion for these side effects in patients on targeted therapy. Most ophthalmic adverse effects can be treated with specific ocular therapy without discontinuation of cancer treatment, although it is important to be aware of the life-threatening and vision-threatening circumstances that would require therapy cessation in conjunction with the patient's oncologist. This review aims to summarize the ophthalmic adverse effects of targeted and hormonal anticancer agents and briefly describe their management.