Premacular hemorrhage due to isotretinoin use

Physiological and Psychological Effects of Isotretinoin in the Treatment of Patients with Acne: A Narrative Review

Isotretinoin (ISO) is a powerful vitamin A derivative that offers the potential for treatment of permanent remission of acne; however, its potential side effects on both physiological and psychological aspects limit its application. This article reviews the side effects of ISO from physiological and psychological aspects in detail, to better screen the suitable population of ISO and improve the efficiency of clinical treatment. Our findings indicate that ISO may cause teratogenicity, skin reactions, ocular reactions, changes in blood indicators, and occasional acne fulminans. To optimize clinical treatment, more attention should be paid to identifying the specific conditions under which these reactions occur, how severe they are, and how they subside to alleviate patient concerns. Regarding the controversial issue of psychological side effects caused by ISO, researchers should shift their focus to the psychological problems that acne itself may cause.

Ocular manifestations of systemic isotretinoin in patients with acne: a systemic review and meta-analysis

PURPOSE

To examine the effects of systemic isotretinoin treatment on the eye using several ocular examination parameters.

METHODS

We conducted a systemic review for literature published up to June 2021 in both PubMed and Web of Science databases. We included prospective observational or interventional studies evaluating ocular manifestations of isotretinoin in acne patients. The primary outcome measures were anaesthetized and non-anaesthetized Schirmer test, tear break-up time (TBUT), central corneal thickness (CCT), average retinal nerve fibre layer (RNFL) thickness, ganglion cell-inner plexiform layer (GC-IP) thickness, subfoveal choroidal thickness, axial length, ocular surface disease index (OSDI), meibomian gland expression (MGE) and conjunctival stain. The National Institute of Health (NIH) quality assessment tools were used to assess the data quality. The effect size used to analyse the included studies was the weighted mean difference (WMD) and its related confidence intervals (95%CIs).

RESULTS

Twenty-one publications involving 1105 eyes of 842 participants met the inclusion criteria. Isotretinoin use was significantly associated with reduction in the scores of anaesthetized Schirmer (WMD = -2.23, 95%CI: -3.28 to -1.18), non-anaesthetized Schirmer (WMD = -3.74, 95%CI: -4.23 to -3.25), TBUT (WMD = -3.47, 95%CI: -5.09 to -1.86), and CCT (WMD= -7.39, 95%CI: -13.91 to -0.88). Isotretinoin use was significantly associated with increase of OSDI (WMD = 18.29, 95%CI: 7.54-29.03), MGE (WMD = 1.02, 95%CI: 0.70-1.33) and conjunctival stain scores (WMD = 0.61, 95%CI: 0.47-0.76). No significant change was noted in RNFL thickness (WMD = -0.64, 95%CI: -1.80 to 0.51); GC-IP thickness (WMD = 0.42, 95%CI: -1.08 to 1.92); subfoveal choroidal thickness (WMD = -1.80, 95%CI: -6.69 to 3.09), and axial length (WMD = 0.08, 95%CI: -0.19 to 0.35). A significant heterogeneity was found between the study estimates in each of anaesthetized Schirmer, TBUT, MGE, OSDI, and conjunctival stain tests.

CONCLUSION

Isotretinoin use results in a statistically significant reduction of the central corneal thickness, TBUT, and Schirmer test scores. A statistically significant increase in MGE, OSDI and conjunctival stain scores was found. No statistically significant change of average RNFL, GC-IP thickness, subfoveal choroidal thickness, or axial length was observed. Further well-designed studies should evaluate the long-term effect of isotretinoin on the eye and reach a firmer conclusion.

Isotretinoin and the eye: A review for the dermatologist

Due to the prevalence of acne vulgaris, isotretinoin is one of the most prescribed drugs among physicians and dermatologists. Although exhibiting an adequate safety profile, adverse events secondary to isotretinoin use are common. Before prescribing isotretinoin, physicians usually inquire about pregnancy and perform serologic tests including cholesterol, triglycerides, and liver enzymes. Ocular manifestations are commonly neglected. Despite being generally mild, ocular manifestations related to either topical or systemic isotretinoin may cause important ocular morbidity. The ocular surface is the most affected site within the eye; however, retinal and optic nerve disease also have been documented. Evaporative dry eye disease, which may range from mild to severe, is the most common adverse ocular effect associated with isotretinoin use. The aim of this review is to present an up-to-date overview for the dermatologist about the prevention, diagnosis, and treatment of the ocular side effects of isotretinoin, and when to refer to the eye specialist.

Side effects of retinoid therapy on the quality of vision

Retinoids are compounds chemically related to vitamin A, which are frequently used in dermatological practice (1). They are characterized by numerous mechanisms of action leading to normalization of keratinocyte proliferation and maturation. They have anti-seborrhoeic, immunomodulatory and anti-inflammatory effects (1, 2). A number of side effects to retinoid treatment have been recorded; one group of such side effects relates to eyes and vision. Dry eye syndrome and blepharoconjunctivitis are the most common side effects, appearing in 20-50 % of patients treated with retinoids. They often contribute to the occurrence of other side-effects such as eye discomfort and contact lens intolerance. Due to the widespread use in clinical practice, the adverse effects, including ocular side effects, should be studied. To confirm the variety of adverse effects of retinoids, several case reports of rare side-effects are presented.

Evaluation of corneal topography and biomechanical parameters after use of systemic isotretinoin in acne vulgaris

Purpose. We report the effect of isotretinoin on corneal topography, corneal thickness, and biomechanical parameters in patients with acne vulgaris. Method. Fifty-four eyes of 54 patients who received oral isotretinoin for treatment of acne vulgaris were evaluated. All patients underwent a corneal topographical evaluation with a Scheimpflug camera combined with Placido-disk (Sirius), ultrasonic pachymetry measurements, and corneal biomechanical evaluation with an ocular response analyzer at baseline, in the 1st, 3rd, and 6th months of treatment, and 6 months after isotretinoin discontinuation. Results. The thinnest corneal thickness measured with Sirius differed significantly in the 1st, 3rd, and 6th months compared with the baseline measurement; there was no significant change in ultrasonic central corneal thickness measurements and biomechanical parameters (corneal hysteresis and corneal resistance factor) throughout the study. Average simulated keratometry and surface asymmetry index increased significantly only in the first month of treatment according to the baseline. All changes disappeared 6 months after the end of treatment. Conclusion. Basal tear secretion and corneal morphologic properties were significantly influenced during the systemic isotretinoin treatment and the changes were reversible after discontinuation. No statistical important biomechanical differences were found to be induced by isotretinoin.

Ocular complications associated with systemic medications used in allergy/immunology practice

The repertoire of treatment options available to allergists and immunologists is ever increasing and with this comes the increased potential for these treatments to cause adverse ocular side effects. Corticosteroids remain the first line of treatment for most immunological disorders and physicians should be alerted to their extensive ocular morbidity profile. Patients requiring longer-term therapy may often receive immune modulators or newer biologic agents. While effective, these medications may have additional ocular side effects; as newer agents are more frequently used, some of these may not be previously documented. A number of patients will seek alternative or herbal remedies for these long-term conditions, often unknown to the treating physician; these too can cause harmful ocular morbidity. We review the latest information about the potential ocular side effects that may be encountered in treating patients with medications used in allergic and immunological disorders.