Drug-Induced Macular Edema

Incidence of Acute Cystoid Macular Edema After Starting a Prostaglandin Analog Compared With Other Classes of Glaucoma Medications

PURPOSE

There is a longstanding belief that prostaglandin analogs (PGAs) may predispose patients with glaucoma to develop acute cystoid macular edema (CME). However, there is little solid evidence supporting this notion. The purpose of this study is to compare CME incidence rates among patients initiating treatment with different glaucoma medication classes.

DESIGN

Database study.

PARTICIPANTS

39948 patients who were newly prescribed glaucoma medications METHODS: Using data from 10 health systems contributing data to the Sight Outcomes Research Collaborative (SOURCE) Ophthalmology Data Repository, we identified all adults with glaucoma who had been newly started on a topical glaucoma medication. Patients with pre-existing documentation of macular edema were excluded. We assessed the incidence of CME among patients with glaucoma who were newly started on PGAs, topical beta blockers (BBs), alpha agonists (AAs), and carbonic anhydrase inhibitors (CAIs). Using multivariable logistic regression, and adjusting for sociodemographic factors, we assessed the odds of developing CME among patients prescribed each of the 4 glaucoma medication classes. We also performed a subset regression analysis including lens status as a co-variate.

MAIN OUTCOME MEASURES

Incidence of CME within 3 months of initiating therapy with different topical glaucoma medications.

RESULTS

Among the 39,948 patients were newly treated with a topical glaucoma medication, 139 (0.35%) developed CME. The incidence of CME was 0.13%, 0.65%, 0.55%, 1.76% for users of PGAs, BBs, alpha agonists (AAs) and carbonic anhydrase inhibitors (CAIs), respectively. After adjusting for sociodemographic factors, users of topical BBs, AAs and CAIs had substantially higher odds of developing CME compared with PGA users (P<0.001 for all comparisons). The subset analysis also showed higher odds ratio of the non-PGA medication classes in association with CME.

CONCLUSIONS

Clinicians should reconsider the notion that PGAs carry a higher risk of CME versus other glaucoma medication classes. If additional studies support the findings of these analyses, clinicians may feel more comfortable prescribing PGAs to patients with glaucoma without fear they will predispose patients to CME.

Alisol A, the Eye-Entering Ingredient of Alisma orientale, Relieves Macular Edema Through TNF-α as Revealed by UPLC-Triple-TOF/MS, Network Pharmacology, and Zebrafish Verification

Purpose

Alisma orientale (AO, Alisma orientale (Sam). Juzep) has been widely employed for the treatment of macular edema (ME) in traditional Chinese medicine due to its renowned water-relief properties. Nonetheless, the comprehensive investigation of AO in alleviating ME remained unexplored. This study aims to identify the active components of AO that target the eye and investigate its pharmacological effects and mechanisms on ME.

Methods

The study commenced with UPLC-Triple-TOF/MS analysis to identify the primary constituents of AO. Zebrafish eye tissues were then analyzed after a five-day administration of AO to detect absorbed components and metabolites. Subsequently, network pharmacology, molecular docking, and molecular dynamics simulations were employed to predict the mechanisms of ME treatment via biological target pathways. In vivo experiments were conducted to corroborate the pharmacological actions and mechanisms.

Results

A total of 7 compounds, consisting of 2 prototype ingredients and 5 metabolites (including isomers), were found to traverse the blood-eye barrier and localized within eye tissues. Network pharmacology results showed that AO played a role in the treatment of ME mainly by regulating the pathway network of PI3K-AKT and MAPK with TNF-α centered. Computational analyses suggested that 11-dehydro-16-oxo-24-deoxy-alisol A, a metabolite of alisol A, mitigates edema through TNF-α inhibition. Furthermore, zebrafish fundus confocal experiments and HE staining of eyes confirmed the attenuating effects of alisol A on fundus angiogenesis and ocular edema, representing the first report of AO's ME-inhibitory effects.

Conclusion

In this study, computational analyses with experimental validation were used to understand the biological activity and mechanism of alisol A in the treatment of ME. The findings shed light on the bioactive constituents and pharmacological actions of AO, offering valuable insights and a theoretical foundation for its clinical application in managing ME.

Comparative analysis of changes in retinal layer thickness following femtosecond laser-assisted cataract surgery and conventional cataract surgery

BACKGROUND

To investigate the influence of femtosecond laser-assisted cataract surgery (FLACS) on macula by examining changes in retinal layers after FLACS and to compare these changes with those after conventional cataract surgery (CCS).

