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EDITORIAL
Year : 2004  |  Volume : 52  |  Issue : 2  |  Page : 95-7

Major ocular complications after organ transplantation.



Correspondence Address:
P Lanzetta


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PMID: 15283213

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How to cite this article:
Lanzetta P, Monaco P. Major ocular complications after organ transplantation. Indian J Ophthalmol 2004;52:95

How to cite this URL:
Lanzetta P, Monaco P. Major ocular complications after organ transplantation. Indian J Ophthalmol [serial online] 2004 [cited 2020 Dec 2];52:95. Available from: https://www.ijo.in/text.asp?2004/52/2/95/14614

Organ transplantation has evolved over the years. Renal transplantation has become a very successful and routine procedure. Heart transplantation is a mainstay of therapy for patients of heart failure. In liver transplantation, significant improvements in both patient and graft survival have been made during the last decade. With near optimal rates of early transplant patient and allograft survivals, the focus has shifted to the alleviation of medical complications that can improve outcomes. Pharmacologic immunosuppression has played a major role in the advancement of organ transplantation. However, immunosuppression has been shown to carry the risk of systemic diseases and other problems.

Visual loss is a rare but potentially devastating complication of organ transplantation. Postoperative therapy with steroids, cyclosporine, tacrolimus, other immunosuppressants and conditioning chemotherapeutic drugs have been associated with the development of cataract, ocular surface disorders, retinopathies and neurotoxic phenomena.

Corticosteroid cataract is a common complication that occurs frequently in spite of the use of cyclosporine, and is similar to the azathioprine era. The incidence of corticosteroid cataract after renal transplantation varies from more than 60% to 78%.[1],[2] Total body irradiation is also a major risk factor for the development of cataract.[3] In general, a reduction in the total dose of corticosteroid during the first year has no influence on cataract occurrence.[2] Increased intraocular pressure due to the intake of corticosteroids is seen in about 10% of patients receiving renal transplantation and postoperative corticosteroid therapy.[1] Systemic corticosteroids may also either aggravate or cause idiopathic central serous chorioretinopathy with multifocal serofibrinous retinal pigment epithelial detachments and retinal detachment in patients who become symptomatic after renal transplantation.[4] Central serous chorioretinopathy has also been described after bone marrow transplantation and the use of systemic corticosteroids and cyclosporine.[5] Patients undergoing renal, heart, and heart-lung transplantation may develop loss of vision caused by serous retinal detachment associated with geographic zones of leopard-spot pattern of clumping of orange retinal pigment epithelium and retinal pigment epithelium depigmentation in the posterior fundi of both eyes.[6] Oral corticosteroids, cyclosporine, and azathioprine, singly or in combination, may be of pathogenetic importance.[4],[5],[6],[7]

Ischaemic retinal microvasculopathy and visual loss after renal transplantation and bone marrow transplantation in patients treated with cyclosporine alone or conditioned with total body irradiation, busulfan, and/or cyclophosphamide have been documented.[3],[4],[5],[6],[7],[8],[9],[10],[11],[12][13],[14] Cyclosporine alone may be responsible for capillary/arteriolar damage.[13] In some studies, estimates of the incidence of retinal microvasculopathy were biased by ascertainment of only symptomatic cases.[9] The true incidence may be higher. In a prospective study, 46% of transplant patients with ischaemic fundi were asymptomatic.[11] Bone marrow transplant retinopathy occurs, on average, within 6 months of bone marrow transplantation. The earliest reported case of bone marrow transplant retinopathy was 3 months and the longest latent period was 25 months. The development of bone marrow transplant retinopathy is not influenced by age, gender, or race of the transplant recipients.[11],[12],[13],[14] Between 10% and 28% of patients who receive the cyclosporine experience some type of neurotoxic adverse event.[15] The case of a bone marrow transplant recipient who developed blindness 22 months after bone marrow transplant has been reported, where neuroretinal damage without microvascular retinopathy was suggested, without excluding an optic nerve lesion.[8] Cyclosporine has been implicated in the development of optic nerve head oedema in some cases associated with pseudotumour cerebri,[14],[15],[16],[17],[18] and as a cause of cortical blindness.[19] Occipital white matter appears to be uniquely susceptible to the neurotoxic effects of cyclosporine.[15] The disc oedema resolves when the cyclosporine dose is decreased or discontinued.[14] The disc oedema occurs on average about 150 days after bone marrow transplant, which is similar to the latent period for the development of the retinopathy.[14] After allogenic bone marrow transplant, about 1% of patients may develop transient unilateral or bilateral sixth nerve palsies and bilateral ptosis. Cyclosporine, possibly together with ganciclovir may represent the promoting factor.[20]

