Eyeworld

EW NEWS & OPINION 18 O phthalmologists are well versed in the complica- tions of corneal trans- plants, but how well do they know the ocular complications of lung transplants? Ocular complications related to lung transplants can indicate serious health problems. Eye complications in lung transplant patients have even been linked to increased mor- tality. "Herein, we report six cases of infectious ocular complications among 46 patients examined at Cole Eye Institute after unilateral or bilat- eral lung transplant at the Cleveland Clinic," wrote lead study author Ahmad B. Tarabishy, M.D., Cole Eye Institute, Cleveland Clinic, Cleveland. "Five of six patients died within a few months of presenta- tion." That's likely no coincidence, ac- cording to the study, published online in the British Journal of Oph- thalmology in December 2010. "We suspect that infectious ocular com- plications may be an indication of an excessive level of immunosup- pression that may lead to additional infection, sepsis and even death," Dr. Tarabishy reported. Concerning transplants A minority of patients that undergo lung transplantation end up with eye infections. In this series, 545 pa- tients received lung transplants, 46 (8.4%) had eye exams afterward, and of those, six (13%) had ocular infec- tions. Yet five of six patients with ocular infectious complications died within 6 months of eye evaluation. "One patient with P boydii infec- tion died from disseminated infec- tion, while three other patients died of causes other than the infection re- lated to their infectious ocular com- plication," Dr. Tarabishy reported. "Laboratory evaluation of patients with infectious complications indi- cated that their immune status was worse than those without infectious complications." Already patients with lung transplants "have among the high- est mortalities of solid organ trans- plant patients," Dr. Tarabishy acknowledged. Interestingly, al- though the lung transplant was first performed in 1963, the 5-year mor- tality rate still stands at 50%, accord- ing to Dr. Tarabishy. Additionally, eye infection seems to exacerbate things. "The mean white blood cell count in pa- tients with non-infectious and infec- tious findings was 7.36 and 5.98 K/ml, respectively," Dr. Tarabishy noted. "The average absolute neu- trophil count was 5.19 and 4.64 K/ml, respectively. The average ab- solute lymphocyte count was 1.49 and 0.74 K/ml, respectively." P. boydii is a particularly vicious organism, Dr. Tarabishy noted. Apart from causing endophthalmitis, P. boydii infection in eight patients with disseminated disease after solid organ transplant led to 100% mor- tality. Increased immunosuppression causes other problems."Squamous cell carcinoma occurred in two pa- tients, involving the eyelid in one patient and the conjunctiva in an- other," Dr. Tarabishy reported. "The increased incidence of squamous cell carcinoma in solid organ transplant and other immunosuppressed popu- lations is well recognised." A surprising new finding in- volves the appearance of a full-thick- ness macular hole and retinal detachment in two patients with pulmonary arterial hypertension. "We think a combination of fac- tors may have caused a serous macu- lar detachment or severe cystoids oedema that led to the formation of a macular hole, turning the serous retinal detachment into a rheg- matogenous retinal detachment," Dr. Tarabishy reported. "Haemody- namic changes at the time of sur- gery, which involves placement on cardiopulmonary bypass, may have led to an acute rise in systemic ve- nous pressure, possibly causing an exacerbation of the serous effusion. Moreover, the surgical repair of these cases did not follow the usual course, and all patients had recur- rent proliferative vitreoretinopathy and multiple surgeries." Unfortunately, outcomes for lung transplant patients with ocular complications appear grim. "Routine preoperative and postoperative eye examinations for organ transplant patients have been proposed by some authors based on the occur- rence of infectious complications after transplantation," Dr. Tarabishy noted, but added, "Based on these data, it is unclear whether routine ophthalmological examination in this population is beneficial." Nevertheless, for all patients who undergo lung transplantation, vigilant monitoring is warranted. "At the Cleveland Clinic, patients are immediately started on an im- munosuppressive regimen after transplantation consisting of tacrolimus, an antimetabolite such as mycophenolate mofetil or aza- thioprine, and high-dose corticos- teroids," Dr. Tarabishy noted. "The post-transplant protocol requires that patients are never off corticos- teroids at any time, and most pa- tients are maintained on 5 mg once a day at the lowest dose, and that serum tacrolimus levels are main- tained between 5 and 20 ng/ml. Pa- tients are followed closely by the transplantation centre at the Cleve- land Clinic and undergo an exten- sive battery of surveillance testing for rejection and immunosuppres- sive complications." Bjorn Johansson, M.D., Linkoping University Hospital, Linkoping, Sweden, said that it's not "unreasonable" to find a connection between eye infection in lung trans- plant patients and increased mortal- ity. "We do quite a lot of bilateral cataract surgery," Dr. Johansson said. "If a patient is on an immunosup- pressant medication, like steroids or cytotoxic agents, we do one eye at a time because we don't want to risk bilateral infection." In other words, Dr. Johansson draws a connection between im- munosuppressant medications— which are mainstays of lung transplantation therapy—and eye infection and increased mortality. "I would say it's probably not the lung disease itself [contributing to increased mortality] but more likely the immunosuppressant," Dr. Johansson said. Notably, resumed causes of death in the patients in this study included septic shock and various infections. Only one patient died as a result of chronic lung rejection. EW Editors' note: Dr. Johansson has no fi- nancial interests related to his com- ments. Dr. Tarabishy has no financial interests related to this study. Contact information Johansson: bjorn.johansson@lio.se Tarabishy: btarabishy@gmail.com April 2011 by Matt Young EyeWorld Contributing Editor Ocular complications can cause serious problems in lung transplant patients said. "That would mean special arrangements for every patient here." Dr. Johansson has operated on people from different countries in the Middle East and southern Eu- rope. He reported that many people get PEX when they are older, usually more than 70 years old. EW Editors' note: Dr. Johansson has no fi- nancial interests related to his com- ments. Dr. Vasavada has no financial interests related to his study. Contact information Johansson: bjorn.johansson@lio.se Vasavada: icirc@abhayvasavada.com Study continued from page 16

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