METHODS

This study included 113 unrelated Korean patients with age-related cataract who underwent CCS or FLACS in Severance Hospital between September 2019 and July 2021. Optical coherence tomography was performed before and 1 month after surgery. The total retinal layer (TRL) was separated into the inner retinal layer (IRL) and outer retinal layer (ORL); moreover, the IRL was subdivided into the retinal nerve fiber layer, ganglion cell layer, inner plexiform layer, inner nuclear layer (INL), outer plexiform layer, and outer nuclear layer. We performed between-group comparisons of the postoperative thickness in each retinal layer and the postoperative differences in retinal thickness. The average retinal thickness of the four inner macular ring quadrants was used for comparative analysis.

RESULTS

Compared with the CCS group, the FLACS group exhibited a thicker ORL (P = 0.004) and a thinner INL (P = 0.007) after surgery. All retinal layer thickness values showed significant postoperative changes regardless of the type of surgery (P < 0.05). The postoperative increase in TRL and IRL thickness was significantly smaller in the FLACS group than in the CCS group (P = 0.027, P = 0.012).

CONCLUSIONS

The 1-month postoperative retinal changes were less pronounced in the FLACS group than in the CCS group.

Development of diabetic macular oedema shows associations with systemic medication - An epidemiological study

PURPOSE

To identify associations between systemic drugs and the incidence of diabetic macular oedema (DME). Of interest was to find beneficial and/or deleterious associations of used drugs.

METHODS

A historic cohort design based on administrative data. Study population consisted of 150 353 individuals with diabetes. Endpoint event was the development of DME (ICD-10 H36.01), censoring events were death or study end December 2017. The follow-up started between 1997 and 2010. The systemic medication consisted of 95 substances. We constructed a nested case-control study design comparing 2630 cases with DME to 13 144 age- and sex-matched controls without DME. Results are reported as odds ratios (ORs) with 95% confidence intervals (CIs) based on conditional logistic regression models.

RESULTS

Incidence rate for DME was 1.80 per 1000 person-years (95% CI 1.73-1.87). In all, we observed a lower incidence rate of DME in females (IRR 0.57; 95% CI 0.52-0.62) compared to males. Exposure to hormone replacement therapy estradiol (OR 0.42; 0.25-0.68), temazepam (0.23; 0.08-0.62) and allopurinol (0.61; 0.43-0.86) were associated with lower risk of DME, while use of insulin or insulin analogue (3.30; 2.99-3.64), sulfonylureas (1.21; 1.05-1.40), diuretic furosemide (1.90; 1.61-2.24), calcium channel blocker amlodipine (1.53; 1.34-1.75), ACE inhibitors ramipril (1.66; 1.46-1.89) and enalapril (1.38; 1.16-1.64) were associated with an increased risk of DME.

CONCLUSIONS

Large-scale studies examining the incidence of DME are lacking. Our findings suggest that associations of systemic medications with the incidence of DME may shed light on the pathogenesis of complex DME, encouraging further studies.

Macular edema after siponimod treatment for multiple sclerosis: a case report and literature review

BACKGROUND

As a modulator of the sphingosine 1-phosphate receptor, siponimod is administered as a therapeutic intervention for multiple sclerosis. A previous phase 3 study first reported siponimod-associated macular edema. Since that report, there were only few relevant reports in clinical settings. Here, we report a case of secondary progressive multiple sclerosis developed macular edema after siponimod treatment. We also review the progress of sphingosine 1-phosphate receptor modulators, elaborate on accepted mechanisms in treating multiple sclerosis, and discuss the causation of siponimod-associated macular edema.

CASE PRESENTATION

A 38-year-old Chinese female patient with secondary progressive multiple sclerosis, who had recurrent numbness of the limbs and right leg fatigue, developed mild macular edema following 4 months of siponimod treatment. The macular edema resolved after discontinuing the medication, and did not recur after resuming siponimod.

CONCLUSION

Although siponimod-associated macular edema may be rare, mild, transitory, and manageable, it cannot be ignored and requires ongoing vigilance.

Effect of fingolimod therapy on quantitative macular changes among patients with relapsing-remitting multiple sclerosis: a four-year follow-up study from Oman

PURPOSE

Fingolimod (FTY-720) is an immunomodulatory oral agent approved for the treatment of relapsing-remitting multiple sclerosis (RRMS); however, several clinical trials have shown that some recipients may develop macular oedema (ME) as an adverse reaction. As there are no studies assessing the long-term (> 1 year) effect of fingolimod on the macula, this study aimed to evaluate the quantitative effect of fingolimod therapy on central macular thickness (CMT) and total macular volume (TMV) over a four-year period.

