Vision is one of our most important senses. Damage to the eye can occur in transplant patients because of underlying disease, medications used to treat the disease and to prevent graft rejection, and infection due to immunosuppression.
Significant toxicity from medications and other therapeutic interventions before and after organ transplantation is uncommon and often treatable or reversible. As with most medical complications, early detection is usually the key. Chronic steroid therapy increases the risk of cataracts, as does total body irradiation. Cataracts are caused by clouding of the lens inside the eye, and cause painless blurring of vision, often with glare and haloes. Cataracts need to be removed only if they are visually significant to the patient, and cataract surgery in transplant patients usually poses no more risk than it does in the general population. Steroids also increase the risk of glaucoma, and any patient taking steroid medications on a chronic basis should get periodic eye examinations, because glaucoma causes no symptoms early in the course of the disease.
Chemotherapeutic drugs such as cyclophosphamide can affect the surface of the eye, much as they affect the rapidly dividing cells of the intestinal tract. Symptoms include irritation and foreign body sensation. Ocular lubricants and occasionally steroid eyedrops can alleviate the symptoms. Cyclosporine can cause damage to the optic nerve, resulting in blurred vision. In most cases, the ocular problem can be alleviated with a decrease in the dose of the medication, but sometimes the drug must be discontinued altogether.
Another complication of organ transplantation is infection due to suppression of the body’s immune system. “Metastatic endophthalmitis” is the term used to describe spread of infection (either fungal or bacterial) through the bloodstream to the eyeball, often with devastating complications. Endophthalmitis causes rapid loss of vision, with pain and redness. The ophthalmologist can sometimes play a key diagnostic role in patients with fever of unknown origin; identification of early metastatic endophthalmitis (before blood cultures turn positive) may allow specific antibiotic or antifungal therapy rather than the “shotgun” approach used when no specific pathogen has been identified.
Graft-versus-host disease (GVHD) is a condition most prominent in bone marrow transplant patients. Ocular GVHD can cause mild to profound dry eye, conjunctival scarring, and corneal ulceration. Aggressive lubrication of the eye with preservative-free drops and ointments is critical, and punctal plugging (occlusion of the drainage ducts of the eyelids with removable silicone plugs) may also be helpful. Affected patients should avoid wind, dust, smoke, and other environmental irritants as much as possible.
Ocular findings can also be an indicator of recurrence of malignancies. Double vision, for example, can be caused by intracranial disease, and iritis (inflammation in the front part of the eye) in patients treated for leukemia is considered relapse of the leukemia until proven otherwise. Although periodic eye examination can detect many early problems, it is important that transplant patients with new ocular symptoms, such as eye pain, blurred or distorted vision, double vision, redness, or floaters, let their doctors know promptly.
— J.P. Dunn, M.D., Ocular Immunology Service, The Wilmer Eye Institute
