Breast cancer medications and vision: effects of treatments for early-stage disease

Sex Hormones Influence the Helmholtz-Kohlrausch Effect

Purpose

Saturated lights appear brighter than white lights of the same luminance. This is the Helmholtz-Kohlrausch (H-K) effect, and the phenomenon can be estimated by modeling achromatic luminance and saturation to total brightness. Current H-K effect models are different between women and men and are also more variable in women, which may be due to hormonal changes across the menstrual cycle (MC).

Methods

Total brightness (B) and achromatic luminance (L) were measured across blue, green, yellow-green, yellow, and red hues. These data were measured along with salivary hormone levels for nine cycling women and seven oral contraceptive (OC) users at points representing the menstrual, peri-ovulation, and luteal phases.

Results

Simple brightness/luminance (B/L) ratio estimates of the H-K effect did not differ by OC use or MC phase, but B/L ratios were higher for the red stimulus in cycling women than OC users during the luteal phase. Estrogen, progesterone, and their interaction predicted 18% of the variation in brightness for cycling women. For OC users, only estrogen could be fit to brightness models where it accounted for 5% of brightness variance.

Conclusion

These findings first provide clear support for separating cycling women from OC users, particularly when examining long-wavelength mechanisms. Next, the interaction of OC use and MC phase on B/L ratios for the red stimulus adds to a rich history of long-wavelength mechanisms. Lastly, the current result amends previous brightness models with multiple hormone terms for cycling women but not OC users.

Hysterectomy for Benign Indications and Risk of Cataract Formation in South Korean Women

Background and Objectives: Few studies have investigated the relationship between female reproductive hormones, especially estrogen, and the incidence of cataracts. This study sought to evaluate the effects of hysterectomy on the risk of lens opacity in Korean women. Materials and Methods: This retrospective cohort study utilized data collected from 2007 to 2020 for 255,576 postmenopausal women in the Korean National Health Insurance database. Participants were divided into those who did and did not undergo hysterectomy. The hysterectomy group was further divided into two subgroups according to the type of adnexal surgery performed. The prevalence of cataracts was then compared among the control, hysterectomy alone, and hysterectomy with adnexal surgery groups. Results: The control group included 137,999 participants who did not undergo hysterectomy, while the treatment group included 93,719 women who underwent hysterectomy alone or in combination with adnexal surgery. The incidence of cataracts was higher in the control group than in the treatment group, as demonstrated in a 1:1 propensity score-matching analysis adjusted for potential confounding variables. Conclusions: The incidence of cataracts was significantly lower in the group with hysterectomy than in the control group, but the difference was subtle. The current findings may aid in identifying the role of female reproductive hormones in cataract development.

Tamoxifen related chorioretinal structural changes

PURPOSE

To evaluate the vascular structure of the choroid and each retinal layer in patients with breast cancer on tamoxifen therapy and compare them with healthy subjects.

MATERIALS AND METHODS

124 eyes of 62 patients with breast cancer who were on tamoxifen therapy (group 1) and 80 eyes of 40 healthy controls (group 2) were included in this prospective cohort study. The structure of the choroid was evaluated using enhanced depth imaging spectral-domain optical coherence tomography (EDI-OCT) and choroidal binarisation. Spectral-domain OCT (SD-OCT) was performed to analyse the peripapillary nerve fibre layer thickness (pRNFL) and each retinal layer thickness. A subgroup analysis was performed based on chemotherapy history in Group 1. All parameters were compared between Group 1 and the healthy controls and between the subgroups of Group 1.

RESULTS

The subfoveal choroidal thickness and temporal and nasal directions were increased in Group 1 when compared with Group 2 (p < 0.05, each comparison). Choroidal vascularity index was significantly decreased in Group 1 compared with Group 2 (63.15 ± 3.11% and 65.37 ± 4.63%, p < 0.001). There were no significant differences in each retinal layer, pRNFL thickness, and choroid structural parameters between the subgroups of Group 1.

CONCLUSIONS

Increased choroidal thickness may be the initial finding of subclinical tamoxifen-induced retinopathy. Patients with breast cancer undergoing tamoxifen therapy may be screened prior to tamoxifen therapy and followed during treatment by SD-OCT.

Unilateral Tamoxifen-Induced Retinopathy as a Consequence of Breast Cancer Treatment—Multimodal Imaging Value

Tamoxifen is a drug used in breast cancer therapy, which inhibits the division of neoplastic cells targeting estrogen receptors. The drug is generally well-tolerated and its use does not cause serious side-effects. The standard dose of the drug is 20 mg once a day for 3 to 5 years. Available epidemiological data have shown that the incidence of ocular toxicity of tamoxifen ranges between 0.9% and 12.0% and increases with higher tamoxifen dose. A rare known complication of tamoxifen use is the development of retinopathy. We present a case of 57-year-old woman presented to an ophthalmologist with decreased visual acuity in her right eye. She has been treated with tamoxifen 20 mg daily for 7 years for breast cancer. Clinical examination and multimodal imaging methods help confirm the diagnosis of unilateral tamoxifen associated retinopathy (TAR). Optical coherence tomography angiography (OCTA) was crucial in the diagnostic process and differential diagnosis, especially in differentiating it from type 2 macular telangiectasias. The correct diagnosis of TAR is very important in deciding the treatment option of tamoxifen. Based on our diagnosis, the oncologist recommended another course of treatment. Tamoxifen therapy was discontinued and switched to letrozole 2.5 mg once a day. The patient attends ophthalmological examination regularly. Visual acuity, OCT and OCTA results remain stable.

Menopausal hormone therapy and the risk of cataracts in postmenopausal women in South Korea

PURPOSE

Postmenopausal women have a higher prevalence of cataracts than men of a similar age. This study aimed to evaluate the effects of menopausal hormone therapy (MHT) on lens opacities in postmenopausal women.

