Blockage of the lacrimal drainage apparatus as a side effect of docetaxel therapy

The Association Between Taxane Use and Lacrimal Disorders

PURPOSE

The current study seeks to investigate the association between lacrimal disorders and the use of docetaxel and paclitaxel.

METHODS

A disproportionality analysis was conducted using the United States FDA Adverse Event Reporting System (FAERS). All adverse event reports containing the term docetaxel or paclitaxel were selected. Lacrimal adverse events were identified using the lacrimal disorders Standardized MedDRA Query (SMQ), which includes disorders that affect lacrimal gland and drainage system including blockage of nasolacrimal duct, occlusion/stenosis of punctum, lacrimal gland neoplasms, and inflammations and infections.

RESULTS

The proportionate reporting ratio (PRR) comparing lacrimal events among docetaxel to paclitaxel users was 2.47 (95% CI, 2.03-3.02). With respect to specific lacrimal events, dacryostenosis (PRR 19.54 [95% CI, 7.19-53.13]), increased lacrimation (PRR 3.2 [95% CI, 2.42-4.23]), lacrimation disorder (p = 0.02), and xeropthalmia reports (p > 0.001) were significantly more common.

CONCLUSIONS

The growing body of epidemiologic, clinical, and pathophysiologic research supports the case that docetaxel leads to adverse lacrimal events in certain patients and should be taken into consideration when oncologists consider docetaxel vs. paclitaxel.

Prevalence and risk factors for depression and anxiety in patients with nasolacrimal duct obstruction

Objective

To investigate the prevalence and risk factors for depression and anxiety in patients with nasolacrimal duct obstruction (NLDO).

Methods

We conducted a telephone-based survey of patients with NLDO who underwent dacryocystorhinostomy (DCR) at the Department of Ophthalmology of Peking University Third Hospital in China between January 2016 and January 2021. Depression and anxiety were assessed with the PHQ-9 (range 0-25) and STAI (range 20-80) scales. PHQ-9 ≥ 5 and STAI ≥ 55 were considered clinically significant. Logistic regression and linear regression were performed to determine the factors related to depression and anxiety.

Results

Of 565 patients approached, 344 (60.9%) completed the survey. A total of 13.1% of patients had mild-severe depression and 63.4% had severe anxiety. Univariate logistic regression revealed that hypertension, dry eye, and cataract were associated with mild to severe depression (P = 0.018, 0.045, 0.035, respectively). Dry eye was associated with severe anxiety (P = 0.007). Univariate linear regression revealed that male and income levels were significantly negatively correlated with PHQ-9 scores (P = 0.011, 0.010, respectively). Hypertension and dry eye were significantly positively correlated with PHQ-9 scores (P = 0.030, P < 0.001, respectively). Male, income levels, and educational levels were significantly negatively correlated with STAI scores (P = 0.022, P < 0.001, P = 0.005, respectively). Dry eye was significantly positively correlated with STAI scores (P < 0.001).

Conclusion

Prevalence of depression and anxiety disorders was relatively high among NLDO patients. Our results demonstrate the importance of depression and anxiety screening and psychosocial support for patients with NLDO, which can improve their quality of life and compliance with medical appointments.

Ocular adverse effects of anti-cancer chemotherapy

Cancer ranks as the second leading cause of mortality in Europe, following cardiovascular diseases. Every year, 2.6 million people are diagnosed with this disease, and 1.2 million die. It has an impact not only on individual health but also on society and the economy. The survival rate has improved with the introduction of new diagnostic methods and anti-cancer chemotherapy. While more aggressive chemotherapeutic regimens and combination therapies have demonstrated efficacy against cancer cells, they also have detrimental effects on normal cells, leading to systemic and ocular adverse reactions associated with cytotoxicity, inflammation, and neurotoxicity. Consequently, we have an increased survival rate, but the appearance of these ocular adverse effects decreases the quality of life. Ocular toxicity induced by chemotherapeutic agents is often underestimated. While prevention may not be possible, proper management by an ophthalmologist, an integral part of the oncology patient's medical team, is crucial. The ophthalmologist should assess the patient before initiating chemotherapeutic treatment and continue monitoring throughout to identify any adverse ocular reactions resulting from the systemic chemotherapy. This article aimed to briefly highlight the adverse reactions occurring at the ocular surface in patients undergoing chemotherapeutic treatment. Fortunately, these ocular side effects are limited only to the period in which the chemotherapeutic treatment is done, with most of them disappearing a few weeks after stopping the treatment.

