Acute onset of ocular complications with interferon

Bilateral Transient Visual Obscurations with Headaches during Alpha-II Interferon Therapy: A Case Report

A 40 year-old woman receiving alpha interferon therapy for chronic active hepatitis C presented transient bilateral visual obscurations with associated visual field defects and headaches, with elevated cryoglobulin levels. These manifestations mimicked the clinical picture of migraine and were associated with worsening of previous moderate Raynaud's syndrome and diffuse paraventricular lesions of the white matter seen in cerebral MRI. Bilateral posterior cerebral transient ischemic episodes rather than an anterior visual pathway lesion were thought to be responsible for the clinical symptoms though the exact role of interferon in these vasospastic-like disorders remains speculative. Their possible relationship with increased cryoglobulinemia is uncertain. We suggest that Raynaud's phenomenon may have a predisposing role for these manifestations.

Recent developments in the treatment of posterior uveitis

Uveitis is an intraocular inflammation that can be caused by infection, autoimmune disease, trauma or malignancy. It is a serious cause of visual handicap and therapy is targeted at: removal of possible infectious agents, the immunological processes that lead to or sustain the inflammation and finally to prevent or treat the destructive effects of the inflammation on the delicate ocular structures. In this review the latest developments concerning the treatment of posterior uveitis are illuminated, e. g., new approaches concerning the treatment of infectious uveitis including the therapy of herpes virus (VZV, HSV and CMV), bacterial and toxoplasma infections of the eye. Several new ways to influence the immune response and inflammation are described including the use of interferons, modulation of cytokines, soft steroids, other new immunosuppressive drugs and treatment of autoimmune uveitis by oral tolerization. An overview is given to illustrate new ways to administer drugs into eyes, such as intravitreal devices. Finally new developments in the field of the treatment of the various complications of uveitis (cystoid macular edema) are described.

Ischemic Optic Neuropathy in Chronic Viral Hepatitis C Treated with Interferon and Ribavirin

Ischemic Optic Neuropathy (ION) is a rare complication of interferon (IFN) during treatment of Hepatitis C virus (HCV) with all reported cases occurring within three months of the start of therapy. We report a case of a late bilateral sequential ischemic optic neuropathy after 36 weeks of pegylated-interferon therapy. In contrast to previous reports, we recommend a regular ophthalmological follow-up throughout the whole course of interferon therapy.

Pegylated interferon alpha-associated optic neuropathy

A 52-year-old man with chronic hepatitis C presented with painless, bilateral, simultaneous nonarteritic anterior ischemic optic neuropathy (NAION) and peripheral neuropathy. Symptoms began 19 weeks after starting peginterferon alpha-2a. The peripheral neuropathy and vision of the right eye improved, but the vision of the left eye worsened after stopping interferon. We identified 23 additional cases of NAION during interferon alpha therapy. At least 12 of these patients suffered bilateral NAION. Patients lost vision 1-40 weeks after initiating therapy. Of 21 eyes that had documented initial and follow-up acuities, 8 improved, 1 worsened, and the rest remained stable. One patient had a painful peripheral neuropathy. Treatment with interferon alpha may result in NAION. Discontinuation of therapy deserves consideration after weighing individual risks and benefits.

Ocular side effects of anti-rheumatic medications: what a rheumatologist should know

Nearly every drug may cause changes to ocular tissues through a variety of mechanisms. Medication overdoses, drug-drug interactions but also chronic administration of medications at the recommended doses may lead to ocular toxicity. The ocular side effects, screening for eye toxicity and treatment guidelines for anti-inflammatory and immunosuppressive drugs commonly used by rheumatologists are reviewed herein.

Development of ocular myasthenia during pegylated interferon and ribavirin treatment for chronic hepatitis C

A 63-year-old male experienced sudden diplopia after 9 weeks of administration of pegylated interferon (IFN) alpha-2b and ribavirin for chronic hepatitis C (CHC). Ophthalmologic examinations showed ptosis on the right upper lid and restricted right eye movement without any other neurological signs. A brain imaging study and repetitive nerve stimulation test indicated no abnormality. The acetylcholine receptor antibody titer and response to acetylcholinesterase inhibitors were negative, and the results of thyroid function tests were normal. The patient's ophthalmological symptoms improved rapidly 3 weeks after discontinuation of pegylated IFN alpha-2b and ribavirin. The ocular myasthenia associated with combination therapy of pegylated IFN alpha-2b and ribavirin for CHC is very rarely reported; therefore, we present this case with a review of the various eye complications of IFN therapy.