METHODS

This retrospective cohort study analysed population-based health insurance data in South Korea collected from 2002 to 2019. To determine the risk factors associated with cataract, postmenopausal women (N = 2,506,271) were grouped according to post-MHT use. The treatment group was further divided into the following subgroups: tibolone, combined oestrogen plus progestin by manufacturer, oral oestrogen, combined oestrogen plus progestin by physician and topical oestrogen groups. The main outcome measure was the prevalence of cataracts.

RESULTS

The control group comprised 463,151 postmenopausal women who had never used MHT after menopause, while the treatment group included 228,033 postmenopausal women who had used MHT continuously for at least 6 months. The treatment group had a higher incidence of cataracts than the control group based on Cox proportional hazards ratio analysis. Low socioeconomic status and high parity were identified as risk factors for cataracts, and reduced risk of cataracts was associated with living in rural areas and drinking alcohol.

CONCLUSIONS

Women undergoing post-MHT, including tibolone, had a higher incidence of cataracts. Cataract development should be a concern when examining postmenopausal patients using MHT.

Suspected Neratinib Macular Toxicity Presenting As Macular Telangiectasia Type II

The purpose of this case report is to present the first case of neratinib maculopathy. We describe the initial presentation, baseline characteristics, imaging findings, and outcomes. The case report is accompanied by a thorough literature review including possible mechanisms of tyrosine kinase inhibitor (TKI) maculopathy. Neratinib is a novel TKI that is commonly used in the treatment of breast-associated malignancies. Neratinib toxicity presents similarly to macular telangiectasia type II but differs with the fine granular hypofluorescent areas spanning the limit of the posterior pole and vascular arcades as well as the nasal aspect of the optic nerve.  We report a case of suspected macular toxicity secondary to neratinib. Concomitant use of neratinib in conjunction with docetaxel and other chemotherapeutics with known retinal side effects should alert clinicians of an increase in the risk of macular toxicity. Albeit commonly reported ocular side effects of TKIs, maculopathy is a rare and potentially overlooked side effect. Patients that have planned chemotherapy should undergo a baseline retinal examination.

Partial thickness subfoveal hole in a patient treated with tamoxifen: a case report and review of the literature

BACKGROUND

We describe a patient presenting with a partial thickness subfoveal hole in the right eye after tamoxifen treatment for breast cancer.

CASE PRESENTATION

A 76-year-old Caucasian female presented with a 1-day history of acute central scotoma and blurry vision in the right eye. The patient had been receiving oral tamoxifen for 5 years as adjuvant treatment for stage I lobular breast cancer. Her past ocular history was significant for complete, uneventful, and bilateral posterior vitreous detachment. Clinical examination and optical coherence tomography revealed a new, partial thickness subfoveal hole sparing the inner retinal layers. Observation was recommended. At the last follow-up examination, 1 year after the initial presentation, the subfoveal hole remained stable and visual acuity remained stable.

CONCLUSION

Tamoxifen has been associated with a plethora of ophthalmic adverse events, including macular holes, some of which are partial thickness subfoveal holes. Holes with this almost unique morphology are uncommon, and eye care professionals should be aware of this association given the frequency of tamoxifen use, as well as the low success rate of surgical repair with pars plana vitrectomy.

RetINal Toxicity And HydroxyChloroquine Therapy (INTACT): protocol for a prospective population-based cohort study

PURPOSE

Hydroxychloroquine (HCQ) is an important medication for patients with systemic lupus erythematosus (SLE), rheumatoid arthritis (RA) and other rheumatic diseases. Although it is well-tolerated and cost-effective, the risk of HCQ retinal toxicity is of increasing concern. The aim of this study is to re-examine the HCQ retinal toxicity incidence rate, risk factors and clinical course after discontinuation.

METHODS

We designed a prospective population-based cohort study in adult patients with SLE or RA, currently receiving HCQ for five or more years, who are residents of British Columbia (BC), Canada. Based on administrative data, we identified 5508 eligible participants (1346 SLE and 4162 RA). They will participate in annual or biannual retinal screening over 5 years in alignment with the recently revised American Academy of Ophthalmology guidelines. To standardise procedures for retinal screening, imaging, diagnostic criteria, severity staging and data transfer, a consensus meeting was convened in December 2019 with participation of BC retinal specialists and the research team. Agreement was attained on: use of spectral domain-optical coherence tomography as the primary objective screening modality; classification of images into categories of normal, equivocal or abnormal; and transferring the equivocal and abnormal images plus corresponding subjective test results via cloud-based server from each clinic to a reading centre. Confirmation of HCQ retinal toxicity diagnoses and severity staging will be performed by three independent and masked reviewers. The incidence of HCQ retinal toxicity will be calculated, accounting for the competing risk of death. Hazard ratios for each risk factor will be calculated for the risk of HCQ retinopathy, after adjusting for confounders. We will also estimate the risk of HCQ retinal toxicity progression over 5 years.

ETHICS AND DISSEMINATION

This study has received approval from the University of British Columbia Clinical Research Ethics Board (H20-00736) and the Vancouver Coastal Health Research Institute.

Evaluation of Optic Nerve Head Parameters and Electro-Physiology Among Breast Cancer Patients on Tamoxifen

Introduction

To evaluate if early tamoxifen toxicity can be detected by comparing pre-and post-treatment optic nerve head parameters and visual function using Heidelberg Retinal Tomograph III (HRT III) and Pattern Visual Evoked Potential (Pattern VEP).

Method

This is a prospective study involving 76 eyes of 38 breast cancer patients treated with tamoxifen in Hospital Universiti Sains Malaysia, Kelantan, Malaysia. These patients were examined by a single doctor and the investigations were done by a single technician. The visual acuity, optic nerve function, visual field, optic nerve head parameters on HRT III and Pattern VEP were assessed. The examination was performed before and three months after treatment initiation.