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.

Risk of Ocular Adverse Events With Taxane-Based Chemotherapy

Importance

Taxane-based chemotherapy agents, such as docetaxel and paclitaxel, are used for treating a wide range of cancers. Although much has been published on adverse events related to taxanes, data on ocular outcomes with these very important drugs are scant.

Objective

To quantify the risk of 3 mutually exclusive ocular adverse events of epiphora, cystoid macular edema (CME), and optic neuropathy with taxane-based chemotherapy agents by undertaking a large pharmacoepidemiologic study.

Design, Setting, and Participants

This retrospective cohort study design used a private health-claims database from the US that captures health information of more than 150 million enrollees. The study team created a cohort of new users of women with cancer who were taking taxane-based chemotherapy (docetaxel or paclitaxel) and new users of tamoxifen as controls. Study members were observed to the first incidence of each of the 3 mutually exclusive outcomes. An analysis of taxane-only users was also undertaken.

Exposure

Tamoxifen (unexposed) and taxanes (ie, paclitaxel and docetaxel) as the exposed.

Main Outcomes and Measures

First diagnosis of (1) epiphora, (2) cystoid macular edema (CME), or (3) optic neuropathy ascertained using International Statistical Classification of Diseases and Related Health Problems, Ninth Revision or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision.

Results

Among the 18 219 users in the epiphora analysis and optic neuropathy analysis, there were 1824 taxane users (paclitaxel and docetaxel) (age, mean [SD], 62.1 [12.7] years) and 16 395 tamoxifen users (age, mean [SD], 54.6 [12.8] years), respectively. The crude hazard ratio (HR) for epiphora was 5.55 (95% CI, 2.99-10.29) and adjusted HR was 5.15 (95% CI, 2.79-9.54). For optic neuropathy, the crude HR was 4.43 (95% CI, 1.10-17.82) and the adjusted HR was 4.44 (95% CI, 1.04-18.87). Among the 18 433 users in the CME analysis, there were 1909 taxane users (paclitaxel and docetaxel) (age, mean [SD], 62.5 years) and 16 524 tamoxifen users (age, mean [SD], 54.6 years). The crude HR for CME comparing taxane users with tamoxifen users was 1.37 (95% CI, 0.72-2.60) and adjusted HR was 1.33 (95% CI, 0.70-2.53). The HRs for epiphora and CME in the taxane cohort during the time of exposure compared with the period prior to use of the drugs were 2.86 (95% CI, 1.11-7.39) and 2.27 (95% CI, 0.68-7.54), respectively.

Conclusions and Relevance

In a cohort of women who were using taxane chemotherapy agents, there was an association with elevated risk for epiphora, CME, and optic neuropathy. Ophthalmologists and oncologists should be aware of these adverse events in women with breast cancer who receive these drugs.

Docetaxel for Breast Cancer Treatment-Side Effects on Ocular Surface, a Systematic Review

Docetaxel is a very effective chemotherapeutic agent for the treatment of metastatic or locally advanced breast cancer. Epiphora (hyperlacrimation) has been shown to be the most common eye condition in patients receiving docetaxel-based chemotherapy. This symptom does not decrease visual acuity, but decreases the quality of life. Daily activities (reading, working on the computer, watching TV, and so on) are affected, with patients complaining about an alteration of daily life with the appearance of this symptom. The mechanism by which epiphora occurs is considered to be the canalicular stenosis, but the trials on the subject failed to reach statistical significance. The objective of this scoping review is to determine whether there is a treatment regimen-dependent relationship between docetaxel administration and the presence of epiphora in women with breast cancer. The inclusion criteria were met by 10 trials, from which one was excluded owing to data selection biases. Accordingly, nine studies were evaluated quantitatively and qualitatively in the present review. We included subjects with docetaxel as single treatment or docetaxel in combination with other chemotherapy compounds. The occurrence of epiphora among subjects treated with docetaxel, regardless of the therapeutic regimen used, was statistically significant (p = 0.005). The proportion of patients with epiphora after weekly administration of docetaxel (54 out of 131 subjects, 41.22%) was different compared with that of those who received docetaxel at three week intervals (112 out of 325 subjects, 34.15%), but the difference between the two was not statistically significant (p = 0.732). The present study demonstrates that epiphora occurs more frequently in patients receiving weekly docetaxel-based chemotherapy than those taking the three-weekly regimen, but the difference is not statistically significant. Ophthalmologic assessment of all patients starting this treatment is recommended. The causal relationship between canalicular stenosis and epiphora is not fully elucidated as long as this ocular symptom occurs in women who do not have stenosis of the lacrimal system. Further well-designed trials are required to bring new insights into the mechanisms of epiphora pathogenesis in subjects treated with docetaxel.

