Cyclosporine-induced retinal toxic blindness

"For your eyes only": ophthalmic complications following lung transplantation

Ophthalmic complications in the lung transplant population are a little-known entity. It includes a spectrum of diseases ranging from infections such as cytomegalovirus (CMV) retinitis, herpetic keratitis, Pseudallescheria boydii to non-infectious complications such as posterior subcapsular cataracts (PSCs), cyclosporine retinopathy, and post-transplant lymphoproliferative disorder (PTLD). These diseases can be attributed to high levels of immunosuppression, advanced age, and drug-specific side effects. Underlying comorbidities such as diabetes mellitus may also play a role in the pathogenesis. Patients can present with varied symptoms such as blurry vision, floaters or eye pain. Prompt diagnosis often requires a high index of suspicion. With increasing numbers of transplants being performed worldwide, it is imperative for the pulmonologist and transplant physician to recognize these often subtle symptoms. Any visual symptom should trigger an ophthalmological evaluation in order to manage these complications; some of which pose the risk of systemic dissemination and significant morbidity. The following article provides an in-depth review of the common presenting symptoms, treatments and recent advances related to common ophthalmic complications following lung transplantation. While this article focuses on the lung transplant sub-population, the authors would like to point out that some of these complications are shared by other solid-organ transplants as well, by virtue of their shared immunosuppressive therapies.

Early isolated optic neuropathy caused by cyclosporine

PURPOSE

To examine, for the first time, whether cyclosporine intake has an early isolated effect on the optic nerve.

MATERIALS AND METHODS

This observational case series consisted of 192 eyes of 98 patients treated with cyclosporine. Patient age and duration and dosage of cyclosporine were recorded, and visual acuity, optic nerve function, visual fields, and visual evoked potential (VEP) were tested. Fundus examination was also performed. Patients with glaucoma, vascular retinopathies, and deep amblyopia were excluded.

RESULTS

Mean patient age was 46 years, average duration of treatment was 6 years, and median dosage of cyclosporine was 200 mg daily. VEP was tested in 73 patients (142 eyes) and yielded a delayed P100 wave in 9 (12.32%) (14 eyes). Among these 9 patients, abnormal findings were also noted on the Ishihara colour test in 42.86% of the eyes, and on the visual field test in 64.3% of the eyes. Abnormal VEP showed a significant correlation (p < 0.05) with older age (> 46 years) and a non-significant correlation with longer duration of treatment. Higher abnormal VEP potential was not correlated with higher cyclosporine dose, and there was no correlation between abnormal VEP and blood level of cyclosporine.

CONCLUSION

Optic neuropathy was significantly associated with older age in cyclosporine-treated patients. A correlation between optic neuropathy with longer duration of cyclosporine treatment was noted but was not statistically significant. We suggest that tests of optic nerve function, including VEP, be a part of the follow-up of patients receiving cyclosporine.

Retinal changes in solid organ and bone marrow transplantation patients

Objective

To evaluate retinal changes in patients who underwent solid organ or bone marrow transplantation.

Methods

A retrospective analysis of medical records of patients evaluated from February 2009 to December 2016. All patients included underwent funduscopy. Clinical and demographic data regarding transplantation and ophthalmological changes were collected.

Results

A total of 126 patients were analyzed; of these, 108 underwent transplantation and 18 were in the waiting list. Transplantation modalities were heart, lung, kidney, liver, pancreas, combined pancreas and kidney and bone marrow transplantation. The main pre-transplantation comorbidities were diabetes and arterial hypertension. Of the 108 transplanted patients, 82 (76%) had retinal changes. All patients who underwent pancreas or combined pancreas and kidney transplantation had diabetic retinopathy. The main retinal changes found were diabetic retinopathy, hypertensive retinopathy, retinal vascular occlusions, chorioretinal infections and central serous chorioretinopathy.

Conclusion

Retinal changes were either related to preexisting conditions, mainly diabetic retinopathy, or developed postoperatively as a complication of the surgical procedure, or as an infection related to the immunosuppressive status, or due to drug toxicity. These patients may present with complex ophthalmological changes and should be carefully evaluated prior to surgery and further followed by an ophthalmologist skilled in the management of diabetic retinopathy and posterior pole infections.

Laser Photocoagulation for Central Serous Retinopathy Associated with Graft-Versus-Host Disease

PURPOSE

To describe the clinical characteristics and treatment of recurrent central serous retinopathy (CSR) following bone marrow transplantation (BMT).

METHODS

Between June 1998 and September 1999, 116 patients underwent allogeneic BMT at Hadassah Medical Center. Ocular complaints were expressed by 57.8% of these patients, who were examined and followed by the same ophthalmologist every 2-4 weeks. The ocular examination included Schirmer's test, slit-lamp examination, tonometry, and dilated funduscopy. If fundus abnormalities were noted, fluorescein angiography and indocyanine-green chorioangiography were performed.

RESULTS

Three patients presented with BMT-induced relapsing CSR. The severity of the CSR correlated well with the dosage of the systemic corticosteroids. These patients were eventually treated with laser photocoagulation, which, in all cases, resolved the CSR and improved visual acuity. During a 3-4 year follow-up period, no recurrence of CSR was documented despite continuous systemic corticosteroid treatment.

CONCLUSIONS

In BMT patients, chronic corticosteroid treatment can cause a persistent/relapsing CSR. Since corticosteroids cannot be discontinued in such cases, photocoagulation should be considered at an early stage to prevent continuous ocular morbidity.