Results

There was no tamoxifen ocular toxicity found three months post-treatment with tamoxifen. There was no change in visual acuity and optic nerve function post-treatment initiation. There were no statistically significant changes found in optic nerve head parameters on HRT III and P 100 peak latency and amplitude on Pattern VEP.

Conclusion

Ocular toxicity is a recognized complication of tamoxifen treatment. Tamoxifen optic neuropathy is a potentially irreversible, visually disabling complication. Tamoxifen ocular toxicity was not found three months after tamoxifen treatment initiation among estrogen receptor (ER)-positive breast cancer patients. No early changes in optic nerve head parameters and P 100 peak latency and amplitude changes were found after three months of treatment. A longer duration of monitoring with HRT III and Pattern VEP may be needed to adequately observe for early, subclinical changes in optic nerve head parameters and visual function among tamoxifen users.

Ocular Side Effects of Aromatase Inhibitor Endocrine Therapy in Breast Cancer - A Review

BACKGROUND

Aromatase inhibitor therapy is currently the preferred choice in postmenopausal women with estrogen receptor positive breast cancer. This article reviews the ocular side effects of treatment with aromatase inhibitors (AIs) in patients with breast cancer.

MATERIALS AND METHODS

A comprehensive search was performed on PubMed, Web of Science and Google scholar.

RESULTS

After duplication removal, 14 clinical studies and 5 case reports, published between 2008 and 2021, were identified. Most frequently, AI treatment resulted in minor to moderate dry eye symptoms. "De novo" onset of Sjogren syndrome during AI therapy was also reported. Retinal and optic nerve side effects varied from mild, subclinical anatomic and functional impairment to severe decreased vision, secondary to hemi-central retinal artery occlusion, bilateral optic neuritis or uveitis with bilateral macular edema.

CONCLUSION

Visual disturbances encountered during AI treatment may be underestimated. Ophthalmic screening is important for early detection and appropriate treatment.

Review of the Literature on Ocular Complications Associated With Aromatase Inhibitor Use

Aromatase inhibitors (AIs), such as anastrozole, letrozole, and exemestane, are commonly used as adjuvant endocrine therapy in hormone-receptive breast cancer in postmenopausal women. Their adverse effects are well documented, except for visual disturbances. The purpose of this study was to review the current literature on ocular disease linked to AI use. Due to the scarcity of published data, any suggested ophthalmic adverse events were included to increase awareness of these drugs. The ocular side effects of tamoxifen use are well documented and were not included. Cases of rare side effects such as papilloedema, macular oedema, and uveitis associated with anastrozole and letrozole have been reported. Studies demonstrating retinopathy, in the form of crystalline retinopathy, hemicentral retinal artery occlusion, and retinal haemorrhages, are also noted. All three third-generation AIs can also lead to ocular surface diseases such as corneal epithelial changes, blepharitis, and keratitis. There is slightly more literature available regarding anastrozole-related ocular diseases. Although these are likely rare side effects, we recommend a high level of clinical suspicion when assessing patients with visual symptoms and on AIs. Larger prospective studies are necessary to further investigate these complications.

Central neurotoxicity induced by trastuzumab emtansine (T-DM1): a case report

Trastuzumab emtansine (T-DM1) is a human epidermal growth factor receptor 2 (Her2) - targeted antibody-drug conjugate that is approved for patients previously treated with trastuzumab and a taxane for Her2-positive advanced breast cancer and those who have progressed within 6 months of completion of adjuvant chemotherapy, as well as for patients with residual invasive Her2-positive disease after the completion of adjuvant chemotherapy. Peripheral neuropathy is a common adverse event; however, ocular events have also been described. With the current report we present the case of a 67-year old woman who developed transient grade 2-3 blurred vision after the first T-DM1 infusion, which was complicated with grade 2 diplopia causing vertigo after the second infusion. After extended investigation, this symptomatology was attributed to central neurotoxicity, and gradually resolved after T-DM1 discontinuation.

Retinal toxicities of systemic anticancer drugs

Newer anticancer drugs have revolutionized cancer treatment in the last decade, but conventional chemotherapy still occupies a central position in many cancers, with combination therapy and newer methods of delivery increasing their efficacy while minimizing toxicities. We discuss the retinal toxicities of anticancer drugs with an emphasis on the mechanism of toxicity. Uveitis is seen with the use of v-raf murine sarcoma viral oncogene homolog B editing anticancer inhibitors as well as immunotherapy. Most of the cases are mild with only anterior uveitis, but severe cases of posterior uveitis, panuveitis, and Vogt-Koyanagi-Harada-like disease may also occur. In the retina, a transient neurosensory detachment is observed in almost all patients on mitogen-activated protein kinase kinase (MEK) inhibitors. Microvasculopathy is often seen with interferon α, but vascular occlusion is a more serious toxicity caused by interferon α and MEK inhibitors. Crystalline retinopathy with or without macular edema may occur with tamoxifen; however, even asymptomatic patients may develop cavitatory spaces seen on optical coherence tomography. A unique macular edema with angiographic silence is characteristic of taxanes. Delayed dark adaptation has been observed with fenretinide. Interestingly, this drug is finding potential application in Stargardt disease and age-related macular degeneration.