Regression of Castration-Resistant Prostate Cancer by a Novel Compound HG122

Prostate cancer (PCa) is a common aggressive disease worldwide which usually progresses into incurable castration-resistant prostate cancer (CRPC) in most cases after 18-24 months treatment. Androgen receptor (AR) has been considered as a crucial factor involved in CRPC and the study of AR as a potential therapeutic target in CRPC may be helpful in disease control and life-cycle management. In this study, we identified a potent small molecule compound, HG122, that suppressed CRPC cells proliferation and metastasis, and inhibited tumor growth both in subcutaneous and orthotopic tumor model. In addition, HG122 reduced the mRNA expression of PSA and TMPRSS2 which are target genes of AR, resulting in cell growth inhibition and metastasis suppression of CRPC, without affecting the expression of AR mRNA level. Mechanically, HG122 promoted AR protein degradation through the proteasome pathway impairing the AR signaling pathway. In conclusion, HG122 overcomes enzalutamide (ENZ) resistance in CRPC both in vitro and in vivo, thus suggesting HG122 is a potential candidate for the clinical prevention and treatment of CRPC.

Risk of Ophthalmic Adverse Events in Patients Treated with Immune Checkpoint Inhibitor Regimens: A Systematic Review and Meta-analysis

Background: Immune checkpoint inhibitors (ICIs) -induced adverse events (AEs) have been reported affecting almost all human organs. However, studies about ocular AEs are few. A meta-analysis was performed to evaluate the risks of ICI-related ophthalmic AEs compare to chemotherapy.Methods: Eligible studies were selected from phase II/III randomized controlled trials investigating ICIs. The data were analyzed by R software and Stata.Results: Odds ratio of treatment-related AE (trAEs) and nonspecific ophthalmic trAEs (NS-trAEs) were lower for PD-1/PD-L1 inhibitors than chemotherapy (OR 0.44, p < .05; OR 0.28, p < .001; OR 0.18, p < . 05; OR: 0.18, p < .001respectively). Compared with monotherapy, PD-1 plus CTLA-4 inhibitors increased the risks of immune-related AEs (irAEs) (OR 4.52, p < .01); ICIs plus chemotherapy increased the risks of trAEs and irAEs (OR 2.82, p < .001; OR 3.63, p < .05 respectively).Conclusions: PD-L1/PD-1 inhibitors had lower risks of trAEs and NS-trAEs than chemotherapy; Compared with monotherapy, combination therapy had higher risks of ophthalmic trAEs and irAEs.Abbreviation PD-1: programmed cell death protein 1; PD-L1: programmed cell death protein ligand 1; CTLA-4: cytotoxic T-lymphocyte-associated protein 4; ICI: immune checkpoint inhibitor; AE: adverse event; trAE: treatment-related adverse event;irAE: immune-related adverse events; NS-trAE: nonspecific ophthalmic treatment-related adverse event; RCT: randomized controlled trials; PFS: progression-free survival; OS: overall survival; ORR: objective response rate; MM: melanoma; NSCLC: non-small cell lung cancer; SCLC: small cell lung cancer; HNSCC: head-neck squamous cell carcinoma; PICOL: patient, intervention, comparison, and outcome; Versus: VS; Chem: chemotherapy; 95%CI: 95% confidence interval; FEM: fixed-effects model; REM: random-effects model; NA: not applicable; MeSH: medical subject heading.

