Ocular complications in heart, lung and heart-lung recipients

Ocular Symptoms in Kidney, Liver, and Heart Transplant Patients

OBJECTIVES

The purpose of this study was to report the ocular manifestations in kidney, liver, and heart transplant recipients.

MATERIALS AND METHODS

We reviewed the medical records of kidney, liver, and heart transplant recipients who were examined at the ophthalmology clinic of a tertiary hospital between October 2021 and October 2022. We evaluated the ocular complaints of the patients, ophthalmological examination findings, the etiology of the underlying disease, comorbidities, posttransplant duration, and the medications used. Ocular pathologies were classified as corneal, conjunctival, lens, vitreoretinal, and optic disc pathologies for the analysis.

RESULTS

Our study included 233 patients (191 kidney, 40 liver, 2 heart transplant patients). Mean age of patients was 42.94 ± 17.45 years. Among the patient group, 80.3% had at least 1 pathological ocular finding. In subgroup analysis, 12.4% of the patients had corneal pathologies, 19.3% had conjunctival pathologies, 33.0% had lens pathologies, 33.5% had vitreoretinal pathologies, and 18.9% had optic disc-related pathologies. The most common finding was dry eye, followed by cataract and vitreoretinal pathologies. The most common vitreoretinal pathology was diabetic retinopathy, followed by hypertensive retinopathy. The ocular pathology incidence in kidney and liver transplant patients was similar (P = .05). The 2 heart transplant patients did not have any ocular pathologies except refractive errors. In addition, no significant correlation was observed between posttransplant duration and ocular pathologies (P = .28).

CONCLUSIONS

Ocular findings were seen in most of the kidney and liver transplant recipients. Therefore, it is required that these patients undergo routine ocular screenings in order to facilitate early diagnosis and prompt treatment when needed.

Uncommon Complications of Lung Transplantation in a Referral Center

Background

Many efforts were made to determine the uncommon clinical complications after lung transplantation and treatment options to tackle them; however, many of these rare complications have not been mentioned in recent publications. Evaluating and recording adverse effects after organ transplantation can significantly prevent post-transplant mortality. This study aimed to examine rejection factors by examining individuals undergoing lung transplantation surgery.

Materials and Methods

In a prospective longitudinal study, we followed up on complications of 60 lung recipients post lung-transplantation surgery for six years from 2010 to 2018. All complications were recorded in follow-up visits or hospital admissions during these years. Finally, the patients' information was categorized and evaluated by designing a questionnaire.

Results

From a total of 60 transplant recipients, from 2010 to 2018, 58 patients were initially enrolled in our study, but two were lost to follow-up. Uncommon complications witnessed in the post-transplantation period included endogenous endophthalmitis, herpetic keratitis, duodenal strongyloidiasis, intestinal cryptosporidiosis, myocardial infarction, diaphragm dysfunction, Chylothorax, thyroid nodule, and necrotizing pancreatitis.

Conclusion

Meticulous postoperative surveillance is crucial for managing lung transplant patients for early detection and treatment of common and uncommon complications. Therefore, it is necessary to establish procedures for assessing the patients' constancy until complete recovery.

Aspergillus endophthalmitis: Potential role for vitreous galactomannan testing?

Eye damage during invasive aspergillosis is rarely described and biological diagnosis remains challenging. Here we report the case of a heart transplant recipient with ocular aspergillosis complicating disseminated aspergillosis. Although voriconazole was rapidly given, a decrease in visual acuity of the right eye was consistent with endophthalmitis, resulting in an emergency vitrectomy. The diagnosis was rapidly confirmed: laboratory results showed the presence of Aspergillus fumigatus in a vitreous sample. A series of systemic antifungal medications (liposomal amphotericin B, caspofungin, and voriconazole), several liposomal amphotericin B ocular injections, and pars plana vitrectomy resulted in a limited positive clinical outcome. Interestingly although standard mycological follow-up procedures were negative, Aspergillus antigen testing gave an index of 5.92 on vitreous humour, thus a new intraocular injection of liposomal amphotericin B was performed and voriconazole reinitiated. Ten other vitreous samples from patients without fungal infections were also tested, all showing indexes below 0.25. Although larger studies are needed, this case illustrates that galactomannan testing of vitreous humour could be useful for the diagnosis of fungal endophthalmitis if these data are confirmed in other patients, in particular, if standard mycology is negative and PCR is not available.