METHODS

This retrospective longitudinal cohort study was performed between January 2014 and December 2018. A total of 21 patients with RRMS receiving fingolimod therapy were recruited and followed-up over 4 years to assess CMT and TMV changes measured using spectral domain optical coherence tomography. A paired sample t-test was used to compare mean CMT and TMV values calculated at baseline prior to the initiation of fingolimod therapy with those observed at three, six, 12, 24, 36 and 48 months of treatment.

RESULTS

None of the patients developed ME over the four-year study period. In addition, there was no significant difference in baseline mean CMT values and those observed at a four-year follow-up. Although mean TMV values remained constant initially, there was a significant decrease towards the end of the study period.

CONCLUSIONS

Long-term fingolimod therapy did not result in significant CFT changes. While there was a reduction in TMV towards the end of the study, this is likely due to the degenerative effect of the disease itself on the nerve fibres of the retina.

Non-vasogenic cystoid maculopathies

Besides cystoid macular edema due to a blood-retinal barrier breakdown, another type of macular cystoid spaces referred to as non-vasogenic cystoid maculopathies (NVCM) may be detected on optical coherence tomography but not on fluorescein angiography. Various causes may disrupt retinal cell cohesion or impair retinal pigment epithelium (RPE) and Müller cell functions in the maintenance of retinal dehydration, resulting in cystoid spaces formation. Tractional causes include vitreomacular traction, epiretinal membranes and myopic foveoschisis. Surgical treatment does not always allow cystoid space resorption. In inherited retinal dystrophies, cystoid spaces may be part of the disease as in X-linked retinoschisis or enhanced S-cone syndrome, or occur occasionally as in bestrophinopathies, retinitis pigmentosa and allied diseases, congenital microphthalmia, choroideremia, gyrate atrophy and Bietti crystalline dystrophy. In macular telangiectasia type 2, cystoid spaces and cavitations do not depend on the fluid leakage from telangiectasia. Various causes affecting RPE function may result in NVCM such as chronic central serous chorioretinopathy and paraneoplastic syndromes. Non-exudative age macular degeneration may also be complicated by intraretinal cystoid spaces in the absence of fluorescein leakage. In these diseases, cystoid spaces occur in a context of retinal cell loss. Various causes of optic atrophy, including open-angle glaucoma, result in microcystoid spaces in the inner nuclear layer due to a retrograde transsynaptic degeneration. Lastly, drug toxicity may also induce cystoid maculopathy. Identifying NVCM on multimodal imaging, including fluorescein angiography if needed, allows guiding the diagnosis of the causative disease and choosing adequate treatment when available.

PENTOSAN POLYSULFATE SODIUM-INDUCED PIGMENTARY MACULOPATHY WITH NONLEAKING CYSTOID MACULAR EDEMA SUCCESSFULLY TREATED WITH ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY

PURPOSE

To report a case of nonleaking cystoid macular edema (CME) associated with pentosan polysulfate sodium (PPS)-induced pigmentary maculopathy.

METHODS

Multimodal imaging, including optical coherence tomography, fundus photography, autofluorescence, and fluorescein angiography, was used to substantiate our diagnosis, further characterize the cystoid macular edema showed by our patient and to monitor the response to treatment.

RESULTS

A 59-year-old woman was referred for decreased visual acuity and bilateral macular edema. She had been treated for interstitial cystitis with PPS for 10 years. Multimodal imaging showed the characteristic features of PPS-induced pigmentary maculopathy. Moreover, fluorescein angiogram showed nonleaking cystoid macular edema in both eyes. She was treated successfully with intravitreal injections of bevacizumab.

CONCLUSION

To our knowledge, this report is the first to demonstrate that PPS-associated cystoid macular edema can be nonleaking on fluorescein angiography and responds well to intravitreal anti-vascular endothelial growth factor injections.

Loratadine-associated cystoid macular edema: A case report

Purpose

To report the first known case of bilateral cystoid macular edema in a patient undergoing long-term loratadine treatment.

Observations

A 49-year-old Chinese woman who had been undergoing treatment with loratadine for the past 6 years presented with decreased visual acuity and bilateral cystoid macular edema (CME). Upon cessation of loratadine, macular edema partially resolved, and visual acuity markedly improved. Fundus autofluorescence (FAF), optical coherence tomography (OCT), and fluorescence fundus angiography (FFA) were used to document the severity of CME and its subsequent resolution after cessation of loratadine therapy.

Conclusions and Importance

Long-term use of loratadine might cause CME that partially resolves with discontinuation of the drug. The pathophysiology of drug-induced CME without leakage remains unclear. Dysfunction of histamine receptor1-expressed retinal neurons and the associated signal transduction, toxicity to Müller cells or RPE cells with subsequent intracellular fluid accumulation, and subclinical damage to the blood-retina barrier leading to leakage of extracellular fluid, have been proposed.