[Ocular complications of hepatitis C treatment]

INTRODUCTION

Hepatitis C is a viral infection that can lead to hepatocellular carcinoma. According to current recommendations, the treatment is based on the association of pegylated interferon and ribavirin. Strict treatment criteria are available and apply for the 8,000 patients diagnosed every year in France. Ophthalmological side effects are numerous, unpredictable, and sometimes severe.

CASE REPORT

We report the case of a patient treated with an association of interferon and ribavirin for hepatitis C, who presented two periods of decreased visual acuity 4 years apart. Interferon-related toxic retinopathy was suggested for the first event, while optical neuropathy was diagnosed for the second.

CONCLUSION

Ocular complications of hepatitis C treatment with interferon and ribavirin are frequent but often benign. Our recommendations are periodic ophthalmological examinations, including visual acuity and fundus examination, before starting the treatment, at 3 months, and if necessary at 9 months.

Interferon-alpha2a and Vogt-Koyanagi-Harada disease: a double-edged sword?

Successful therapy based on the use of interferon-alpha has been reported in different types of severe chronic uveitis. The immunomodulatory effects of this drug, combined with its antiviral properties seem to contribute to its efficacy in the treatment of different forms of severe and refractory uveitis such as Vogt-Koyanagi-Harada disease, Behçet-associated uveitis, or even human herpes virus 8 (HHV-8) associated uveitis. At the same time, severe ocular complications have been reported in patients treated with interferon-alpha for chronic viral hepatitis C. Among these complications, six cases of Vogt-Koyanagi-Harada-like disease have been described.We report a small case series of two patients with refractory Vogt-Koyanagi-Harada disease, treated with interferon-alpha and discuss the potential benefits or detrimental role of interferon therapy in these patients.

Vascular Ophthalmological Side Effects Associated with Antiviral Therapy for Chronic Hepatitis C are Related to Vascular Endothelial Growth Factor Levels

We have screened for the incidence of vascular ophthalmological side effects (VOSE) in chronic hepatitis C (CHC) patients undergoing pegylated interferon (peg-IFN) plus ribavirin (RBV) therapy and sought evidence for angiogenesis activation. Thirty-four CHC patients were prospectively evaluated (18 patients with 180 μg/week of peg-IFN-α2a plus 800 mg/day of RBV and 16 with 1.5μg/kg/week of peg-IFN-α2b plus 800–1,200 mg/day of RBV). Complete ophthalmological evaluation and serum vascular endothelial growth factor (VEGF) levels were assessed before and at the end of therapy. Thirteen patients (38.2%) developed VOSE, eight (23.5%) featured subconjunctival haemorrhage, and five (14.7%) had evidence of retinopathy – all were unrelated to age, sex, genotype, the type of antiviral schedule used and response to therapy. At the end of treatment, the VOSE group had significantly higher serum VEGF levels than the group of patients without detectable side effects (median 281 [range 106–386] vs 117 [83–225] pg/ml, P=0.05). These differences increased when VEGF values were corrected by platelet count. In the VOSE group, baseline VEGF and VEGF/platelet values were also significantly higher (164 [55–260] vs 64 [21–172] pg/ml, P=0.046; and 0.920 [0.217–1.543] vs 0.320 [0.100–0.661] pg/106 platelets, P=0.024, respectively]. In a multivariate model VEGF/platelet values at end of treatment and hepatic fibrosis stage were the only predictors of VOSE development. In 3 out of 13 patients visual acuity was affected and 2 had residual lesions in the follow-up. In this exploratory study, antiviral therapy of CHC frequently induces VOSE, apparently through an activation of angiogenesis.