Zebrafish Optomotor Response and Morphology Are Altered by Transient, Developmental Exposure to Bisphenol-A

Estrogen-specific endocrine disrupting compounds (EDCs) are potent modulators of neural and visual development and common environmental contaminants. Using zebrafish, we examined the long-term impact of abnormal estrogenic signaling by testing the effects of acute, early exposure to bisphenol-A (BPA), a weak estrogen agonist, on later visually guided behaviors. Zebrafish aged 24 h postfertilization (hpf), 72 hpf, and 7 days postfertilization (dpf) were exposed to 0.001 μM or 0.1 μM BPA for 24 h, and then allowed to recover for 1 or 2 weeks. Morphology and optomotor responses (OMRs) were assessed after 1 and 2 weeks of recovery for 24 hpf and 72 hpf exposure groups; 7 dpf exposure groups were additionally assessed immediately after exposure. Increased notochord length was seen in 0.001 μM exposed larvae and decreased in 0.1 μM exposed larvae across all age groups. Positive OMR was significantly increased at 1 and 2 weeks post-exposure in larvae exposed to 0.1 μM BPA when they were 72 hpf or 7 dpf, while positive OMR was increased after 2 weeks of recovery in larvae exposed to 0.001 μM BPA at 72 hpf. A time-delayed increase in eye diameter occurred in both BPA treatment groups at 72 hpf exposure; while a transient increase occurred in 7 dpf larvae exposed to 0.1 μM BPA. Overall, short-term developmental exposure to environmentally relevant BPA levels caused concentration- and age-dependent effects on zebrafish visual anatomy and function.

Extra-skeletal effects of bisphosphonates

Bisphosphonates (BPs) are pyrophosphate analogues widely used in diseases related to bone loss and increased bone turnover. Their high affinity for bone hydroxyapatite makes them ideal agents for bone diseases, while preventing them from reaching other cells and tissues. Data of the last decade, however, have demonstrated extra-skeletal tissue deposition and a variety of non-skeletal effects have been recently recognized. As such, BPs have been shown to exert anti-tumor, immunomodulatory, anti-inflammatory and anti-diabetic effects. In addition, new delivery systems (liposomes, nanoparticles, hydrogels) are being developed in an effort to expand BPs clinical application to extra-skeletal tissues and enhance their overall therapeutic spectrum and effectiveness. In the present review, we outline current data on extra-skeletal actions of bisphosphonates and attempt to unravel the underlying pathophysiological mechanisms.

Prevalence of symptomatic dry eye in breast cancer patients undergoing systemic adjuvant treatment: A cross-sectional study

Objectives

To investigate the prevalence of symptomatic dry eye (SDE) on women undergoing systemic adjuvant therapy for breast cancer and its association with treatment settings.

Methods

Woman undergoing breast cancer systemic adjuvant therapy were included in exposure group. An age-matched non-treatment control group was recruited. This cross-sectional questionnaire-based study utilised validated Ocular Surface Disease Index (OSDI) and NCCN-FACT-Breast Cancer Symptom Index (NFBSI-16) questionnaires to determine the presence of SDE and investigate other breast cancer treatment complications. Additionally, demographic data and medical histories were collected.

Results

Of 423 eligible participants, 200 in each of the control group and the exposure group were included in the final analysis. The prevalence of SDE was 59.0% in breast cancer patients with adjuvant treatment, statistically significantly higher than 25.5% in the control group (P < 0.01). Additionally, exposure group experienced higher prevalence of moderate and severe SDE, which were 20.0% and 19.5% respectively compared with 9.0% and 4.0% in the control group (P = 0.002, P < 0.001). There was a significantly high prevalence of SDE among patients who had received over four cycles of systemic therapy (71.0%, P < 0.001) and the application of targeted therapy (71.2%, P = 0.014). The severity of SDE positively correlated with the cycles of treatment administered.

Conclusion

SDE was significantly predominant in women with breast cancer undergoing systemic adjuvant treatment. Our findings suggest dry eye assessments among patients receiving more than four cycles of chemotherapy or targeted therapy, thus early revealing possible dry eye conditions to both patients and clinicians for further specialized examination and treatment.

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Breast cancer patients undergoing systemic treatment have fairly high prevalence of symptomatic dry eye.

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Around 40% of them experienced from moderate to severe degree of dry eye.

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The severity of symptomatic dry eye in exposure group showed cycle-dependency.

Tamoxifen maculopathy: The importance of screening and long follow-up

We report a case of a patient treated with tamoxifen 20mg daily as hormone therapy for breast cancer. On regular ophthalmological follow-up, tamoxifen maculopathy was detected on SD-OCT (Spectral Domain Optic Coherence Tomography, Carl Zeiss Meditec®), so the medication was discontinued. Despite discontinuation of the medication, the maculopathy progressed over time. We have been following our patient for seven years. Tamoxifen may produce a toxic maculopathy which may progress despite discontinuation of the medication. We consider our case interesting, given the lengthy follow-up of the patient with sequential SD-OCT images. To the best of our knowledge, our case represents the longest follow-up period for a patient with tamoxifen maculopathy. Moreover, we would like to stress the importance of screening in asymptomatic patients on this medication, in order to detect early pathological signs.

Episodic memory for visual scenes suggests compensatory brain activity in breast cancer patients: a prospective longitudinal fMRI study

It has been hypothesized that breast cancer and its chemotherapy can impart functional neural changes via an overlap with biological mechanisms associated with aging. Here we used fMRI to assess whether changes in neural activity accompanying visual episodic memory encoding and retrieval suggest altered activations according to patterns seen in functional imaging of cognitive aging. In a prospective longitudinal design, breast cancer patients (n = 13) were scanned during memory encoding and retrieval before and after chemotherapy treatment, and compared to healthy-age matched controls (n = 13). Our results indicate that despite equivalent behavioral performance, encoding and retrieval resulted in increased activation of prefrontal regions for the breast cancer group compared to controls for both before and after chemotherapy treatment. This was accompanied by decreased activity in posterior brain regions after chemotherapy, particularly those involved in visual processing, for the breast cancer group compared to controls. These findings are discussed as evidence for a possible anterior shift in neural processing to compensate for deficiencies in posterior brain regions, consistent with an accelerated aging account. Cancer and chemotherapy can impact brain regions underlying episodic memory, leading to additional recruitment of control regions, which may be linked to mechanisms related to aging.