Ophthalmic adverse effects of taxanes: The Mayo Clinic experience

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Lacrimal drainage system stenosis associated with Trastuzumab emtansine (Kadcyla®, T-DM1) administration: a case report

Background

Trastuzumab emtansine (Kadcyla®, T-DM1) is an antibody-drug conjugate used to treat HER2 (human epidermal growth factor receptor 2) overexpressing metastatic breast cancer. In this report, we present the first case of lacrimal drainage system stenosis identified after T-DM1 administration, and its successful treatment with a topical steroid.

Case presentation

A 36-year-old female with metastatic breast cancer was referred for excessive tearing of both eyes. She previously underwent mastectomy and was treated with multiple anti-cancer regimens. However, metastases to liver and bone were identified and T-DM1 was administered. After 2 months, epiphora developed in both eyes and the patient was referred for ophthalmologic examination. The height of the tear meniscus was increased. The fluorescein dye disappearance test (FDDT) showed a delayed clearance in both eyes. Diagnostic lacrimal probing demonstrated a lower distal canalicular stenosis in both eyes. Dacryocystography indicated multiple focal narrowing of nasolacrimal duct in the right eye and diffused narrowing of nasolacrimal duct in the left eye. Topical eyedrop of tobramycin 0.3% and dexamethasone 0.1% were prescribed four times a day. After 2 months of treatment, the patient reported relief from epiphora, and the height of tear meniscus was normalized in both eyes.

Conclusion

T-DM1 administration in breast cancer treatment can induce lacrimal drainage system stenosis, which can be treated effectively with a topical steroid.

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.

The use of prophylactic Nunchaku stents to reduce the risk of nasolacrimal duct obstruction in patients with midfacial tumours undergoing radiotherapy

The treatment of midfacial tumours with radiotherapy, chemotherapy and radio-iodine can cause nasolacrimal duct fibrosis resulting in epiphora. Nasolacrimal patency can be maintained by stenting. We report our experience of prophylatic Nunchaku stent insertion in 5 patients prior to midfacial radiotherapy. Four out of 5 patients (80%) had patent nasolacrimal ducts without any symptoms of epiphora following removal of the stents. One patient was initially asymptomatic with patent nasolacrimal duct, but subsequently developed epiphora. Nunchaku stents may provide a simple and effective way of preventing epiphora, obviate the need for nasal retrieval that is required for other nasolacrimal stents, and reduce the risk of requiring further lacrimal surgery.

Cancer-associated epiphora: a retrospective analysis of referrals to a tertiary oculoplastic practice

AIM

To report the underlying causes and treatment outcome of lacrimal drainage obstruction in patients with cancer-associated epiphora.

METHODS

A single-centre retrospective review was performed for consecutive referrals to an oculoplastic surgeon for cancer-associated epiphora between 2010 and 2016. Charts were reviewed for underlying neoplastic conditions, pharmacy records, radiotherapy records, levels of obstruction of the lacrimal drainage apparatus and treatment methods and outcome.

RESULTS

Forty-three patients (70 eyes) were included in this study. The most common cause of epiphora was radiotherapy on the head and neck (35%), followed by oral S-1 (33%) and docetaxel (23%). The nasolacrimal duct was the most common obstruction site in patients who underwent radiotherapy (59%), whereas the punctum or canaliculus was mostly affected in patients treated with S-1 (94%) or docetaxel (100%). S-1-treated patients showed severe obstruction of the entire canaliculus (11/24 (46%)) with the lowest success rate at 58% (S-1 vs radiotherapy: p=0.012; S-1 vs docetaxel: p=0.002). Moreover, the patients treated within 1 year after the first symptom showed a significantly higher proportion of symptom improvement (85%) than did those treated after 1 year (27%) in the S-1 group (p=0.011).

CONCLUSIONS

Cancer-associated epiphora can have various causes. The level of obstruction and treatment outcome vary according to underlying causes, and S-1-associated epiphora and delayed treatment are related to unsatisfactory results. Given the importance of early intervention, oncologists should be alert to tearing symptoms and cooperate with ophthalmologists in the early stages to improve patients' quality of life.