AN ASSOCIATION BETWEEN STELLATE NONHEREDITARY IDIOPATHIC FOVEOMACULAR RETINOSCHISIS, PERIPHERAL RETINOSCHISIS, AND POSTERIOR HYALOID ATTACHMENT

PURPOSE

Stellate nonhereditary idiopathic foveomacular retinoschisis is a disorder characterized by splitting of the retina at the macula, without a known underlying mechanical or inherited cause. This study investigates demographic, anatomical, and functional characteristics of subjects with stellate nonhereditary idiopathic foveomacular retinoschisis, to explore potential underlying mechanisms.

METHODS

In this single-site, retrospective, and cross-sectional, observational study, data were collected from 28 eyes from 24 subjects with stellate nonhereditary idiopathic foveomacular retinoschisis. Descriptive statistics were reported, based on the observed anatomico-functional features.

RESULTS

The visual acuity remained stable (median 20/20) in all subjects over a median follow-up of 17 months. All cases demonstrated foveomacular retinoschisis within Henle's fiber layer, at the junction of the outer plexiform and outer nuclear layers. This schisis cavity extended beyond the limits of the macular OCT temporally in all eyes. In most affected eyes, there were documented features of peripheral retinoschisis and broad attachment of the posterior hyaloid at the macula. Functional testing in a cross-sectional subset demonstrated normal retinal sensitivity centrally but an absolute scotoma peripherally.

CONCLUSION

Stellate nonhereditary idiopathic foveomacular retinoschisis seems to be associated with peripheral retinoschisis and anomalous or incomplete posterior hyaloid detachment. Despite chronic manifestation, this does not significantly affect central visual function but can manifest with profound loss of peripheral visual function.

The response of anti-VEGF therapy and tamoxifen withdrawal of tamoxifen-induced cystoid macular edema in the same patient

BACKGROUND

Numerous cases with ocular toxicity secondary to tamoxifen have been reported, and became more apparent with keratopathy, cataract, optic neuritis, macular holes, crystalline retinopathy with or without cystoid macular edema (CME). Withdrawing tamoxifen with the approval of the oncologist is the major treatment for cases with tamoxifen-induced retinopathy.

CASE PRESENTATION

We herein reported a patient with a two-year history of painless and reduced visual acuity in both eyes who received tamoxifen therapy for 6 years. Tamoxifen-induced rentinopathy with CME showed significant development even though the patient has already discontinued tamoxifen treatment for 6 months. Anatomic improvements after intravitreal ranibizumab injection in both eyes were significant but were temporary. Surprisingly, CME in both eyes has been resolved spontaneously after 10 months in the penultimate visit without any therapy.

CONCLUSION

Intravitreal ranibizumab injection temporarily improved the anatomy of the eyes in a case with tamoxifen-induced CME, and only tamoxifen withdrawal can bring a sustained effect.

Retinal disease in the neurology clinic

PURPOSE OF REVIEW

Retinal disease can manifest with visual symptoms similar to those which result from central nervous system disorders. We provide a framework for considering retinal causes of common visual complaints presenting to a neurology clinic.

RECENT FINDINGS

Technological advances have afforded quicker detection and a more thorough understanding of these retinal entities and are crucial to consider when evaluating visual complaints in the neurology clinic.

SUMMARY

It is essential to maintain a working knowledge of common retinal conditions that symptomatically overlap with common neurologic conditions. Furthermore, the ophthalmoscopic exam and retinal imaging modalities can both aid in the diagnosis and workup of visual complaints and neurologic disease.

Real-world incidence of fingolimod-associated macular oedema

BACKGROUND

Fingolimod (Gilenya, Novartis, Basel Switzerland) 0.5 mg orally once-daily is widely used for relapsing-remitting multiple sclerosis. Patients are usually screened four months after starting fingolimod for fingolimod-associated macular oedema (FAME). Large registration trials with stringent eligibility criteria have reported a FAME incidence of 0 - 2.08%.

OBJECTIVES

To determine the real-world incidence of FAME in a London population, and to describe the clinical characteristics and management of confirmed cases.

METHODS

All patients started on fingolimod from September 2012 to September 2018 were referred for ophthalmology clinical examination and macular spectral-domain optical coherence tomography (SD-OCT) at four months after starting treatment. Exclusion criteria were failure to attend or non-gradable OCT images.