Association of adjuvant aromatase inhibitor with cataract risk in postmenopausal women with breast cancer

Background

Aromatase inhibitor (AI) is a cornerstone drug for endocrine therapy of postmenopausal hormone receptor-positive breast cancer. The relationship between AI medication and subsequent cataract risk is yet inconclusive.

Methods

A total of 1,697 postmenopausal, early-staged, and hormone receptor-positive breast cancer patients from the prospectively-maintained database of the Breast Surgery Department at Fudan University Shanghai Cancer Center were included, with 542 patients received no endocrine therapy and 1,155 treated with AI only. We explored the influence the use of AI or not and the duration of AI on the subsequent incidence of cataract.

Results

A total of 146 (8.6%) cataracts were observed in the whole study population. The incidence of cataract is highly related to age, with incidence of cataract in patients <50 years old, 50-60 years, ≥60 years was 2.9%, 6.9%, and 13.3%, respectively (P<0.001). There was no significant relationship between adjuvant AI use and cataract (7.4% in no endocrine group vs. 9.2% in the AI group) with an adjusted hazard ratio of 1.20 (95% confidence interval: 0.8-1.7, P=0.30). The incidence of cataract in patients with long-term AI (more than 5 years) could be high up to 14.7%, but without statistical significance compared to those the shorter duration (P=0.52).

Conclusions

There is no significant association between use of AI and cataract in postmenopausal breast cancer patients. Of note, age is an important risk factor for cataract and it is necessary to surveil the eye health in postmenopausal elderly women.

Acute exposure to 4-OH-A, not PCB1254, alters brain aromatase activity but does not adversely affect growth in zebrafish

Acute developmental exposure to pharmaceuticals or environmental contaminants can have deleterious, long lasting effects. Many of these compounds are endocrine disruptors (EDCs) that target estrogen signaling, with effects on reproductive and non-reproductive tissues. We recently reported that zebrafish larvae transiently exposed to the pharmaceutical EDC 4-OH-A display visual deficits as adults. Here, we examine whether these long-term effects are due to compound-induced morphological and/or cellular changes. Zebrafish aged 24 h, 48 h, 72 h, or 7 days post-fertilization (larvae) or 3-4mos (adults) were exposed to either 4-OH-A or PCB1254 for 24 h. After that time, notochord length, eye diameter, inter-eye distance, and heart rate were measured from larvae; and aromatase (estrogen synthase) activity was measured in homogenates of adult brain tissue. In general, indices of larval growth and development were not altered by 24 h exposure to either compound. 4-OH-A potently inhibited aromatase activity, while PCB1254 did not, with inhibition continuing even after removal from treatment. These results support differential function of EDCs and indicate that developmental exposure to 4-OH-A causes sustained inhibition of aromatase, which could be associated with altered adult behaviors.

Dosage-dependent reduction of macular pigment optical density in female breast cancer patients receiving tamoxifen adjuvant therapy

It is now increasingly common for breast cancer patients to receive adjuvant tamoxifen therapy for a period of up to 10 years. As survival rate increases, managing tamoxifen ocular toxicities is important for patients' quality of life. Macular pigments in photoreceptor cells protect against free radical damage, which can cause macular degeneration. By reducing macular pigment concentration, tamoxifen may increase the risk of macular degeneration. Here, we compared macular pigment optical density (MPOD) and central macular thickness between breast cancer patients on tamoxifen adjuvant therapy (n = 70), and a control group (n = 72). Multiple regression analysis indicated that MPOD decreases with increasing tamoxifen dosage, up to a threshold of about 20 g, after which MPOD plateaus out. Mean MPOD in the treatment group (mean = 0.40) was significantly lower (p-value = 0.02) compared to the control group (mean = 0.47) for the left eye, and for the right eye (treatment mean = 0.39; control mean = 0.48; p-value = 0.009). No significant difference in mean central macular thickness was found between the treatment and the control group (p-values > 0.4). In the control group, MPOD and central macular thickness showed significant correlation (r∼0.30; p-values < 0.01) for both eyes. However, in the treatment group, loss of significant correlation was observed in the left eye (r = 0.21; p-value = 0.08). The present results show that MPOD decreases non-linearly as a function of tamoxifen dosage, and highlight the potential of tamoxifen to reduce macular pigment concentration through an unknown mechanism that does not depend on macular thinning solely.

Tamoxifen Use in a Patient with Idiopathic Macular Telangiectasia Type 2

Crystalline deposits and neurosensory retinal cavitary changes can develop in both tamoxifen retinopathy and nonproliferative idiopathic macular telangiectasia type 2 (MacTel2). MacTel2 is typically differentiated from tamoxifen retinopathy based on the presence of late leakage and mid-phase telangiectatic vessels on fluorescein angiography (FA) and the presence of hyperautofluorescence. Unlike MacTel2, tamoxifen retinopathy is known to be a progressive disease and the cessation of tamoxifen results in resolution of retinopathy. We report a unique case of nonproliferative MacTel2 in a 36-year-old Hispanic woman with tamoxifen use and the vision outcome 30 months after cessation of tamoxifen. The FA and optical coherence tomography angiography findings of this patient support the diagnosis of MacTel2, but her cessation of tamoxifen led to partial reversal of the topographic findings and improvement in visual acuity. This patient is also unique in the unusually young age of presentation for MacTel2. Our case supports that there are common pathways in the pathogenesis of tamoxifen retinopathy and MacTel2, and tamoxifen use could potentially accelerate foveal atrophy in patients with MacTel2.