External Versus Endoscopic Endonasal Dacryocystorhinostomy

DCR is the treatment of choice for NLDO. External DCR has remained the standard approach since the 1890s. With advances in technique and technology, and more otolaryngologists and ophthalmologists performing endoscopic DCR, more studies have been conducted, some with equivalent success rates between the 2 approaches. Endoscopic endonasal DCR offers the advantages of avoiding a skin incision with similar success rates with experienced surgeons. However, the technique necessitates more surgical equipment, and has a steep learning curve. Both approaches have low complication rates and serious complications are very rare. The decision for the type of approach to use depends on the surgeon’s experience, the patient’s preference or concerns, and the resources available within a particular health system.

Posterior segment toxicity after gemcitabine and docetaxel chemotherapy

PURPOSE

To report outer retinal disruption and uveal effusion after gemcitabine and docetaxel combination therapy.

CASE REPORT

A 78-year-old woman presented with blurry vision after two cycles of gemcitabine and docetaxel combination chemotherapy for stage IV sarcoma. At presentation, visual acuity was finger counting and 20/25 in the right and left eyes, respectively. Slit-lamp examination and B-scan ultrasonography revealed severe uveal effusion in the right eye and choroidal folds in the left eye. Spectral domain optical coherence tomography showed disruption of photoreceptor inner segment ellipsoid band in the right eye. The patient was monitored weekly with ophthalmic examination and B-scan ultrasonography, while continuing with gemcitabine monotherapy. At 8 weeks follow-up, uveal effusion improved considerably and visual acuity was 20/40 and 20/20 in the right and left eyes, respectively.

CONCLUSIONS

Uveal effusion and outer retinal disruption were reported after gemcitabine and docetaxel chemotherapy. Early detection and close ophthalmic monitoring may allow concurrent cancer treatment and prevention of possible chemotherapy-induced ocular side effects.

Epiphora in lung cancer patients receiving docetaxel: a case series

Background

Docetaxel is a key antineoplastic drug for treatment of non-small cell lung cancer. Ocular adverse events of docetaxel include epiphora (excess tearing) and conjunctivitis. Epiphora has been reported to be associated with canalicular and nasolacrimal duct stenosis, but it is not necessarily caused by lacrimal duct obstruction.

Case presentation

We encountered three Japanese non-small cell lung cancer patients who developed epiphora after the administration of docetaxel-based chemotherapy. One patient with lacrimal puncta stenosis showed improvement with probing and irrigation. The other two patients resolved following cessation of docetaxel or administration of artificial tears.

Conclusion

As epiphora can interfere with activities of daily life and negatively affect quality of life, it is important for thoracic oncologists to be aware of this adverse event.

Toxic optic neuropathy in the setting of docetaxel chemotherapy: a case report

BACKGROUND

To describe the first reported case of toxic optic neuropathy secondary to docetaxel (Taxotere®) chemotherapy.

CASE PRESENTATION

A 53-year-old female presented with predominantly unilateral visual loss, but extensive bilateral visual field defects and bilateral optic nerve head swelling 2 weeks after first dose of docetaxel (Taxotere®) and trastuzumab (Herceptin®) chemotherapy for a left sided node-positive, HER2 positive breast cancer. Extensive investigation ruled out other causes of optic neuropathy. She was treated with high dose corticosteroids intravenously for 1 week then a tapering oral dose over 8 weeks. Visual field defects gradually resolved and visual acuity improved. Docetaxel chemotherapy was discontinued but targeted therapy with trastuzumab continued without further complication.

CONCLUSION

Docetaxel can cause a toxic optic neuropathy possibly due to an ischemic or neurotoxic mechanism at the optic nerve head. With cessation of docetaxel therapy and treatment with systemic corticosteroids, visual recovery can occur without significant residual visual deficit.

Ophthalmic complications of targeted cancer therapy and recently recognized ophthalmic complications of traditional chemotherapy

As our understanding of cancer pathophysiology has increased, so have the number of targeted therapeutic agents available. By targeting specific molecules involved in tumorigenesis, targeted therapeutic agents offer the potential for significant efficacy against tumor cells while minimizing the adverse effects. We highlight the recently recognized ophthalmic complications of targeted cancer therapy, as well as recently recognized complications of traditional chemotherapeutic agents.

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.