RESULTS

Of 228 patients, two had FAME at initial screening, giving an incidence of 0.88% (95% confidence interval 0.10-3.10). Another case emerged subsequently, at 637 days, resulting in a final incidence of 1.32% (95% confidence interval 0.30-3.80). Fingolimod was discontinued in two cases. FAME resolved in all cases within two to 10 months, with no persistent visual loss or symptoms.

CONCLUSIONS

The real-world FAME incidence is consistent with fingolimod registration studies. FAME may have a delayed onset and may be better detected with newer OCT devices.

Docetaxel-induced maculopathy possibly potentiated by concurrent hydroxychloroquine use

Purpose

To report a case of bilateral non-leaking cystoid macular degeneration induced by docetaxel, possibly potentiated by hydroxychloroquine.

Observations

A 63-year-old female patient with a long-term history of rheumatoid arthritis controlled on hydroxychloroquine for 33 years with no evidence of retinopathy developed bilateral loss of vision after having been on docetaxel chemotherapy for breast cancer. Optical coherence tomography showed bilateral cystic maculopathy with no angiographic evidence of leakage on fluorescein angiography. The patient was treated conservatively with no further interventions. Marked improvement of the macular degeneration occurred over the subsequent 9 months, but without visual improvement, although a cataract likely confounded final visual acuity measurement.

Conclusions and importance

Docetaxel-induced maculopathy has been previously reported, but with only four case reports in literature, and most often in conjunction with concurrent therapies or conditions also known to cause macular edema. This is the first case report of docetaxel-induced maculopathy in a setting of hydroxychloroquine therapy which may possibly has potentiated the effect of docetaxel to induce maculopathy. Impaired transcellular retinal pigment epithelial transport might be the cause of non-leaking cystic maculopathy.

New anti-hyperglycaemic agents for type 2 diabetes and their effects on diabetic retinopathy

There has been an increase in the range of non-insulin anti-hyperglycaemic agents used to treat type 2 diabetes. With the globally rising rates of type 2 diabetes and complications such as diabetic retinopathy, it is important for ophthalmologists to be aware of these new agents and their impacts on diabetic retinopathy and diabetic macular oedema. We conducted a review of the literature to determine if there were any beneficial or harmful effects of the currently used anti-hyperglycaemic agents on diabetic retinopathy or diabetic macular oedema. Our review of the current literature found that apart from thiazolidinediones, anti-hyperglycaemic agents have been reported to have beneficial or neutral effects on diabetic eye complications. Thiazolidinediones (pioglitazone is the only one currently available) have been linked to incident or worsening diabetic macular oedema, although the rate is believed to be low. Glucagon-like peptide 1 (GLP1) agonists (incretins) in general are beneficial except semaglutide which is associated with increased rates of diabetic retinopathy complications. These results have implications for selection of anti-hyperglycaemic agents for patients with diabetic retinopathy or macular oedema. Further studies need to be conducted to identify if reported beneficial effects are independent of the impact of glycaemic control. Early worsening of retinopathy with tight glycaemic control should also be noted in interpretation of future studies.

Glucagon-Like Peptide 1 Receptor Agonists and the Risk of Incident Diabetic Retinopathy

OBJECTIVE

Previous studies suggested that glucagon-like peptide 1 receptor agonists (GLP-1 RAs) may initially worsen and possibly increase the risk of diabetic retinopathy. However, data on this possible association remain limited. Thus, this population-based study aimed to determine whether use of GLP-1 RAs is associated with an increased risk of incident diabetic retinopathy.

RESEARCH DESIGN AND METHODS

Using the U.K. Clinical Practice Research Datalink (CPRD), we conducted a cohort study among 77,115 patients with type 2 diabetes initiating antidiabetic drugs between January 2007 and September 2015. Adjusted hazard ratios (HRs) and 95% CIs of incident diabetic retinopathy were estimated using time-dependent Cox proportional hazards models, comparing use of GLP-1 RAs with current use of two or more oral antidiabetic drugs. In an ancillary analysis, new users of GLP-1 RAs were compared with new users of insulin.

RESULTS

During 245,825 person-years of follow-up, 10,763 patients were newly diagnosed with diabetic retinopathy. Compared with current use of two or more oral antidiabetic drugs, use of GLP-1 RAs was not associated with an increased risk of incident diabetic retinopathy overall (HR 1.00, 95% CI 0.85-1.17). Compared with insulin, GLP-1 RAs were associated with a decreased risk of diabetic retinopathy (HR 0.67, 95% CI 0.51-0.90).

CONCLUSIONS

The associations with diabetic retinopathy varied according to the type of comparator. When compared with use of two or more oral antidiabetic drugs, use of GLP-1 RAs was not associated with an increased risk of incident diabetic retinopathy. The apparent lower risk of diabetic retinopathy associated with GLP-1 RAs compared with insulin may be due to residual confounding.