Breast cancer survivorship: state of the science

PURPOSE

Only recently has breast cancer survivorship earned formal recognition as a research discipline. Complicating survivorship research is the frequent overlap between aging and treatment sequelae. The ACS/ASCO 2016 Breast Cancer Survivorship Care Guideline (Guideline) reflects comprehensive literature review through April 2015, while the jointly sponsored, inaugural Cancer Survivorship Symposium in 2016 (Symposium) reflects ongoing research activity in the area. Together, these platforms provide an opportunity to examine the use of randomized trials and controlled studies in survivorship care research.

METHODS

All 236 citations from the Guideline and all 250 abstracts from the Symposium were reviewed independently by two authors and assigned to prospectively determined categories.

RESULTS

Guideline citations were most frequently reviews (n = 88, 37.3%) and non-randomized, non-controlled studies (n = 51, 21.6%). Thirty-seven (15.7%) randomized trials were cited. Only 9% of Guideline recommendations were based on randomized clinical trial evidence, while 64% were based on evidence level "0" (expert opinion, clinical practice, etc.). Symposium abstracts consisted largely of non-randomized, non-controlled studies (n = 113, 45.2%), with ten completed randomized trials (4%). Few Guideline citations or Symposium abstracts incorporated matched, cancer-free controls.

CONCLUSIONS

Based on the literature underlying the ASCO Guideline as well as a survey of the Cancer Survivorship Symposium abstracts, a significant proportion of the survivorship literature at least through 2015 consisted of non-randomized, non-controlled studies. To optimally address survivorship issues, cancer therapy sequelae need to be distinguished from normal aging in studies incorporating cancer-free controls, and randomized clinical trials are needed to inform intervention strategies.

Acute developmental exposure to 4-hydroxyandrostenedione has a long-term effect on visually-guided behaviors

Estrogenic and anti-estrogenic endocrine disrupting compounds (EDCs) are recognized as critical modulators of neural development, including sensory system development. Using the zebrafish model, we tested the effect of transient developmental exposure to a known anti-estrogenic EDC on adult visually-guided behavior. In particular, we exposed zebrafish aged 24-hour post-fertilization (hpf), 72 hpf, or 7-days post-fertilization (dpf) to the aromatase inhibitor 4-hydroxyandrostenedione (4-OH-A) for 24h. After this time, the fish were removed from treatment, placed into control conditions, and reared until adulthood (3-4months) when visually-guided optomotor responses (OMR) were assessed. Our results show significant decreases in positive OMR in adults exposed to 4-OH-A at 72 hpf and 7 dpf. These deficits were not accompanied by changes in overall swimming behaviors and startle responses, suggesting 4-OH-A specifically effected the visual system. Overall, this study identified long-term, quantifiable effects in visually-guided adult behaviors resulting from transient developmental exposure to the anti-estrogenic EDC, 4-OH-A. Further, these effects were noted when 4-OH-A exposure occurred after hatching, suggesting estrogen signaling is important for visual system maturation.

Ocular Surface Disease in Breast Cancer Patients Using Aromatase Inhibitors

Aromatase inhibitors (AIs) are widely used as adjuvant hormonal therapy in postmenopausal women with hormone receptor-positive breast cancer. The purpose of this study was to investigate the potential impact of AIs on the anterior segment of the eye and especially the ocular surface. Participants in our study were 41 hormone receptor-positive early stage breast cancer patients (80 eyes), treated with AIs, while 80 eyes of 40 age- and gender-matched healthy controls, not previously used AIs for any purpose, were also evaluated. All participants underwent a complete ophthalmological examination, including best corrected visual acuity (BCVA) assessment, slit-lamp biomicroscopy, and dilated fundus examination. Ocular surface disease-related symptoms and signs were also recorded. The most common symptom was found to be blurred vision, while other symptoms included foreign body sensation, tearing, redness, and photophobia. Slit-lamp examination revealed blepharitis and meibomian gland dysfunction in 75% and 42.5% of patients, respectively. Superficial punctate keratitis and conjunctival injection were also present. Our results demonstrated a high prevalence of ocular surface disease-related symptoms and signs in patients receiving AIs compared to healthy controls. This study may raise a flag regarding the use of AIs. However, further and larger prospective longitudinal studies are needed to examine the possible effect of AIs alone or in combination with chemotherapy in the eyes of breast cancer patients.

Medication use trajectories of postmenopausal breast cancer survivors and matched cancer-free controls

While adverse medical sequelae are associated with breast cancer therapies, information on breast cancer impact on medication use is limited. Therefore, we compared medication use before and after diagnosis of early stage breast cancer to medication use in matched, cancer-free controls. Of 68,132 Women's Health Initiative participants, 3726 were diagnosed with breast cancer and, after exclusions, in 1731 breast cancer cases, medication use before and >3 years after diagnosis (mean 5.3 ± 2.1 SD) was compared to use in 1731 cancer-free matched controls on similar inventory dates. The medication category number at follow-up inventory was the primary study outcome. Medication category use (n, mean, SD) was comparable at baseline and significantly increased at follow-up in both cases (2.48 ± 1.66 vs. 4.15 ± 2.13, baseline vs follow-up, respectively, P < .0001) and controls (2.44 ± 1.67 vs. 3.95 ± 2.13, respectively, P < .0001), with clinically marginal but statistically significant additional medication category use by cases (0.20 ± 2.40, P < .0001). Tamoxifen users used somewhat more selected medication categories at follow-up assessment (mean 3.40 ± 1.89 vs. 3.21 ± 1.99, respectively, P = 0.05), while aromatase inhibitor users used more medication categories (mean 4.85 ± 2.10 vs. 4.44 ± 1.94, respectively, P = 0.02). No increase in medication category was seen in cases who were not current endocrine therapy users. Breast cancer survivors having only a clinically marginal increase in medication use compared to cancer-free controls. These findings highlight the importance of incorporation of control populations in studies of cancer survivorship.