A study of docetaxel weekly or every three weeks in combination with carboplatin as first line chemotherapy in epithelial ovarian cancer: Hematological and non-hematological toxicity profiles

The purpose of this study was to compare the toxicity profiles of docetaxel administered on a weekly schedule and the standard three-week schedule in the treatment of advanced primary ovarian carcinoma. Eligible patients were treated with intravenous docetaxel (30 mg/m²) on days 1, 8 and 15, and carboplatin (AUC 5) on day 1 or with docetaxel (75 mg/m²) and carboplatin (AUC 5) on day 1; Q21 days for 6 cycles. This study was a pooled study of two primary phase II studies. A total of 108 patients received the weekly schedule and 59 patients received the three-week schedule. All patients were evaluated for toxicity. The overall response rate was 79% and the biochemical response 93% for the weekly schedule. The median overall survival rate was 35.3 months. Neutropenia was significantly more common (ANOVA; p<0.0001) in the three-week group than in the weekly group during all six courses of chemotherapy. Fever and infections were also more common in this group. Thrombocytopenia and anemia were slightly more common in the weekly group. Fatigue, epiphora, nail changes and taste disturbances were specific side-effects following weekly docetaxel. Peripheral sensory neuropathy (grade 1–2) increased with every cycle of treatment, but in a similar manner in the two groups. Grade 3–4 neuropathy was not recorded. Oral mucositis and myalgia were two side-effects associated with the three-week schedule. Nausea and vomiting, diarrhea and dyspnea were a limited problem in both groups. Cardiac toxicity was rare and did not differ between the two docetaxel schedules. The weekly administration was favored due to the lower rates of neutropenia, fever, infections, oral mucositis and myalgia. However, epiphora and nail changes were specific side-effects of the weekly treatment. Both regimens appeared to be rather well tolerated with similar compliance (66 and 70%) with regard to completion of the planned six courses of chemotherapy.

Phase II study of docetaxel weekly in combination with carboplatin every 3 weeks as first-line chemotherapy in stage IIB to stage IV epithelial ovarian cancer

OBJECTIVES

The purpose of this study was to assess the response rate, toxicity, progression-free survival, and overall survival in a series of patients with advanced-stage ovarian carcinoma treated with a first-line weekly docetaxel and 3 weekly carboplatin regimen.

METHODS

All eligible patients were treated with intravenous docetaxel (30 mg/m) on days 1, 8, and 15, and carboplatin (area under the curve, 5) on day 1; every 21 days for at least 6 cycles.

RESULTS

One hundred six patients received at least one cycle of primary chemotherapy (median, 6.0; range, 1-9), and they were evaluable for toxicity assessment. Eighty-five patients had evaluable (measurable) disease and received at least 3 courses of chemotherapy and were evaluable for clinical response rate. The overall response rate was 78.8% (95% confidence interval, 70.1%-87.5%), and the biochemical response 92.8% (95% confidence interval, 87.2%-98.4%). The median progression-free survival was 12.0 months and the median overall survival was 35.3 months. Thirty-six patients (34.0%) experienced grades 3 and 4 neutropenia, which resulted in the removal of 3 patients. Six patients (5.7%) experienced grades 3 or 4 thrombocytopenia. No patients experienced grade 3 to grade 4 sensory neuropathy. Epiphora, nail changes, and fatigue were frequently recorded nonhematologic adverse effects.

CONCLUSIONS

The tolerable hematologic toxicity (no need for colony-stimulating factors) and the low rate of neurotoxicity (only grades 1-2) and response rates in line with the standard 3-week paclitaxel-carboplatin regimen for advanced primary ovarian carcinoma after suboptimal cytoreductive surgery make this regimen an interesting alternative in selected patients.

Outcomes of dacryocystorhinostomy in patients with head and neck cancer treated with high-dose radiation therapy

PURPOSE

To evaluate the outcomes of dacryocystorhinostomy (DCR) in patients with head and neck cancer treated with high-dose radiation therapy.

METHODS

The clinical records of 43 consecutive patients with head and neck cancer who underwent DCR after high-dose external beam radiation therapy plus ablative surgery and/or chemotherapy between December 2001 and April 2011 were retrospectively reviewed.

