Ocular Surface Disease in Breast Cancer Patients Using Aromatase Inhibitors

Abstract

Aromatase inhibitors (AIs) are widely used as adjuvant hormonal therapy in postmenopausal women with hormone receptor-positive breast cancer. The purpose of this study was to investigate the potential impact of AIs on the anterior segment of the eye and especially the ocular surface. Participants in our study were 41 hormone receptor-positive early stage breast cancer patients (80 eyes), treated with AIs, while 80 eyes of 40 age- and gender-matched healthy controls, not previously used AIs for any purpose, were also evaluated. All participants underwent a complete ophthalmological examination, including best corrected visual acuity (BCVA) assessment, slit-lamp biomicroscopy, and dilated fundus examination. Ocular surface disease-related symptoms and signs were also recorded. The most common symptom was found to be blurred vision, while other symptoms included foreign body sensation, tearing, redness, and photophobia. Slit-lamp examination revealed blepharitis and meibomian gland dysfunction in 75% and 42.5% of patients, respectively. Superficial punctate keratitis and conjunctival injection were also present. Our results demonstrated a high prevalence of ocular surface disease-related symptoms and signs in patients receiving AIs compared to healthy controls. This study may raise a flag regarding the use of AIs. However, further and larger prospective longitudinal studies are needed to examine the possible effect of AIs alone or in combination with chemotherapy in the eyes of breast cancer patients.

Ocular Side Effects of Aromatase Inhibitor Endocrine Therapy in Breast Cancer – A Review

“…Several clinical studies evidenced that hormonal therapy with aromatase inhibitors impacts ocular surface and Meibomian glands, resulting in a significant proportion of cases with dry eye disease, associated with meibomian disfunction. In 7 studies (21)(22)(23)(24)(25)(26)(27), the diagnosis of dry eye was based on ophthalmic examination, whereas in the study of Cuzick et al (28), on self-reporting of signs and symptoms (Table I).…”

“…An OSDI >12 was considered to indicate dry eye in all studies included in the review (21,24,28). Among subjective signs reported by patients, the most frequent were foreign body sensation, blurred vision, redness, and photophobia (23,25). The alteration of the lacrimal film was strongly related to deficiency in the lipid layer, due to decreased meibomian function and blepharitis.…”

Subepithelial Corneal Deposits Associated with Exemestane

“…Although estrogen receptors are more readily associated with reproductive organs, they are also known to be present in the cornea, lens, retina, meibomian glands, and the lacrimal glands [7][8][9][10][11]. Several studies have reported on adverse ocular effects of AIs [12][13][14]. Inglis et al [4] used the Ocular Surface Disease Index questionnaire and found a significantly higher rate of self-reported dry eye disease in patients taking AIs compared to controls.…”

“…Gibson et al noted no significant difference in ocular surface symptoms in AI users compared to controls but did note worse meibomian gland expressibility and pain perception in AI users [13]. Others have also reported increased rates of anterior segment pathology including meibomian gland dysfunction [14], blepharitis, superficial punctate keratitis, conjunctival injection [6,14], and Sjögren's syndrome in AI users [15]. One isolated case report documented epithelial deposits associated with exemestane use [5].…”

Review of the Literature on Ocular Complications Associated With Aromatase Inhibitor Use

“…The patient’s visual acuity remained unaffected despite the persisting corneal changes. Chatziralli et al investigated the correlation between AI use and ocular surface disease [ 17 ]. Slit-lamp examination revealed blepharitis and meibomian gland dysfunction in 75% of the AI users compared to 42.5% of the control group.…”