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Nov 23, 2011 - Reversible branch retinal artery occlusion following intravenous cisplatin chemotherapy for cervical carcinoma. Arijit Mitra • Matthew R.
Int Ophthalmol (2011) 31:429–432 DOI 10.1007/s10792-011-9476-2

CASE REPORT

Reversible branch retinal artery occlusion following intravenous cisplatin chemotherapy for cervical carcinoma Arijit Mitra • Matthew R. Edmunds Nawaz Walji • Indrajit N. Fernando Robert A. H. Scott • Peter Good

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Received: 5 December 2010 / Accepted: 25 October 2011 / Published online: 23 November 2011 Ó Springer Science+Business Media B.V. 2011

Abstract Cisplatin (CDDP) is a chemotherapeutic agent widely used to treat solid tumours. We present a case of reversible CDDP-associated branch retinal artery occlusion. Keywords Branch retinal artery occlusion  Cisplatin  Chemotherapy  Cervical carcinoma

Case report Following Wertheim’s hysterectomy for a FIGO stage IB2 squamous cell carcinoma of the cervix with pelvic lymph node metastasis, a previously healthy 57-yearold woman commenced adjuvant pelvic chemoradiation (45 Gy in 25 fractions plus weekly cisplatin [CDDP] 40 mg/m2). Following the second cycle of weekly CDDP, she was referred with sudden-onset, painless blurring of vision of the left eye.

A. Mitra (&)  M. R. Edmunds  R. A. H. Scott  P. Good Birmingham and Midland Eye Centre, City Hospital, Dudley Road, Birmingham, West Midlands B18 7QH, UK e-mail: [email protected] N. Walji  I. N. Fernando Queen Elizabeth Hospital, Edgbaston, Birmingham, West Midlands, UK

On examination, visual acuities were 6/6 OD and 6/9 OS. There was a three-disc diameter area of mild retinal pallor inferotemporal to the fovea but no emboli were visible. Ocular examination was otherwise unremarkable. A diagnosis of branch retinal artery occlusion (BRAO) was made (Fig. 1). The central vision was preserved due to a patent cilioretinal artery. Humphrey visual field analysis (24–2 and 10–2) and Amsler grid testing demonstrated a superonasal scotoma (Fig. 2). Optical coherence tomography showed selective localised loss of inner retinal layers, as the inner two-thirds of the inner retinal layer receive nutrition from the retinal circulation. The outer onethird of the neural retina was spared as they are supplied from the choroidal circulation (Fig. 3). Visual evoked potential and electroretinogram examinations were normal. In the absence of any arteriopathic risk factors (e.g., smoking history, hypertension or diabetes mellitus) CDDP was considered to be the most likely underlying cause for the BRAO. CDDP was discontinued and the patient completed radiotherapy as planned. The visual field loss recovered completely within three months of stopping CDDP (Fig. 4). The patient remains in complete remission from the cervical carcinoma.

Comment CDDP is an effective and widely used antineoplastic agent in the treatment of solid tumours, especially

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Fig. 1 Fundus picture of the left eye showing mild pallor from retinal oedema of the inferotemporal macula

germ cell cancer. The reported incidence of vascular toxicity associated with chemotherapy is 1% [1]. Vaso-occlusive complications have been reported in

Fig. 3 Optical coherence tomography scan showing selective loss of inner retinal layer of the left eye on one side of the fovea as compared to the other side

Fig. 2 Humphrey visual fields demonstrating a supero-nasal scotoma of the left eye at the time of presentation from BRAO (left image shows 24–2 fields and right image shows 10–2 fields)

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Fig. 4 Humphrey visual fields demonstrating complete resolution of the supero-nasal scotoma of the left eye

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patients with malignancies both as a consequence of the disease and the treatment. Vascular toxicity associated with CDDP includes Raynaud’s phenomenon, cardiac ischaemia and infarction, arterial thrombosis and cerebrovascular accidents [2]. The exact mechanism of the vascular toxicity of CDDP is not clear. Proposed mechanisms include vasospasm and vascular occlusion; hypomagnesaemia and autonomic dysfunction cause vasospasm. Altered platelet aggregation, elevated levels of plasma von Willebrand concentration, hypercholesterolaemia [3] and vascular endothelial injury cause vascular occlusion [4]. In our patient, hypomagnesaemia, which is seen in 75–80% of patients receiving CDDP chemotherapy, as well as autonomic dysfunction and particularly enhanced alpha-adrenergic tone, may have caused vasospam, which led to hypoperfusion of the branch retinal artery. This was reversed on discontinuing CDDP. Previously reported ophthalmic complications associated with CDDP chemotherapy include macular retinal pigment abnormality, retinal ischaemia with neovascularisation, retinal microvascular complications, subclinical retinal dysfunction, cone dysfunction, optic neuropathy and cortical blindness [5–11]. To the best of our knowledge this is the first case report of reversible branch retinal artery occlusion from CDDP therapy. Conflict of interest The authors do not have any proprietary interest in any product mentioned.

References 1. Cool RM, Herrington JD, Wong L (2002) Recurrent peripheral arterial thrombosis induced by cisplatin and etoposide. Pharmacotherapy 22:1200–1204

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