RESULTS

There were 23 men and 20 women. The median age was 56 years (range, 2-92 years). Thirty-one patients were Caucasian, 6 Hispanic, 4 Asian, and 2 African American. Thirty patients (70%) presented with epiphora, 3 (7%) with dacryocystitis, and 10 (23%) with both epiphora and dacryocystitis. Symptoms were unilateral in 34 patients (79%) and bilateral in 9 patients (21%). The most common primary cancer diagnoses were squamous cell carcinoma (n = 14), sarcoma (n = 8), adenoid cystic carcinoma (n = 4), and basal cell carcinoma (n = 4). The most common primary tumor locations were the sinonasal cavity (n = 16), maxillary sinus (n = 9), palate (n = 3), and ethmoid sinus (n = 3). Thirty-seven patients (43 eyes) had DCR with silicone tube placement, and 6 patients (7 eyes) had DCR with Pyrex glass tube placement. Following DCR, 31 patients (72%) had resolution of their symptoms, and 12 patients (28%), 9 with silicone tubes and 3 with Pyrex glass tubes, had persistent or recurrent epiphora (DCR failure). The most common reason for failure was significant residual canalicular and nasal mucosal scar tissue. Eight of these 12 patients underwent additional surgery, most commonly with placement of a Pyrex glass tube. Seven (35%) of the 20 patients who underwent DCR less than 12 months after radiation therapy and 5 (21%) of the 23 patients who underwent DCR at least 12 months after radiation therapy had recurrent symptoms.

CONCLUSIONS

Dacryocystorhinostomy in patients with head and neck cancer previously treated with high-dose radiation therapy is generally successful, especially when delayed until at least 12 months after the completion of radiation therapy. A common reason for DCR failure after high-dose radiation therapy is severe canalicular and nasal mucosal scarring.

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.

Effects on the visual system might contribute to some of the cognitive deficits of cancer chemotherapy-induced 'chemo-fog'

The diminution in certain aspects of cognitive function that is reported to occur in some patients during or after adjuvant cancer chemotherapy is variously known as 'chemo-fog', 'chemo-brain' or other such term. In addition to reported deficits in attention, concentration and other functions, most, if not all, of the studies report deficits involving visual-spatial function or visual memory. Since the visual system is part of the nervous system, it seems reasonable to ask if it is susceptible to some of the deleterious effects produced by adjuvant chemotherapeutic drugs. We propose here the possibility that some portion of the vision-related aspects of the 'chemo-fog' spectrum of cognitive deficits results from a direct action of the adjuvant drugs on the visual system or from drug/drug or site/site interaction between effects on the visual system and other critical brain regions.

[Epiphora. Age-related changes of the ocular surface, eyelid function and the efferent tear ducts]

Symptomatic epiphora is predominantly present in the elderly It is caused either by hypersecretion in ocular surface disorders, mostly as a reflex, by decreased tear transport and mechanical stenosis of the efferent tear ducts. These three different causes have to be taken into consideration by differential diagnosis and lead to different forms of therapy. Ocular surface disorders (wet dry eye) are treated by topical medication, lid malfunctioning and dacryostenosis by surgery and possibly by topical adjuvant anti-inflammatory medication. The present article reviews the current concepts on epiphora as an age-associated symptom and the epidemiology and pathogenesis of dacryostenosis and dacryolithiasis.

Docetaxel treatment in the elderly patient with hormone refractory prostate cancer

Docetaxel is an anti-microtubular agent in the family of the taxanes, now FDA approved as first line chemotherapy for the treatment of hormone refractory metastatic prostate cancer. Recent data from two large randomized Phase III trials showed a survival advantage in hormone refractory prostate cancer patients treated with docetaxel. This discovery changed the perceptions about utilization of chemotherapy for this devastating disease and introduced a new paradigm/standard of care treatment for this patient population. The management of elderly patients with metastatic prostate cancer is an important issue because according to data from the Surveillance, Epidemiology, and End Results (SEER) program, the American Cancer Society, and the United Nations, the incidence of prostate cancer in elderly men is expected to increase since people are living longer. In this paper we will review the results of trials evaluating docetaxel in hormone refractory prostate cancer and the implications of these trials as they relate to diagnosis and management of this disease in the elderly man.

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.