Presumed topiramate-induced maculopathy

The case of a patient who developed decreased vision while taking topiramate (TPM) for symptomatic epilepsy is described. Ophthalmological examination revealed findings suggestive of maculopathy. TPM was discontinued; however, vision failed to improve significantly over 6 months of follow-up. We hypothesize that the patient's maculopathy was induced by TPM. TPM, like vigabatrin, may exert retinal toxicity causing persistent visual impairment.

Ocular complications of heart transplantation in a Chinese population

The purpose of this study was to investigate ocular complications among a group of patients on long-term, high-dose immunosuppression and corticosteroids for the maintenance of orthotopic heart transplants. Additionally, we provided information pertinent for the early diagnosis and treatment of eye diseases. In this study, we retrospectively assessed the clinical data of 138 patients with orthotopic heart transplantations from May 2000 to October 2005, including assessment of ophthalmic symptoms and signs, as well as the general condition, treatment, and prognosis. Of 138 transplant recipients examined (276 eyes), 47 eyes (17.0%) showed ocular surface diseases. Sixty-four (23.2%) had a posterior subcapsular cataract, and 16 (5.8%) corticosteroid glaucoma. Fifteen (5.6%) had ocular fundus diseases. Various ocular complications related to immunosuppression and corticosteroids appear among heart transplant patients. Cardiac surgeons and ophthalmologists must closely evaluate ocular symptoms in the posttransplantation period.

Light and alcohol evoked electro-oculograms in cystic fibrosis

Cystic fibrosis (CF) is caused by a defect in the cystic fibrosis transmembrane conductance regulator (CFTR) which is a chloride channel. CFTR is expressed in the retinal pigment epithelium (RPE) where it is believed to be important in generating the fast oscillations (FOs) and potentially contributing to the light-electro-oculogram (EOG). The role of CFTR in the alcohol-EOG is unknown. We recruited six individuals with CF (three homozygotes for Delta508 and three heterozygous for Delta508) and recorded the light- and alcohol-EOGs as well as the FOs and compared them to a control group. The results showed that in the CF group the amplitude of the alcohol- and light-EOGs were normal. However, the time to peak of the light- and alcohol-rises were significantly faster than in the control group. We conclude that CFTR is not primarily responsible for the alcohol- or light-rises but is involved in altering the timing of these responses. The FOs showed differences between the homozygotes, heterozygotes and the controls. The amplitudes were significantly higher and the time to the dark troughs were significantly slower in the heterozygote group compared to both controls and the homozygotes. In contrast, the homozygotes did not differ in either amplitude or the timing of the FOs compared to the controls.

Major ocular complications after organ transplantation

We reviewed the existing literature on major ocular complications after organ transplantation. Disorders of the ocular surface were not considered. Published reports were selected through a computerized MEDLINE search of the literature. The incidence of cataract or increased intraocular pressure due to immunosuppressant therapy are common; although retinopathy, optic neuropathy, or central nervous system involvement are less frequent they may be related to severe and irreversible visual loss. Patients undergoing organ transplantation should receive careful and regular ocular examinations.

Retinal complications of bone marrow and solid organ transplantation

PURPOSE OF REVIEW

A review is presented of the current literature on retinal complications of bone marrow and solid organ transplantation.

RECENT FINDINGS

Retinal complications of bone marrow and solid organ transplantation include microvascular retinopathy, infection, and hemorrhagic findings. Other clinical observations include central serous chorioretinopathy, bilateral optic disc edema, and cyclosporine-related retinal toxicity. The cause of these clinical findings is likely to be multifactorial, resulting from the combined effects of cyclosporine, total body irradiation, infections, high-dose chemotherapy, and recurrent malignancies.

SUMMARY

Understanding of these clinical entities of the posterior segment is important in minimizing the potentially sight-threatening complications from bone marrow and solid organ transplantation.

Neurologic complications of transplantation

BACKGROUND

Organ transplantation is one of the most dynamic fields in medicine and has evolved into a life-saving option for thousands of patients with previously fatal conditions. The posttransplantation clinical course is frequently associated with neurologic complications that are usually related to pretransplant morbidity, the surgical procedure of transplantation, immunosuppression, and opportunistic infection.

REVIEW SUMMARY

Neurologic complications of organ transplantation may be divided into complications common to all types of allografts and complications that are specific for a particular type of organ transplantation. The most common complications include seizures, opportunistic central nervous system (CNS) infection, metabolic encephalopathy, stroke, intracranial hemorrhage, and drug-related adverse events. Opportunistic CNS infection may have a subtle presentation and should not be overlooked, as the consequences of delayed treatment may be grave. Neurotoxicity of immunosuppressive agents is also a frequent cause of neurologic complications and may occur in the setting of normal serum drug levels. The clinical course of transplant patients is frequently complex, requiring close cooperation between the transplant team and specialty consultants. Prolonged survival of transplant patients will shift the focus of neurologic complications from acute, perioperative to chronic complications of immunosuppression.

CONCLUSIONS

Neurologic complications of organ transplantation are commonly related to opportunistic infection or neurotoxicity of immunosuppressive agents, requiring careful titration of immunosuppression. Timely diagnosis of CNS infection or other causes of neurologic dysfunction may significantly improve recovery and outcome in these patients.

True, true and related?

Several chorioretinal lesions have been observed that are associated with bone marrow transplantation (BMT), such as cotton-wool spots, macular stars, ischemic changes due to microangiopathy, "BMT retinopathy" and choroidal infiltration. Central serous retinopathy (CSR) has rarely been described in the BMT setting. We present a patient who underwent allogeneic BMT and subsequently developed severe chronic graft versus host disease (CGvHD) complicated with CSR.