Ophthalmologic side effects during alpha-interferon therapy for viral hepatitis

BACKGROUND/AIMS

Ophthalmologic side effects have been reported during interferon therapy, particularly retinal lesions and neurovisual impairment. The aim of this prospective study was to assess the nature and the frequency of such lesions during alpha-interferon therapy for viral hepatitis.

METHODS

Between 1995 and 2003, 156 patients treated with standard or pegylated alpha-interferon, with or without ribavirin, had a regular ophthalmologic examination before and during treatment. No patient had signs of retinopathy before treatment. Cotton-wool spots were found in 31 patients and retinal hemorrhage in nine patients during treatment (24% of patients). These lesions remained asymptomatic and disappeared in all patients. A previous history of arterial hypertension (RR 4.60, 95% CI 1.95-10.85), age above 45 years (RR 2.80, 95% CI 1.36-5.85), and use of pegylated alpha-interferon (RR 2.75, 95% CI 1.41-5.38) were significantly associated with retinopathy. Neurovisual impairment was present in 31 patients (20%) before treatment and in 74 patients (47%) during treatment.

CONCLUSIONS

In conclusion, this study showed that signs of retinopathy and neurovisual impairment were common in patients receiving alpha-interferon therapy but were rarely symptomatic. It suggests that alpha-interferon may usually be continued in asymptomatic patients as long as there is careful fundoscopic examination.

Visual side effects of pegylated interferon during therapy for chronic hepatitis C infection

Ocular toxicity, including retinopathy, optic neuropathy and ocular loss, has been infrequently (<1%) reported as a potentially serious adverse event associated with standard interferon therapy. The new pegylated interferons have improved pharmacokinetics which translates to better antiviral efficacy, however, this improved pharmacokinetic profile also has the potential to alter the frequency and extent of their adverse events. We describe a case of chronic hepatitis C infection that developed visual complaints after one month of pegylated interferon, and retinopathy confirmed on ophthalmologic examination. We place our report in context with a review of the literature related to visual complications associated with interferon therapy. From our compilation of case reports, it is apparent that variable doses and duration of interferon therapy have been associated with ocular toxicity, which in turn suggests an idiosyncratic drug reaction. In as much as this adverse event is unpredictable, and its frequency undefined with pegylated interferon therapy, further surveillance will be required for patients undergoing pegylated-interferon therapy. Although ocular toxicity is uncommon, it should be emphasized that it can occur any time after the start of interferon therapy, and physicians now treating chronic hepatitis C patients with pegylated interferon must be aware of this potentially serious adverse event.

[Interferons and Behçet's disease]

BACKGROUND

Behçet's disease is a vasculitis of unknown origin. Various therapeutic agents have been proposed. Interferon alpha 2a or 2b appear to be the most promising.

CURRENT KNOWLEDGE AND KEY POINTS

Numerous anecdotal reports and some short series have shown the efficacy of interferon in some cases previously resistant to conventional therapy, particularly to immunosuppressors. Posology, depending on the author, may vary from three million three times a week to 18 million three times a week. Interferon alpha is useful in cases of ocular, muco-cutaneous and articular involvement. Data is lacking for digestive, vascular and neurological manifestations.

FUTURE PROSPECTS AND PROJECTS

Multicenter trials will nevertheless be required to determine the duration of therapy, risk of relapses, associated therapy and the optimal time to commence interferon treatment.

Tolerability of treatments for viral hepatitis

Interferon-alpha is the most widely used antiviral drug in chronic hepatitis B and C. Tolerability is usually good and serious adverse effects are rare. Most of the adverse effects are mild or transient and do not necessitate drug withdrawal. More than 90% of patients who are given interferon-alpha achieve 6 months to 1 year of treatment without serious adverse effects. The serious adverse effects usually occur in predisposed patients with pre-existing organ dysfunction. Nevertheless, careful selection of patients for therapy and observation during therapy are recommended. Nucleoside analogues are promising drugs in the treatment of chronic hepatitis B through inhibition of viral DNA polymerase. Lamivudine has been licensed for use in this indication. Its tolerability is excellent even when used for periods of 1 year or more. The main concern is the relatively high incidence of viral resistance resulting in breakthrough during or relapse after therapy. In the treatment of chronic hepatitis C, ribavirin, in combination with interferon-alpha is currently the reference therapy. The main adverse effect is haemolytic anaemia, which necessitates careful monitoring and adjustment of dosage in many cases. Recently, large trials showed the better efficacy of pegylated interferons as compared with standard interferon. The combination of pegylated interferon with ribavirin is under evaluation.

