Ocular Changes
Background
Going as far back as the early 1990s, articles have documented ocular changes that are believed to be related to the administration of certain chemotherapeutic drugs. A recent article by O’Dea and colleagues cover historical and current knowledge on the subject and the aspects of a comprehensive visual assessment and describes 4 case studies of patients who experienced visual changes while receiving therapy with oxaliplatin.1 The authors remind us that changes in visual fields and acuity have been attributed to a number of pharmaceutical agents, including allopurinol, cephalosporins, and narcotics, as well as to chemotherapeutic agents such as the antimetabolites, alkylating agents, taxanes, and platinum agents. Targeted agents recently approved for CRC are also reported to cause ocular toxicity.2
Reported adverse effects vary from seemingly mild changes such as dry eyes and blurred vision, to more severe and sometimes permanent changes, such as retinal damage, glaucoma, and cataracts. Medications taken for comorbid conditions also can cause ocular changes; therefore, a full medication assessment should be undertaken when a patient reports visual changes. Comorbid conditions such as diabetes mellitus, lupus, multiple sclerosis, and pheochromocytoma can also cause visual changes. In certain types of cancer known to metastasize to the brain, persistent visual changes should prompt radiologic examination of the brain to rule out brain metastases.
Case reports of blepharatis related to long term (>15 weeks) cetuximab monotherapy were reported by Dranko et al.2 Chemotherapy agents specific to the care of patients with colorectal cancer (CRC) that may cause visual changes is oxaliplatin. Leonard and coworkers conducted a survey to evaluate neurotoxicity secondary to oxaliplatin therapy.3 Eighty-six patients with metastatic CRC being treated with oxaliplatin plus capecitabine were interviewed. The participants reported blurred vision, eye pain, and visual field cuts. The incidence rates were < 20%, and all changes were transient and resolved after discontinuing oxaliplatin therapy. The prescribing information for oxaliplatin reports low rates (< 20% for all grades) of visual disturbances, including tearing, conjunctivitis, and abnormal lacrimation.4
Fluorouracil (5-FU) may cause dry eyes and/or excessive tearing.5 In a 2000 case report, Waikhom and colleagues reported severe ocular irritation associated with capecitabine therapy6; the package insert for capecitabine reports a 5% to 15% incidence for all types of visual disturbance.7 Bevacizumab has not been reported to cause visual changes or abnormalities. In fact, bevacizumab is currently under study to treat neovascular age-related macular degeneration.8
It is easy to miss the association between chemotherapy and visual changes, because the incidence is uncommon. and many other conditions can cause ocular changes. Nurses caring for patients with CRC can assist them by doing a thorough review of systems related to visual changes during CRC therapy, and referring a patient to an ophthalmologist for a complete visual assessment when a patient reports these changes.
Assessment Tools
National Cancer Institute Common Toxicity Criteria (CTCAE) version 3
http://www.fda.gov/cder/cancer/toxicityframe.htm
Health on the Net Foundation, Vision FAQ, Section 5: Disease of the Eye
(Posterior Eye Disease)
http://www.hon.ch/Library/Theme/VisionFaq/section5.html
Patient Care Management Protocols/Algorithms
Optometric clinical practice recommendations for monitoring ocular toxicity of selected medications can be viewed online at: http://www.aoa.org/documents/OcularToxicity.pdf
References
- O’Dea D, Handy C, Wexler A. Ocular changes with oxaliplatin. Clin J Oncol Nurs. 2006;10:227-229.
- Dranko S, Kinney C, Ramanathan RK. Ocular toxicity related to cetuximab monotherapy in patients with colorectal cancer. Clin Colorectal Cancer. 2006;6:224-225.
- Leonard G, Wright M, Quinn M. Survey of oxaliplatin-associated neurotoxicity using an interview-based questionnaire in patients with metastatic colorectal cancer. BMC Cancer. 2005;5:116-125.
- Eloxatin (oxaliplatin for injection) prescribing information. Available at:
http://products.sanofi-aventis.us/eloxatin/eloxatin.html. - Wilkes G, Barton-Burke M. 2006 Oncology Nursing Drug Handbook. Boston: Jones and Bartlett Publishers; 2005.
- Waikhom B, Fraunfelder F, Henner W. Severe ocular irritation and corneal deposits associated with capecitabine use. N Engl J Med. 2000;343:740-741.
- Xeloda (capecitabine) tablets prescribing information. Available at: http://www.rocheusa.com/products/xeloda.
- Michels S, Rosenfeld P, Puliafito C, et al. Systemic bevacizumab (Avastin) therapy for neovascular age-related macular degeneration: twelve-week results of an uncontrolled open-label clinical study. Ophthalmology. 2005;112:1035-1047.
Key Definitions
acuity — keenness of sense perception
abnormal lacrimation — abnormal or excessive production of tears as a result of exposure of the eyes to an irritant
cataracts — a clouding of the lens of the eye or its surrounding transparent membrane that obstructs the passage of light
conjunctivitis — inflammation of the conjunctiva, the membrane that lines the inner surface of the eyelids; usually from an allergy, virus or bacterium, often called “pink eye”
glaucoma — a disease of the eye marked by increased pressure within the eyeball that can result in damage to the optic disk and gradual loss of vision
lupus — any of several diseases (as lupus vulgaris or systemic lupus erythematosus) characterized by skin lesions
macular degeneration — loss of central vision in one or both eyes as a result of malfunctioning cone cells in the retina. Two types: "wet " (disciform) and "dry" (atrophic). Also known as age-related macular degeneration (ARMD or AMD), and previously known as senile macular degeneration
pheochromocytoma — a tumor that is derived from chromaffin cells and is usually associated with paroxysmal (recurrent, sudden attacks) or sustained hypertension
visual field cuts — alterations to the extent of area visible to an eye as it looks straight ahead; measured in degrees away from direct line of sight
You've reached the end of this section.
[ Previous Page ] [ Home ]
This page was last modified on 11/29/2007, at 11:32:57 am ET.
Web site developed by Meniscus Limited.