Tacrolimus is a relatively new immunosuppressive agent that is particularly indicated in liver transplantation and bone marrow transplantation. Preclinical toxicity studies in rats showed that tacrolimus may cause cataract due to an accumulation of sorbitol in the lens secondary to the diabetogenic effect of the drug. It is supposed that cataract would not develop with tacrolimus if diabetic parameters are under control.[21] Tacrolimus, like cyclosporine, may have a direct neurotoxic effect.[22] Acute cortical blindness has been reported occurring 5-47 days following bone marrow transplantation and after liver transplantation.[23],[24],[25] Reversibility within few weeks after discontinuation of tacrolimus is generally observed. A case of bilateral anterior ischaemic optic neuropathy 3 months after liver transplantation has been reported in a patient on tacrolimus therapy. Clinical features resembled ischaemic optic neuropathies. Deterioration of vision and bilateral optic atrophy occurred despite discontinuation of the tacrolimus.[22]

Major ocular complications due to immunosuppresant or conditioning chemotherapeutic drugs may also be influenced by other unknown underlying acquired of inherent conditions.

In conclusion, the incidence of ocular complications such as cataract or increased intraocular pressure due to immunosuppression may be relevant. Although more severe cases may occur less frequently, their implication on possible severe visual loss suggests that patients using immunosuppressants after organ transplantations should undergo routine ophthalmologic evaluation especially during the first year of therapy. Patients scheduled for organ transplantation and postoperative immunosuppressant therapy should receive visual acuity measurement, complete eye examination, automated perimetry, and color fundus photography before and every three months after transplantation for the first two years. Ancillary examinations should be performed in selected cases if indicated.



 
  References Top

1.
Shimmyo A, Miyazaky S, Onoe S, et al. Ocular complications after renal transplantation. Nippon Ganka Gakkai Zasshi 1997; 101:220-6  Back to cited text no. 1
    
2.
Nishimoto K, Sasaki K, Yamamura T, Ishikawa I, Shinoda A. Cataract in renal transplantation recipients with combination ciclosporine treatment. Lens Eye Toxic Res 1992; 9:455-67  Back to cited text no. 2
[PUBMED]    
3.
Tichelli A. Late ocular complications after bone marrow transplantation. Nouv Rev Fr Hematol 1994; 36 Suppl 1:S79-82  Back to cited text no. 3
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4.
Gass JDM, Little HL. Bilateral bullous exudative retinal detachment complicating idiopathic central serous chorioretinopathy during systemic corticosteroid theraphy. Ophthalmology 1995;102:737-747  Back to cited text no. 4
    
5.
Fawzi AA, Cunningham ET Jr. Central serous chorioretinopathy after bone marrow transplantation. Am J Ophthalmol 2001; 131:804-5  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.
Gass JDM, Slamovits TL, Fuller DG, et al: Posterior chorioretinopathy and retinal detachment after organ transplantation. Arch Ophthalmol 1992; 110:1717-22  Back to cited text no. 6
    
7.
Bandello F, Incorvaia C, Rosa N et al. Bilateral central serous chorioretinopathy in a patient treated with systemic cortico-steroids for non-Hodgkin lymphoma. Eur J Ophthalmol 2002; 12:123-26  Back to cited text no. 7
    
8.
Lopez-Jimenez J, Sanchez A, Fernandez CS et al. Cyclosporine-induced retinal toxic blindness. Bone Marrow Transplant 1997; 20:243-45  Back to cited text no. 8
    
