Retinopathy associated with pegylated interferon and ribavirin in patients with hepatitis C

Retinopathy associated with pegylated interferon and ribavirin in patients with hepatitis C

Burgueño-Montanes, C. , Pérez-Álvarez, R.
Published in Arch Soc Esp Oftalmol. Published in Arch Soc Esp Oftalmol. 2011;86:193-5. 2011; 86:193-5. - vol.86 núm 06 - Vol.86 No. 06

Source: Arch Soc Esp Oftalmol

Pegylated interferon and ribavirin associated retinopathy in patients with hepatitis C; Burgueño-Montañés C, Pérez-Álvarez R; Archivos de la Sociedad Espanola de Oftalmologia 86 (6), 193-195 (Jun 2011)

Abstract
We describe two patients with hepatitis C treated with pegylated interferon and ribavirin who developed multiple cotton wool spots in the retina of both eyes. The box was labeled eye retinopathy associated with pegylated interferon and in one case resolved spontaneously and another after its withdrawal.

Interferon is an immunomodulating cytokine used as a first line treatment of hepatitis C. Numerous adverse effects have been reported, but ocular ones are less known. We believe that periodic ophthalmological examinations during this treatment are required in order to detect these complications, which can be serious.

Case 1
65 year old woman diagnosed with chronic hepatitis C genotype 1 viral load of 4,300,000 copies / ml and hypertension (HT). Treatment commenced with pegylated IFN α-2b (180μg/semana) with ribavirin (800mg/day).

Given his history of hypertension was requested ophthalmologic examination was performed at 15 days of starting treatment. Presented a visual acuity (VA) of 10/10 with correction in both eyes and fundus (FOR) papillae and normal maculae. Tortuous arterial sclerosis and venous pathologic arteriovenous crossings.

At 3 months, and being asymptomatic, was again assessed. Presented the same AV but in the FO multiple cotton wool spots appeared in arcades and posterior pole, with respect to the macular area, as well as some microbleeds and microaneurysm.

Retinopathy was labeled by IFN (Figure 1) and decided to continue the treatment because of the no impact on the AV, a high viral load and the possibility of close monitoring.

Figure 1. At 3 months of starting treatment.

Virologic response was late at week 24, so that the treatment lasted 72 weeks with good response. During the treatment was neutropenia than 600/mm3 became of anemia and a maximum of 8.5 g / dl of hemoglobin, but did not change the dose of IFN.

In follow-up always had the same AV, exudates were reabsorbed and microbleeds was only in the superior temporal vascular arcade of the right eye (Figure 2, Figure 3).

Figure 2. At 5 months.

Figure 2. At 5 months.

Figure 3. One month after treatment ends

Case 2
37 year old male ex-drug addict injecting and diagnosed with chronic hepatitis C genotype 4 with a low viral load (75 754 IU / ml). Treatment commenced with pegylated IFN α-2b (100μg/semana) and ribavirin (1g/day).

At 2 months after starting treatment attended the consultation and noted blurred vision and "spots" in the visual field from about 10 days earlier.

The ophthalmologic examination showed visual acuity was 0.8 with correction in both eyes and multiple cotton wool spots in the posterior pole.

Retinopathy was diagnosed by IFN treatment was discontinued. In successive controls the picture was improving and at 3 months showed a VA of 10/10 in both eyes and the optic was seen only in absorption cottony exudates lower left fovea.

Discussion
There are several side effects due to the use of IFN, the most common is a flu-like symptoms, but can also occur ophthalmologic disorders and central nervous system, hematopoietic, gastrointestinal, urinary, cardiovascular, musculoskeletal and endocrine systems.

The most typical ocular complication is ischemic retinopathy with cotton wool spots, retinal hemorrhages in the posterior pole and especially around the optic disc, and microaneurysms. May be accompanied by hyperemia of the optic disc and macular edema. They are also described cases of subconjunctival hemorrhage, choroidal neovascularization, vasospasm, neovascular glaucoma, retinal vascular occlusions, ischemic optic neuropathy and Vogt-Koyanagi-Harada like1.

Retinopathy secondary to the use of IFN has been known since 1990, with an incidence varies between 18 series and 86% 2, with pegylated IFN appears to be 16-19% lower 2, 3. There is a relationship between dose and duration of treatment.2. Appears between 8 and 12 weeks after initiation of therapy, before it is very rare. It is usually asymptomatic and associated with a good AV. It can disappear spontaneously during therapy or rapidly after discontinuation of IFN and most visuales2 without sequelae.

The suspension is advisable to decrease and if you have strong AV retiniana1 ischemia. Classically, the pathogenesis has been attributed to immune complex deposition in retinal vessels, and also to increase the adhesiveness IFN leukocyte to the endothelium vascular2 4. Recently Nagooka et al5 evaluated vascular function in these patients include retinal endothelial dysfunction. Furthermore, both hepatitis C and IFN induce the formation of a variety of trombogénicos4 Ac. Ribavirin, besides being able to cause tearing and conjunctivitis may contribute to retinopathy of their synergistic action in combination with IFN4.

Diabetes, hypertension and anemia have been described as riesgo3 factors for the development and progression of retinopathy, and therefore these patients should be followed more closely. Although some studies question the need for eye examinations of asymptomatic patients rutina2 treated with IFN are described cases of ocular complications with visual loss grave1. Should be a review of AV and FOR before starting treatment and then every 3 months. If retinopathy objective review should be made monthly / quarterly until complete resolution.

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