Incretin-Based Therapies and Diabetic Retinopathy: Real-World Evidence in Older U.S. Adults

OBJECTIVE

Recent large trials yield conflicting results on the association between incretin-based therapies (IBTs) and diabetic retinopathy (DR). We examined whether IBTs increase DR risk compared with other antihyperglycemics.

RESEARCH DESIGN AND METHODS

We implemented an active comparator, new-user cohort design using a nationwide 20% random sample of fee-for-service U.S. Medicare beneficiaries aged 65 years or older with Parts A, B, and D coverage between 2007 and 2015. We identified the following cohorts without prior treatment for retinopathy: dipeptidyl peptidase 4 inhibitors (DPP4i) versus sulfonylureas (SU), DPP4i versus thiazolidinediones (TZD), glucagon-like peptide-1 receptor agonists (GLP1RA) versus long-acting insulin (LAI), and GLP1RA versus TZD. Primary outcome was advanced diabetic retinopathy requiring treatment (ADRRT), defined as a procedure code for retinopathy treatment. Incident diabetic retinopathy (IDR), identified by a diagnosis code, was a secondary outcome. We estimated propensity scores to balance confounders and adjusted hazard ratios (95% CI) using weighted Cox proportional hazards models.

RESULTS

We identified 213,652 eligible patients. During a median duration of 0.58 to 0.87 years across comparisons, with a rate from 6.0 to 12.8 per 1,000 person-years, IBTs were not associated with increased ADRRT or IDR risk. The adjusted hazard ratios (95% CI) for ADRRT were 0.91 (0.79-1.04) by comparing DPP4i to SU (n = 39,292 and 87,073); 0.91 (0.75-1.11), DPP4i to TZD (n = 51,410 and 22,231); 0.50 (0.39-0.65), GLP1RA to LAI (n = 9,561 and 82,849); and 0.75 (0.53-1.06), GLP1RA to TZD (n = 10,355 and 27,345).

CONCLUSIONS

Our population-based cohort study of older U.S. adults with diabetes suggests that IBTs used for approximately 1 year do not increase the DR risk.

Cystoid Macular Edema during Treatment with Paclitaxel and Bevacizumab in a Patient with Metastatic Breast Cancer: A Case Report and Literature Review

We present a case of a metastatic breast cancer patient with cystoid macular edema (CME) occurring during treatment with paclitaxel and bevacizumab. She had a history of neoadjuvant chemotherapy and partial mastectomy plus axillary lymph node dissection for stage IIB left-breast cancer. Twenty-four months later, she was diagnosed with multiple bone metastases and underwent chemotherapy with paclitaxel and bevacizumab. Thirty-three months after the initiation of the chemotherapy, she noticed bilateral blurred vision. The retinal thickening with macular edema was observed by optical coherence tomography, resulting in a diagnosis of CME. With cessation of paclitaxel and administrating ocular instillation of a nonsteroidal anti-inflammatory drug, her macular edema gradually reduced and disappeared in a month. While CME caused by chemotherapy is very rare, taxane may cause ocular adverse events such as CME. It is important to urge patients to consult an ophthalmologist promptly when they have visual complaints during taxane chemotherapy.

Macular edema is a rare finding in untreated vitreoretinal lymphoma: small case series and review of the literature

Background

To determine the occurrence of macular edema (ME) in vitreoretinal lymphoma (VRL).

Methods

Retrospective analysis of 17 patients (31 eyes) with VRL. A review of the literature was done as well.

Results

Nine patients (15 eyes) had fluorescein angiography and/or optical coherence tomography at presentation. In the ME group (six eyes of four patients), three patients (five eyes) had prior chemotherapy and radiation. Excluding eyes with radiation retinopathy (three eyes), rate of ME was 25% (3/12). When two unirradiated fellow eyes of eyes with radiation retinopathy were also excluded, ME rate was 10% (1/10). Excluding the eyes with intraocular surgery, the rate of ME was 0%. In the group without ME (nine eyes of six patients), one patient (one eye) was treated with chemotherapy and radiation and three patients (five eyes) with chemotherapy. Review of the literature showed that the ME was found between 2 and 60% of cases, but most of the cases with ME had prior interventions.

Conclusions

Macular edema in VRL is not uncommon but usually related to prior interventions. Macular edema as an initial presentation of VRL is rare.