9.
O'Riordan JM, FitzSimon S, O'Connor M, McCann SR. Retinal microvascular changes following bone marrow transplantation: the role of cyclosporine. Bone Marrow Transplant 1994; 13:101-4  Back to cited text no. 9
    
10.
Gloor B, Gratwohl A, Hahn H et al. Multiple cotton-wool spots following bone marrow transplantation for treatment of acute lymphatic leukemia. Br J Ophthalmol 1985; 69:320-5  Back to cited text no. 10
    
11.
Bernauer W, Gratwohl A, Keller A, Daicker B. Microvasculopathy in the ocular fundus after bone marrow transplantation. Ann Intern Med 1991; 115:925-30   Back to cited text no. 11
    
12.
Zoja C, Furci L, Ghilardi F et al. Cyclosporine-induced endothelial cell injury . Lab Invest 1986; 55:455-462  Back to cited text no. 12
    
13.
Yamani A, Myers-Powell BA, Whitcup SB et al. Visual loss after renal transplantation. Retina 2001; 21:553-559  Back to cited text no. 13
    
14.
Coskuncan NM, Jabs DA, Dunn JP et al. The eye in bone marrow transplantation. VI. Retinal complications. Arch Ophthalmol 1994; 112:372-79  Back to cited text no. 14
    
15.
Bechstein WO. Neurotoxicity of calcineurin inhibitors: impact and clinical management. Transpl Int 2000; 13:313-26  Back to cited text no. 15
    
16.
Avery R, Jabs DA, Wingard JR et al. Optic disc edema after bone marrow transplantation. Possible role of cyclosporine toxicity. Ophthalmology 1991; 98:1294-1301  Back to cited text no. 16
    
17.
Katz B. Disc edema subsequent to renal transplantation. Surv Ophthalmol 1997; 41:315-20  Back to cited text no. 17
    
18.
Cruz OA, Fogg SG, Roper-Hall G. Pseudotumor cerebri associated with cyclosporine use. Am J Ophthalmol 1996; 122:436-37  Back to cited text no. 18
    
19.
Reece DE, Frei-Lahr DA, Shepard JD et al. Neurologic complications in allogenic bone marrow transplant patients receiving cyclosporine. Bone Marrow Transplant 1991; 8:393-401  Back to cited text no. 19
    
20.
Openshaw H, Slatkin NE, Smith E. Eye movement disorders in bone marrow transplant patients on cyclosporine and ganciclovir. Bone Marrow Transplant 1997; 19:503-5   Back to cited text no. 20
    
21.
Ishida H, Mitamura T, Takahashi Y et al. Cataract development induced by repeated oral dosing with FK 506 (tacrolimus) in adult rats. Toxicology 1997; 123:167-75  Back to cited text no. 21
    
22.
Brazis PW, Spivey JR, Bolling JP et al. A case of bilateral optic neuropathy in a patient on tacrolimus (FK 506) therapy after liver transplantation. Am J Ophthalmol 2000; 129:536-38  Back to cited text no. 22
    
23.
Devine SM, Newman NJ, Siegel JL et al Tacrolimus (FK 506)-induced cerebral blindness following bone marrow transplantation. Bone Marrow Transplant 1996; 18:569-72  Back to cited text no. 23
    
24.
Steg RE, Kessinger A, Wszolek ZK. Cortical blindness and seizures in a patient receiving FK506 after bone marrow transplantation. Bone Marrow Transplant 1999; 23:959-62  Back to cited text no. 24
    
25.
Shutter LA, Green JP, Newman NJ et al. Cortical blindness and white matter lesions in a patient receiving FK506 after liver transplantation. Neurology 1993; 43:2417-18.   Back to cited text no. 25
    



This article has been cited by
1 An Ophthalmological Complication: Central Serous Chorioretinopathy in a Renal Transplant Recipient
Oliaei, F., Rasoulinejad, A., Seifi, B.
Transplantation Proceedings. 2007; 39(4): 1134-1135
[Pubmed]



 

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