Uveitis causes according to immune status of patients

Purpose

The advances in medicine have led to an increased number of people living with some form of immunodeficiency. Most ocular infections in immunocompromised patients may lead to irreversible blindness. We identify the causes of uveitis in immunocompetent and immunocompromised patients.

Methods

A retrospective cohort study of 1354 consecutive patients. All patients underwent a standard work‐up for uveitis.

Results

An immunocompromised state was identified in 171/1354 patients (13%), of whom 40 had Human immunodeficiency virus (HIV) infection, 52 received immunosuppressive medications, 28 had concurrent malignant disorder and 20 had other causes for their immunosuppression. In addition, 93/1354 patients (7%) had diabetes mellitus (DM). The prevalence of intraocular infections was much higher in immunocompromised patients than in immunocompetent patients and DM (p < 0.001). Causes of uveitis differed between the diverse immunocompromised groups. The non‐HIV immunocompromised patients showed primarily intraocular herpes simplex and varicella zoster virus infections, whilst HIV‐positive patients exhibited frequently cytomegalovirus (CMV) retinitis and syphilis. Patients with generalized malignancies were characterized by a lower prevalence of infections and higher prevalence of sarcoidosis. Patients with DM typically showed sarcoidosis and bacterial intraocular infections. The percentage of undetermined uveitis diagnoses was markedly lower in immunosuppressed patients (p < 0.001).

Conclusion

In immunocompromised patients with uveitis, infections were diagnosed in 46% of cases in contrast to 12% in the immunocompetent patients. The causes of uveitis differed among the various types of immunosuppression. Immunocompromised patients with uveitis require a rapid assessment for the most expected infections.

"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.

DIFFUSE CHORIORETINOPATHY WITHOUT SEROUS DETACHMENT ASSOCIATED WITH CARDIAC TRANSPLANTATION

PURPOSE

To analyze an unusual case of widespread chorioretinopathy after cardiac transplantation for its potential etiology and clinical significance.

METHODS

Clinical examinations included widefield and macular color and fundus autofluorescence photography, spectral domain optical coherence tomography, fluorescein angiography and indocyanine green angiography, full-field electroretinography, and Goldmann visual fields.

PATIENT

A 44-year-old Hispanic woman was referred to rule out retinitis pigmentosa. Medical history revealed cardiac transplantation 6 months previously for idiopathic cardiomyopathy.

RESULTS

Visual acuity was 20/20 in both eyes. The fundi showed widespread gray mottling and little pigmentation, but fundus autofluorescence revealed black speckling broadly across the fundus, and geographic retinal pigment epithelium loss in the nasal midperiphery of the left eye. Spectral domain optical coherence tomography showed normal inner retina, and surprising preservation of outer nuclear layer, but the ellipsoid zone line was fragmented, and the interdigitation zone line was replaced with irregular debris. Retinal pigment epithelium was very thin with occasional excrescences. Electroretinography showed mild loss of both rods and cones, with mild flicker peak delay only in the left eye. Fluorescein angiography showed no leakage, but a reticular pigment pattern in the macula. Indocyanine green angiography showed irregular arteriolar remodeling, and few large arteries.

DISCUSSION AND CONCLUSION

Serous retinopathy is well known after organ transplantations, but this patient had retinal pigment epithelium and retinal damage well into the periphery and no leakage. Retinal dystrophy was deemed unlikely given the relatively good electroretinography. The indocyanine green vascular changes raise the possibility of a transient choroidal ischemic event during or shortly after cardiac surgery. The event altered retinal pigment epithelium diffusely, but allowed for enough regeneration to sustain retinal function. Diffuse transplant chorioretinopathy may be discovered if postcardiac transplant patients get peripheral retinal examinations.

IMPACT OF RETINOPATHY SCREENINGS FOR PROSPECTIVE HEART TRANSPLANT CANDIDATES

PURPOSE

To determine the prevalence of retinopathy among patients undergoing heart transplantation screening and to determine the impact of this finding on eligibility for transplantation.

METHODS AND PATIENTS

A retrospective case series was collected to perform an institutional review of all inpatient consults for dilated eye examinations on potential heart transplant candidates over 5.5 years-from March 27, 2008 to October 10, 2014. Measured outcomes included the presence or absence of retinopathy and the effect of retinopathy, if present, on a patient's eligibility for cardiac transplantation.