Central Macular Thickness Monitoring after a Taxane-Based Therapy in Visually Asymptomatic Patients

BACKGROUND

Taxanes are drugs used in various chemotherapeutical protocols to treat solid tumors. They have multiple systemic adverse effects, such as bone marrow suppression, alopecia, nausea, and vomiting, and may rarely cause ocular symptoms. In the past decade, a few reported cases have shown the occurrence of a cystoid macular edema with significant visual loss after the use of a taxane-based chemotherapy. The aim of this study was to compare the central macular thickness (CMT) before and after the initiation of a taxane-based therapy in visually asymptomatic patients and to elucidate the possible impact of these drugs on the vision of cancer patients.

METHODS

Patients with a confirmed diagnosis of a solid tumor were screened for any ophthalmic disease before inclusion and had a baseline macular spectral domain optical coherence tomography (OCT; RTVue-100; Optovue Inc., Fremont, CA, USA) before the initiation of a taxane-based chemotherapy according to different protocols, such as 4EC-4T, 3FEC/3T, or 4TC. OCT was repeated after 4 cycles (or 3 months) of treatment, and CMT was compared to baseline. Patients presenting diabetic retinopathy, age-related macular degeneration or any condition that causes macular edema confirmed by ophthalmic examination were excluded.

RESULTS

Fifty eyes of 25 patients were included; 92% of the subjects were female with a mean age of 48.52 years, 88% were diagnosed with breast cancer, 8% with esophageal cancer, and 4% with ovarian cancer. Docetaxel was the taxane administered to 92% of the patients. The received dose of docetaxel ranged between 110 and 160 mg. The other patients had paclitaxel in their protocols. No significant macular edema or drop in visual acuity were noted in any patient. Nevertheless, the mean CMT was found to be increased, particularly in the parafoveal and perifoveal areas (mean difference of +2.22 μm; p = 0.001).

CONCLUSION

Taxane-based chemotherapy regimens seem to increase macular thickness, with a relative sparing of the fovea, in patients without significant macular edema. Further research is required to better explain the pathophysiology and possible impact of this phenomenon.

Cystoid macular edema associated with preservative-free latanoprost after uncomplicated cataract surgery: case report and review of the literature

Background

Cystoid macular edema associated with latanoprost administration has been reported in patients after complicated cataract surgery with coexisting risk factors. We present the first case of preservative free latanoprost associated cystoid macular edema that occurred many months after uncomplicated cataract surgery.

Case presentation

A 65-year old Caucasian female presented in the Outpatients Clinic complaining of reduced vision and metamorphopsia in the right eye. She had undergone uneventful phacoemulsification 19 months ago in the right eye and was under treatment with preservative free latanoprost eye drops for the last 7 months for ocular hypertension. Her remaining medical and ocular history were otherwise unremarkable. Cystoid macular edema with serous retinal detachment was diagnosed in the right eye using optical coherence tomography and fluorescein angiography. Latanoprost was discontinued and brinzolamide and nepafenac eye drops were administered in the right eye. Two months later, cystoid macular edema completely resolved with restoration of visual acuity. Nepafenac eye drops were administered for another 2 months. Eight months after latanoprost cessation optical coherence demonstrated no sign of cystoid macular edema whereas a subtle epiretinal membrane was noted.

Conclusions

Cystoid macular edema may potentially occur in patients receiving preservative free latanoprost. More interestingly, in our case it was diagnosed in a patient with a long standing pseudophakia after uncomplicated phacoemulsification. No obvious risk factor for macular edema development was recognized. Prompt diagnosis and latanoprost discontinuation resulted in complete resolution of the cystoid macular edema and functional restoration of the eye.

Docetaxel Retinopathy: A Case Report

Background

To report the use of En-face optical coherence tomography (OCT) in a patient treated with docetaxel and tamoxifen for breast cancer for the detection of macular edema (ME) without evidence of leakage on fluorescein angiography (FA).

Case Presentation

A 52-year-old woman treated for breast cancer presented with bilateral visual loss for 2 months. FA showed no significant leakage while spectral-domain OCT scans of both eyes showed foveolar and parafoveolar cystic spaces in a moderately thickened macula. En-face OCT segmented at the inner retina showed the petaloid arrangement of cystic cavities, comparable to a cystoid ME.

Conclusions

The combined use of tamoxifen could have potentiated the toxic effect of docetaxel on the macula. En-face OCT images may reveal a petaloid aspect of the macula due to cysts in the inner retina segmentation, when FA shows no leakage.

