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ARCH SOC ESP OFTALMOL 2008; 83: 615-618
SHORT COMMUNICATION
OPTICAL COHERENCE TOMOGRAPHY STUDY IN
TAMOXIFEN MACULOPATHY
MACULOPATÍA POR TAMOXIFENO. ESTUDIO MEDIANTE LA
TOMOGRAFÍA DE COHERENCIA ÓPTICA
BAGET-BERNALDIZ M1, SOLER LLUIS N1, ROMERO-AROCA P2, TRAVESET-MAESO A1
ABSTRACT
RESUMEN
Case report: We describe the case of a patient who
presented with progressive and bilateral loss of
vision. She had been treated with tamoxifen for 13
years. We performed fluorescein angiography and
optical coherence tomography in order to study the
macula.
Discussion: Loss of visual acuity related to tamoxifen maculopathy may be caused either by retinal
nerve fibre atrophy or macular oedema. Macular
findings obtained by fluorescein angiography and
optical coherence tomography are complementary
(Arch Soc Esp Oftalmol 2008; 83: 615-618).
Caso clínico: Se describe el caso de una paciente
que acudió por pérdida bilateral y progresiva de la
visión después de haber recibido tratamiento con
tamoxifeno durante 13 años. Para el estudio detallado de las alteraciones maculares se realizaron la
angiografía fluoresceínica y la tomografía de coherencia óptica.
Discusión: La pérdida de visión debido a la maculopatía por tamoxifeno puede ser debida tanto a la
atrofia de las capas de fibras nerviosas de la retina
como a la presencia de edema macular. Los hallazgos maculares obtenidos mediante la angiografía
fluoresceínica y la tomografía de coherencia óptica
son complementarios.
Key words: Tamoxifen maculopathy, fluorescein
angiography, optical coherence tomography.
Palabras clave: Maculopatía por tamoxifeno,
angiografía fluoresceínica, tomografía de coherencia óptica.
INTRODUCTION
Tamoxifen is a drug having anti-estrogen effect
frequently used as a coadjutant treatment in breast
cancer. Ocular alterations at the cornea, retina and
optic nerve have been described with this drug,
even utilizing low doses (1). In general, it is esti-
Received: 24/9/07. Accepted: 29/8/08.
Ophthalmology Dept. Sant Joan Hospital. Universitat i Virgili. Reus. Spain.
1 Graduate in Medicine.
2 Ph.D. in Medicine.
Correspondence:
M. Baget Bernaldiz
C/. Selva del Camp, 11
43392 Castellvell del Camp (Tarragona)
Spain
E-mail: [email protected]
mated that the ocular toxicity prevalence caused by
tamoxifen is low (2). Patients suffering loss of
vision in relation to tamoxifen usually exhibit
whitish-yellowish crystal deposits in the nervous
fiber and internal layers of the retina (3). In these
cases, a fluorescein angiography (FA) study is useful because it frequently identifies the presence of
BAGET-BERNALDIZ M, et al.
A 53 year-old female diagnosed with breast cancer
in June 1992. She underwent a radical mastectomy
and tamoxifen was prescribed at a dosage of 20
mg/d, which she took regularly for 13 years (aggregate dose 95 g). During the last year of use of tamoxifen she exhibited a progressive loss of bilateral
vision. The ophthalmological assessment made 6
months after the onset of symptoms revealed a visual acuity (VA) of 0.6 and 0.4 in the right eye (RE) and
left eye (LE), respectively. Intraocular pressure and
biomicroscopic exploration were normal. The eye
fundus showed the presence of multiple whitish-yellowish spots dispersed in both posterior poles,
involving both foveae (fig. 1). A FA study was made,
evidencing the presence of slight bilateral macular
edema (fig. 2). The OCT study showed a single
foveal cyst with focal disruption of the photoreceptor
line without increased macular thickness in RE and
reduced foveal thickness in the LE (fig. 3).
The differential diagnostic was mainly based on
the dominant drusen and the fundus albipunctatus.
The patient did not refer premature vision loss in
any of her forbearers and did not exhibit a significant deposit of crystals on the nasal side of the optic
nerve, the typical area of involvement in dominant
drusen cases. In addition, she did not refer nyctalopia and the scotopic function of the electroretinogram was normal. The phototopic function
of the left eye was slightly depressed, with the elec-
Fig. 1: Bilateral retinography. Multiple whitish-yellowish spots dispersed on both posterior poles.
Fig. 2: Bilateral fluorescein angiography showing
slight fluorescein loss in both foveae.
macular edema. In addition, it has recently been
observed that a supplementary study of the macula
in these patients by means of Optical Coherence
Tomography (OCT) can provide anatomical details
not evidenced by FA (4,5). Treatment of tamoxifen
maculopathy consists in discontinuing its use, upon
which some patients exhibit improved vision.
CASE REPORT
616
ARCH SOC ESP OFTALMOL 2008; 83: 615-618
Tamoxifen an optic coherence tomography
Fig. 3: Bilateral OCT showing a foveal cyst with disruption of the photo receptor line in RE and foveal
atrophy in the LE.
troculogram being normal in both eyes. The patient
was diagnosed with tamoxifen retinopathy and recommended to discontinue the use of the drug.
Twelve months after discontinuation her VA
improved slightly only in the RE, reaching 0.75.
Since then and after 2 years of follow-up her VA
has remained stable. During said period the OCT
pattern as remained unchanged.
DISCUSSION
The study of tamoxifen maculopathy has usually
been made via eye fundus exploration and fluores-
cein angiography. The instant case only had the eye
fundus and FA and would have involved a diagnostic
of slight bilateral macular edema but the OCT
allowed a more detailed observation of the macular
pathology. Therefore, as observed by Gualiano et al
(4) and Bourla et al (5), there isn’t always a correspondence between angiographic evidence of macular edema and the presence of said edema via OCT.
Consequently, we believe that OCT, as a supplement
to FA can provide anatomical details of the macula
which confirm with greater certainty the visual
symptoms and may assist in establishing a visual
prognosis for these patients. In our case a visual
improvement was observed 12 months in the eye
with the foveal cyst (RE) after discontinuing the use
of the drug. This was not the case in the eye with
established foveal atrophy (LE). More tamoxifen
maculopathy cases analyzed with OCT need to be
published in order to determine the different macular
patterns and their corresponding visual prognosis.
REFERENCES
1. Pavlis NA, Petris C, Briassoulis E, Klouvas G, Psilas C,
Repapis J, et al. Clear evidence that long-term, low-dose
tamoxifen treatment can induce ocular toxicity. A prospective study of 63 patients. Cancer 1992; 69: 2961-2964.
2. Heier JS, Dragoo RA, Enzenauer RW, Waterhouse WJ.
Screening for ocular toxicity in asymptomatic patients treated with tamoxifen. Am J Ophthalmol 1994; 117: 772-775.
3. Mittra R, Mieler W, Drug toxicity of the posterior segment. In: Ryan SJ. Retina. St. Louis: Mosby; 2001; II:
1790.
4. Gualino V, Cohen SY, Delyfer MN, Sahel JA, Gaudric A.
Optical coherente tomography findings in tamoxifen retinopathy. Am J Ophthalmol 2005; 140: 757-758.
5. Bourla DH, Sarraf D, Schwartz SD. Peripheral retinopathy and maculopathy in high-dose tamoxifen theraphy.
Am J Ophthalmol 2007; 144: 126-128.
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