RESULTS

A total of 155 heart transplant candidates underwent bedside ophthalmologic examination as part of their heart transplant candidacy workup. Retinopathy was found in 16 (10%) of these patients: diabetic retinopathy in 13 (8.4%) and hypertensive retinopathy in 3 (1.9%). None of these patients were excluded from the transplant candidacy based on the presence of retinopathy.

CONCLUSION

On bedside ophthalmologic examination, retinopathy is an uncommon finding among cardiac transplant candidates. Retinopathy did not preclude transplantation in these patients. We question the utility of the present system of bedside ophthalmic consultation of heart transplant candidates. This may not be an optimal allocation of provider resources. Further studies are warranted to determine an appropriate protocol for ocular evaluation of these patients.

A rare ocular complication after a heart transplant: toxoplasma retinitis

Ocular infections after a heart transplant are rare; but when present, they generally appear during the first year after surgery. Ocular infections may cause significant loss of vision and morbidity if not diagnosed early. For that reason, heart transplant patients should undergo a routine visual examination during follow-up. We report our experience regarding the followup and treatment of a case of toxoplasma retinitis diagnosed in one of our heart transplant recipients.

Ocular manifestations of patients receiving heart transplants: a single-center experience of 311 consecutive cases

PURPOSE

The purpose of this study was to investigate ocular manifestations of patients undergoing heart transplantations.

METHOD

We retrospectively reviewed the clinical data of 311 patients who underwent orthotropic heart transplantations from January 1989 to December 2007, including the demographic data, general conditions, medications, as well as the basic ophthalmic examinations, ophthalmic diagnosis, and management.

RESULTS

Of the 311 heart transplant recipients, common diagnoses included cataract (96 cases; 30.87%), dry eye syndrome (24 cases; 7.72%), allergic conjunctivitis (78 cases; 25.08%), and glaucoma (19 cases; 6.11%). The patients after heart transplantation had much lower incidences of severe opportunistic infections than patients undergoing the same procedure one decade ago. However, autoimmune-related endocrinopathy such as diabetes and Graves' disease became more prevalent. Diabetes-related complications were unexpectedly frequent, including nonproliferative diabetic retinopathy (6 cases; 1.93%), proliferative diabetic retinopathy (6 cases; 1.93%), retinal vein occlusion (6 cases; 1.93%), and neovascular glaucoma (4 cases; 1.29%). The occurrence of cataract formation and steroid glaucoma was often due to post-transplantation steroid use.

CONCLUSION

Ophthalmologists and cardiac surgeons should collaborate and perform regular ophthalmic examinations, especially for those who have new-onset diabetes and difficulty tapering off steroids.

Pulmonary resection for bronchial polyp after lung transplant in a cystic fibrosis patient

Many clinical conditions should be considered in the differential diagnosis of life-threatening events in cystic fibrosis patients after a lung graft transplant. We report on a 17-year-old boy who underwent a lobectomy owing to an inflammatory endobronchial polyp complicated by massive airways bleeding 12 months after having had a bilateral sequential lung graft for cystic fibrosis. This unusual complication underscores the requirement for flexible bronchoscopy in patients with recurrent infection at any stage after transplant. Early diagnosis may prevent life-threatening complications.

Incidence and clinical characteristics of ocular infections after heart transplantation: a retrospective cohort study

BACKGROUND

Ocular infections associated with organ transplantation are well documented following renal and liver transplantation; however, few studies have reported ocular infections following heart transplant.

METHODS

We retrospectively studied patients who underwent heart transplantation in the Mayo Clinic Cardiac Transplant Program from January 1st 1988 through June 30th 2006.

RESULTS

We report the frequency and type of ocular infections among 313 heart transplant recipients. There were eight patients (2.5%) diagnosed with ocular infections including three cases of ophthalmic zoster, one case of cytomegalovirus retinitis, one case of Aspergillus fumigatus endophthalmitis, one case of Haemophilus influenzae conjunctivitis, one case of blepharitis, and one case of preseptal orbital cellulitis.

CONCLUSIONS

Ocular infections are rare after heart transplantation and usually present within the first year post-transplantation. The majority can be regarded as opportunistic infections which may be indicative of infections at other body sites. Ocular infections after heart transplantation may be associated with significant morbidity and visual loss if not promptly diagnosed.