Macular edema might be a rare presentation of hydroxychloroquine-induced retinal toxicity

The aim of this study is to report a rare case of macular edema as a presentation of hydroxychloroquine-related retinal toxicity. We presented a case of a 46-year-old female patient using hydroxychloroquine for underlying rheumatoid arthritis (RA) with blurred vision over the left eye. Uveitis and macular edema were found initially. Systemic survey did not reveal any other etiology. Topical corticosteroid was given under the impression of RA-related uveitis. The uveitis resolved 1 week later, but macular edema persisted in spite of treatment. Under the suspicion of drug-related complication, we try to discontinue hydroxychloroquine. Her symptoms improved gradually after cessation of hydroxychloroquine, and further serial image study confirmed subsiding of the macular edema without any further treatment. Except the well-known signs of the retinal toxicity, macular edema might be a rare presentation of hydroxychloroquine-related retinal toxicity.

Fingolimod Associated Bilateral Cystoid Macular Edema-Wait and See?

Fingolimod 0.5-mg once-daily is an approved therapy for patients with relapsing–remitting multiple sclerosis (MS). Several pivotal and real-world studies have demonstrated that fingolimod is associated with the development of macular edema (ME). Herein, we present a case of a diabetic MS patient who developed severe bilateral ME during fingolimod treatment. By means of this case study we provide a detailed review about fingolimod associated macular edema (FAME), its current incidence with or without diabetes mellitus, and previous therapy attempts and outcomes in MS patients. Intravitreal administration of antibodies raised against vascular endothelial growth factor A (VEGF-A) has not yet been used in the management of FAME, however, the excellent therapeutic response in our patient may justify the use of anti-VEGF-A agents in combination with cessation of fingolimod to achieve fast resolution of FAME and to prevent visual deficits, particularly in bilateral FAME.

Phacoemulsification without preoperative mydriasis in patients with age-related cataract associated with type 2 diabetes

Aim

To study the effect of intracameral injection of preservative-free lignocaine to induce pupil dilatation, without using any preoperative dilating eyedrops or intraoperative mydriatics in patients with age-related cataract associated with type 2 diabetes mellitus.

Design

This was a prospective, observational, and interventional case series conducted at a tertiary eyecare center in rural India.

Materials and methods

A total of 32 patients underwent phacoemulsification under topical anesthesia for visually significant cataract. Preoperative pupillary diameter was measured 3 days prior to surgical procedure under mydriatics (tropicamide 0.8%, phenylephrine hydrochloride 5%). Intraoperative pupillary dilatation was achieved by 1% intracameral lignocaine solution alone. Effective phacoemulsification time (EPT), total surgical time, and final pupillary diameter were recorded at the conclusion of surgery.

Results

The average duration of diabetes was 11.2 (range 5–25) years. There was no difference in dilatation by preoperative pupil-dilating drops (5.2±0.5 mm, range 3–8.3 mm) and intracameral 1% lignocaine during the surgical procedure (P=0.63). There was a negative correlation (r=−0.92) between diabetes duration and dilatation of pupils with dilating drops and intracameral lignocaine. The duration of the surgery, EPT, and phacoemulsification chop had statistically insignificant effects on mydriasis, while the grade of the nucleus had a statistically significant effect on mydriasis. Intracameral lignocaine had no significant effect on blood pressure or pulse. There were no surgical complications that could have compromised the visual outcome. None of the patients developed macular edema in a follow-up period of 3 months; 28 patients (87.5%) had best-corrected visual acuity from 20/30 to 20/20.

Conclusion

Intracameral lignocaine 1% provides sufficient mydriasis for the safe phacoemulsification of cataract in patients with type 2 diabetes of variable duration.

Effect of nepafenac on the foveal profile of glaucomatous patients undergoing phacoemulsification

PURPOSE

Retrospective, pilot study to determine whether nepafenac treatment pre- and postcataract surgery in glaucoma patients using topical hypotensive agents minimized cystoid macular edema by comparing pre- and postsurgical foveal characteristics, as in some cases these agents cannot be withdrawn and, hypothetically, their inflammatory effect on the fovea could be neutralized by the addition of nepafenac.

METHODS

Patients were divided into two subgroups depending on whether or not topical nepafenac was added to the surgical protocol (NEP = nepafenac group and nNEP = non nepafenac group). All had undergone phacoemulsification and data on pre- and postoperative macular status were recorded.

RESULTS

In the nNEP group, there was a significant increase in foveal thickness (FT) in the first month postoperative visit with respect to the preoperative status (p = 0.006), and this situation did not change at the third postoperative month (p = 0.9411). In the NEP group, the increase in FT was not significant at the first month after surgery (p = 0.056) nor at the final visit (p = 0.268), in contrast to the nNEP group.

CONCLUSION

This study of the possible prophylactic effect of nepafenac on postoperative macular edema supports the results of other studies that confirm subclinical edema post phacoemulsification, and found a significantly lower gradient in the increase in FT in patients treated pre- and postoperatively with nepafenac.