Post-chemotherapy sudden vision loss

A 39-year-old female, a known case of ovarian cancer, gave history of sudden, painless diminution of vision in both eyes (OU), 4 months ago during the intravenous administration of the last cycle of chemotherapy [six cycles of paclitaxel–carboplatin and two cycles of nab-paclitaxel/carboplatin]. She was diagnosed elsewhere as central retinal vein occlusion (CRVO) with cystoid macula edema (CME). Reports showed a BCVA of 3/60, and OCT showed CME [Fig. 1a and b]. There were no signs of RVO [Fig. 1c and d] and no leakage in FFA [Fig. 1e-h] in OU.Figure 1: Shows the imaging done elsewhere during the acute phase. (a and b) represent the OCT images of OD and OS, showing cystoid macular edema (CME) with minimal inner layer hyperreflectivity. (c and d) represent the colour fundus photos, which do not show retinal hemorrhages or venous dilatation. (e and f) represent OS FFA with no filling defect or leak. (g and h) correspond to OD FFA, showing peripapillary window defects but no filling defect or leakWhat is your next step? Anti- Vascular Endothelial Growth Factor (VEGF) injection Triamcinolone acetonide injection Observe Focal laser Findings One month later, the edema resolved spontaneously. Two months later, she presented with a BCVA of 6/7.5 in the right eye and 6/18 in the left eye. Fundus examination (OU) showed pigmentary changes around the fovea with a mixed autofluorescence pattern [Fig. 2a-d]. OCT showed foveal thinning with ellipsoid layer defects [Fig. 2e and f]. OCT angiography showed an altered foveal avascular zone, suggesting ischemia [Fig. 2g and h]. The temporal association between the drug administration and the onset of symptoms, simultaneous bilateral involvement, CME without leakage, and spontaneous resolution favor the diagnosis of paclitaxel–carboplatin-induced maculopathy. The lack of retinal hemorrhages and venous dilatation rules out CRVO.Figure 2: Shows the current visit’s imaging findings. (a and b) are the colour fundus images of OD and OS, showing pigmentary alterations at the macula. (c and d) are the fundus autofluorescence (FAF) images of OD and OS, respectively, showing perifoveal mixed FAF patterns. (e and f) depict the swept-source OCT of OD and OS, showing foveal thinning and ellipsoid layer defects. (g and h) correspond to the OCT angiography of the superficial capillary plexus of OD and OS, showing an enlarged foveal avascular zone (OS > OD)Diagnosis Paclitaxel–carboplatin induced maculopathy. Correct answer. C Discussion Taxanes (antimicrotubule agents) may affect the cytoskeleton of retinal pigment epithelium and Muller cells, causing intracellular fluid accumulation and minimal extracellular fluid leakage (less leakage).[1,2] The pathogenesis of carboplatin (a platinum analog)-induced ischemia is unclear, but a few studies have suggested cisplatin-induced platelet activation leading to thrombosis and ischemia.[3] The treatment is discontinuation of the drug.[1,2] Taxane-induced macular edema can mimic other retinal vascular diseases and is managed by stopping the drug. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.