Prospective study of incidence and severity of epiphora and canalicular stenosis in patients with metastatic breast cancer receiving docetaxel

PURPOSE

To determine the incidence and severity of epiphora and canalicular stenosis in patients receiving docetaxel weekly or every 3 weeks.

PATIENTS AND METHODS

In this prospective trial, each patient underwent an ophthalmologic examination and probing and irrigation of the lacrimal drainage apparatus at baseline and every 4 to 6 weeks after initiation of docetaxel. During each visit, epiphora and canalicular stenosis were graded. Patients with epiphora were treated with tobramycin and dexamethasone drops. If epiphora worsened or if findings on probing and irrigation suggested further canalicular narrowing, silicone intubation was offered.

RESULTS

Twenty-eight patients received docetaxel weekly, and 28 patients received docetaxel every 3 weeks. Eighteen patients (64%) who received weekly docetaxel developed epiphora. Epiphora was mild in seven patients, moderate in five, and severe in six. Nine patients had resolution of epiphora with tobramycin and dexamethasone administration. Nine patients had worsened canalicular stenosis; six underwent surgery. The median cumulative docetaxel dose was 496.5 mg at onset of epiphora and 889.5 mg at surgery. Eleven patients (39%) who received docetaxel every 3 weeks developed epiphora. The median cumulative docetaxel dose at onset of epiphora in this group was 420 mg. Epiphora was mild in nine patients, moderate in one, and severe in one. Nine patients had resolution of epiphora with tobramycin and dexamethasone administration. Two patients underwent surgery.

CONCLUSION

Epiphora occurred in 64% of patients in the weekly group and in 39% of patients in the every-3-weeks group. Moderate or severe canalicular stenosis was seen in about one-third of patients in the weekly group and in none of the patients in the every-3-weeks group.

A phase II study of weekly docetaxel in patients with anthracycline pretreated metastatic breast cancer

BACKGROUND

Docetaxel has significant activity in metastatic breast cancer and weekly schedules are associated with less myelosuppression than 3-weekly schedules. We evaluated the toxicity and the activity of weekly docetaxel in anthracycline-pretreated patients.

PATIENTS AND METHODS

A total of 42 patients were studied. Treatment consisted of docetaxel 35 mg/m2 weekly as a 30-min infusion for 6 weeks followed by a 2-week rest, with dexamethasone 8 mg i.v. pre-medication and 4 mg orally 12-hourly for 48 h following treatment.

RESULTS

The median age of the patients was 53 years (range 34-74). Twenty-six (62%) patients had received prior chemotherapy for advanced disease. Patients received a median 10 weeks of treatment (range 1-24). 11 had a partial response (ORR 26%; 95% CI 13-39%), five of whom had relapsed <12 months since the end of previous anthracycline-based chemotherapy. In addition six patients (14%) had stable disease for >16 weeks. Myelosuppression was rare with only 2 patients (5%) experiencing grade 3 neutropenia (no grade 4 neutropenia). Non-haematological grade III toxicities were as follows: fatigue 17%, neuropathy 0%, hyperlacrimation 5%, stomatitis 7%, diarrhoea 14%, and cutaneous toxicity 19%. Skin toxicity consisted of limb/palmar-plantar erythematous reactions, or fixed-plaque erythrodysaesthesia.

CONCLUSIONS

Weekly docetaxel has moderate activity in women with anthracycline pre-treated breast cancer. Although the level of myelosuppression is lower than 3-weekly regimens, this weekly regimen cannot be recommended due to the significant non-haematological toxicities associated with the treatment.

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.

Botulinum toxin for palliative treatment of epiphora in a patient with canalicular obstruction

OBJECTIVE

To describe the use of botulinum toxin injection of the lacrimal gland for palliative treatment of epiphora secondary to canalicular obstruction from docetaxel therapy.

DESIGN

Case report.

INTERVENTION

A 50-year-old female with bilateral canalicular obstruction secondary to docetaxel therapy received botulinum toxin injections (5 units each) into the lacrimal glands of both eyes.

RESULTS

Symptomatic epiphora of the affected eyes was reduced after 2 weeks. No side effects were observed.

CONCLUSIONS

Botulinum toxin injection of the lacrimal gland is an effective palliative treatment for epiphora secondary to canalicular obstruction from docetaxel therapy.