Bilateral cystoid macular edema following docetaxel chemotherapy in a patient with retinitis pigmentosa: a case report

Background

Docetaxel is a chemotherapeutic agent of the taxane class of drugs for the treatment of breast cancer. We present a female patient who noted decreased vision after docetaxel treatment.

Case presentation

A 45-year-old female patient received docetaxel treatment after resection of a breast carcinoma. Funduscopy and optical coherence tomography (OCT) showed cystoid macular edema on both eyes. Dilated funduscopy also showed bone spicule-like pigmented deposits, typical for retinitis pigmentosa. Besides the fundus appearance restricted peripheral vision and scotopic electroretinogram confirmed the diagnosis of retinitis pigmentosa. Chemotherapy was discontinued following a consulation with the oncologist of the patient. After five weeks, visual acuity improved significantly along with decrease of retinal thickness measured by OCT.

Conclusion

Docetaxel may cause ocular adverse effects such as cystoid macular edema. Ophthalmological examination is warranted for patients with visual complaints during docetaxel chemotherapy.

Oestrogen, ocular function and low-level vision: a review

Over the past 10 years, a literature has emerged concerning the sex steroid hormone oestrogen and its role in human vision. Herein, we review evidence that oestrogen (oestradiol) levels may significantly affect ocular function and low-level vision, particularly in older females. In doing so, we have examined a number of vision-related disorders including dry eye, cataract, increased intraocular pressure, glaucoma, age-related macular degeneration and Leber's hereditary optic neuropathy. In each case, we have found oestrogen, or lack thereof, to have a role. We have also included discussion of how oestrogen-related pharmacological treatments for menopause and breast cancer can impact the pathology of the eye and a number of psychophysical aspects of vision. Finally, we have reviewed oestrogen's pharmacology and suggest potential mechanisms underlying its beneficial effects, with particular emphasis on anti-apoptotic and vascular effects.

Sex, eyes, and vision: male/female distinctions in ophthalmic disorders

There is growing recognition: (1) that sex (male and female) and sex hormones (androgens and estrogens) are important for physiologic functions outside those pertaining expressly to reproduction, and (2) that both classes of sex hormones are active in both sexes, and moreover are produced locally in non-gonadal tissues throughout the body. The visual system, in addition to being of tremendous inherent importance, is unique in a very distinctive way; it possesses an organ - the eye - having a window allowing its interior to be examined with exquisite precision and control in both laboratory and clinical settings. Plus, many diseases manifest in the eye or are exclusive to the eye. This special issue of Current Eye Research contains 12 review articles, each addressing a different topical area important for Sex, Eyes, and Vision: Male/Female Distinctions in Ophthalmic Disorders. Of course, the distinctions between topical areas are blurred, and the overlap between the various lines of knowledge and investigation likewise is substantial. Eye diseases can be both neurodegenerative and involve altered blood flow, for instance. In fact, the thematic overlap is greater yet, in that the articles for this special issue address matters of interest to clinicians and scientists who may identify more with women's health or sex & gender fields than with eye & vision fields. Nevertheless, because this special issue needs a home, the following 12 topical areas each have here their own dedicated review: age-related maculopathy, central nervous system function and cognition & perception, diabetic retinopathy, dry eye, glaucoma, inherited diseases, lens and cataract, neuro-ophthalmology, ocular blood flow, ocular inflammatory disorders, optical coherence tomography, and sex/gender eye care disparities. This overview article itself raises additional points expressly concerning: (1) the estrogen therapy timing hypothesis, and (2) breast cancer treatment with aromatase inhibitors.

Gender specific issues in hereditary ocular disorders

This review is intended to summarize the current knowledge from basic science and clinical medical literature cited within PubMed that pertain to gender-related factors and affect those individuals with hereditary ocular disorders. We consider gender-related biological factors that (a) affect disease onset and progression, (b) gender differences for major X-linked ocular disorders, (c) gender-specific conditions, (d) medications that may influence genetic eye disorders, and finally, (e) gender-related issues that influence the management and quality of life of these patients. Several studies have demonstrated the manner in which sex-related hormones in animal models are capable of influencing cell pathway and survival that are likely to affect hereditary eye disorders. There are very few clinical studies that provide compelling evidence for gender differences in human ocular conditions, other than for a number of X-linked disorders. Disease expression for X-linked disorders may be impacted by genetic mechanisms such as lyonization or uniparental disomy. Clinical evidence regarding the impact of gender-related medical conditions and therapies on eye conditions is extremely limited and primarily based on anecdotal evidence. Gender-specific factors may play a major role in the underlying biological pathways that influence the onset, rate of progression, and clinical findings associated with ocular genetic conditions. Clinicians need to be aware of the variable phenotypes observed in female carriers of X-linked disorders of gender specific issues, many of which are inadequately addressed in the current literature. Clinicians need to be sensitive to gender differences in social, cultural, and religious systems and they should also be aware of how their own gender biases may influence how they counsel patients. Finally, it is clear that the lack of effective clinical studies in this area creates an opportunity for future research that will have real benefits for these patients.

Estrogen signalling in the pathogenesis of age-related macular degeneration

Age-related macular degeneration (AMD) is a multifactorial eye disease that is associated with aging, family history, smoking, obesity, cataract surgery, arteriosclerosis, hypertension, hypercholesterolemia and unhealthy diet. Gender has commonly been classified as a weak or inconsistent risk factor for AMD. This disease is characterized by degeneration of retinal pigment epithelial (RPE) cells, Bruch's membrane, and choriocapillaris, which secondarily lead to damage and death of photoreceptor cells and central visual loss. Pathogenesis of AMD involves constant oxidative stress, chronic inflammation, and increased accumulation of lipofuscin and drusen. Estrogen has both anti-oxidative and anti-inflammatory capacity and it regulates signaling pathways that are involved in the pathogenesis of AMD. In this review, we discuss potential cellular signaling targets of estrogen in retinal cells and AMD pathology.