Neurovisual impairment: a frequent complication of alpha-interferon treatment in chronic viral hepatitis

Following our earlier observation of clinically evident optic tract neuropathy in patients receiving low-dose interferon (IFN) therapy, we prospectively evaluated 53 consecutive patients treated for chronic hepatitis B or C with a median dose of 3 MU of IFN-a2b thrice weekly. Measurements included routine ophthalmologic evaluation and recordings of visual evoked responses (VER), electroretinograms (ERG), visual acuity, and visual fields, before, at the end of IFN treatment, and at follow-up visits. Baseline P100 latencies of VERs (base-VER) were abnormally prolonged in 24 patients (32 of 106 eyes, 30.2%); age was the only significant covariate associated with increased risk for an abnormal base-VER by multiple logistic regression (relative risk [RR] 5.3 per each 5-year increase in age). In 45 patients (74 eyes) with normal baseline P100 latencies, the end-of-treatment VERs (end-VER) were significantly prolonged compared with baseline, becoming abnormal in 11 (15 of 74 eyes, 20.3%) (138.8+/-8.7 vs. 117.7+/-5.2 ms, P < .001). This subgroup had older age (59.1+/-11.0 vs. 47.5+/-15.3, P=.007) and reduced visual sensitivity compared with their own pretreatment measurements (24.5+/-1.6 vs. 23.0+/-1.2db, P=.019). Changes of end-VERs by age had a sigmoid distribution with a steep increase of values beyond the 5th decade (R2=.326, P < .001). In a logistic regression model, significant predictors of abnormal end-VERs were, patients' age (RR 5.6 per each 5-year increase), presence of hepatitis B virus (HBV) infection (RR 15.1 compared with hepatitis C virus [HCV] infection) and serum cholesterol levels above 240 mg% (RR 7.1 compared with values < 240 mg%). Subconjunctival hemorrhages were seen in 2 cases and funduscopic examination revealed cotton wool spots in one other. ERG recordings and the P100 amplitude remained unchanged. After stopping IFN, the treatment-associated neurovisual abnormalities reversed to normal in 7 patients (10 of 15 eyes) and persisted in 5 (5 of 15 eyes, 33.3%) for up to 37 (median 7.3) months observation, all patients remaining clinically asymptomatic. In conclusion, subclinical neurovisual impairment is a frequent, largely unrecognized complication of low-dose IFN therapy, and patients with chronic hepatitis B and older age appear to be most susceptible. This apparently innocuous complication is long lasting, possibly irreversible in some patients, with yet undetermined consequences on visual function.

Ocular toxicity and cancer chemotherapy. A review

BACKGROUND

Systemic anticancer therapies can produce acute and chronic organ damage, but the eye is usually considered a protected site. Nonetheless, the oculo-visual system has a potentially high degree of sensitivity to toxic substances. Ocular toxicity induced by cancer chemotherapy includes a broad spectrum of disorders, reflecting the unique anatomic, physiologic, and biochemical features of this essential organ.

METHODS

A review of the literature regarding the ocular toxicity of chemotherapeutic agents, hormonal agents, biologic agents, and high dose chemotherapy with allogeneic and autologous bone marrow transplantation was conducted.

RESULTS

Ocular toxicity induced by anticancer chemotherapy is not uncommon. The development of more aggressive regimens as well as new agents and combination chemotherapies have resulted in a significant increase of reported cases of chemotherapy-induced ocular side effects. In most instances, the mechanisms of ocular toxicity continue to be poorly understood.

CONCLUSIONS

Ocular toxicities induced by chemotherapeutic agents are generally not preventable; therefore, clinicians must be aware of potential vision-threatening complications. Prompt consultation with an ophthalmologist can lead to early detection, proper diagnosis, and appropriate therapeutic measures. Dose reduction or discontinuation of incriminated drugs may help in reducing the severity and the duration of side effects.