Ocular findings in breast cancer patients using tamoxifen

AIM

To examine ocular findings of breast cancer patients using tamoxifen.

METHODS

The records of 79 consecutive breast cancer patients were examined, retrospectively. Female patients who had previously been diagnosed to have breast cancer with either stage I, II, or III disease, and were older than 25 years of age were included in the study. Results of the ophthalmic examination, color discrimination, and contrast sensitivity tests were recorded. Short wavelength automated perimetry (SWAP) sensitivity values were obtained, and average sensitivity values of test points at 5°, 9°, 15°, and 21° from the fixation were calculated.

RESULTS

Forty-nine of the patients had received 20 mg daily dose of tamoxifen therapy (tamoxifen group), while remaining 30 patients had not used tamoxifen (control group). Anterior and posterior segment examination revealed no pathologic findings in both groups. Two patients (5%) in the tamoxifen group had diffuse color loss, while none did in the control group (p = 0.523). Statistically significant differences were not detected between two groups when square roots of total error in color vision, red-green, and blue-yellow partial error scores were compared. Contrast sensitivity values were similar in both groups. Average mean deviation (MD) and average sensitivity values of test points at each 4° were statistically significantly lower in the tamoxifen group than the control group (p = 0.002, p = 0.001, p < 0.001 and p < 0.001 for right eye; p = 0.002, p= 0.001, p < 0.001 and p < 0.001 for left eye). Strong correlation was detected between MD, and duration (r = -0.832 and r = -0.842 for right and left eyes, respectively) and cumulative dose of tamoxifen use (r = -0.864 and r = -0.854 for right and left eyes, respectively).

CONCLUSION

Clinically significant ocular toxicity is not frequently encountered in breast cancer patients, however, SWAP changes may occur early after tamoxifen utilization.

Anastrozole for prevention of breast cancer in high-risk postmenopausal women (IBIS-II): an international, double-blind, randomised placebo-controlled trial

BACKGROUND

Aromatase inhibitors effectively prevent breast cancer recurrence and development of new contralateral tumours in postmenopausal women. We assessed the efficacy and safety of the aromatase inhibitor anastrozole for prevention of breast cancer in postmenopausal women who are at high risk of the disease.

METHODS

Between Feb 2, 2003, and Jan 31, 2012, we recruited postmenopausal women aged 40-70 years from 18 countries into an international, double-blind, randomised placebo-controlled trial. To be eligible, women had to be at increased risk of breast cancer (judged on the basis of specific criteria). Eligible women were randomly assigned (1:1) by central computer allocation to receive 1 mg oral anastrozole or matching placebo every day for 5 years. Randomisation was stratified by country and was done with blocks (size six, eight, or ten). All trial personnel, participants, and clinicians were masked to treatment allocation; only the trial statistician was unmasked. The primary endpoint was histologically confirmed breast cancer (invasive cancers or non-invasive ductal carcinoma in situ). Analyses were done by intention to treat. This trial is registered, number ISRCTN31488319.

FINDINGS

1920 women were randomly assigned to receive anastrozole and 1944 to placebo. After a median follow-up of 5·0 years (IQR 3·0-7·1), 40 women in the anastrozole group (2%) and 85 in the placebo group (4%) had developed breast cancer (hazard ratio 0·47, 95% CI 0·32-0·68, p<0·0001). The predicted cumulative incidence of all breast cancers after 7 years was 5·6% in the placebo group and 2·8% in the anastrozole group. 18 deaths were reported in the anastrozole group and 17 in the placebo group, and no specific causes were more common in one group than the other (p=0·836).

INTERPRETATION

Anastrozole effectively reduces incidence of breast cancer in high-risk postmenopausal women. This finding, along with the fact that most of the side-effects associated with oestrogen deprivation were not attributable to treatment, provides support for the use of anastrozole in postmenopausal women at high risk of breast cancer.

FUNDING

Cancer Research UK, the National Health and Medical Research Council Australia, Sanofi-Aventis, and AstraZeneca.

A review on the role of L-carnitine in the management of tamoxifen side effects in treated women with breast cancer

L-carnitine is an antioxidant and is found to be a protective agent against many diseases including cancer. This review illustrates the possible role of L-carnitine as an add-on therapy to breast cancer patients maintained on tamoxifen. The objectives of carnitine treatment are diverse: improving tamoxifen-related side effects, offering better cancer prognosis by reducing the risk of developing cancer recurrence or metastasis, and modulating the growth factors which may be, in part, a prospective illustration to overcome tamoxifen resistance. So, it could be recommended to supplement L-carnitine to breast cancer patients starting tamoxifen treatment.

Large bilateral foveal cysts in the inner retina of a patient treated with tamoxifen, diagnosed with Fourier-domain optical coherence tomography

Purpose

To report a case of a patient receiving tamoxifen with visual deterioration and describe the unusual optical coherence tomography (OCT) findings.

Method

Observational case report.

Results

A 55-year-old female patient was referred to our department complaining of gradual visual deterioration in both eyes. Medical history was unremarkable apart from breast cancer for which she had received tamoxifen for 10 years (mean dosage 20 mg/day). Best corrected visual acuity was 20/400 in her right eye and 20/40 in her left eye. Fundoscopy in both eyes was without any obvious signs of maculopathy. However, Fourier-domain OCT demonstrated bilateral extensive areas of disruption in inner retinal layers without any signs of crystalline retinopathy. Six months after the cessation of tamoxifen, the situation remains unchanged.

Conclusion

Patients receiving tamoxifen should be monitored with high-resolution OCT for fundoscopically invisible changes in the inner retinal layers, the progression of which may seriously affect the patient’s vision and subsequently their quality of life.