Cyclosporine

  • Calcineurin inhibitor (includes tacrolimus and sirolimus) that fights organ transplant rejection and autoimmune disorders
  • Most common ophthalmic side effect: posterior reversible encephalopathy syndrome (PRES) producing binocular vision loss
  • Caused by toxicity to vascular endothelium and high blood pressure, which provoke vascular leakage into brain
  • Damage greatest in distribution of posterior cerebral artery
  • Acute or subacute onset of visual impairment
  • Unilateral or bilateral homonymous hemianopia
  • Normal eye examination
  • Confusional state
  • Headache
  • Seizures
  • High blood pressure
  • High T2/FLAIR MRI signal concentrated around visual cortex
  • No abnormalities on diffusion-weighted MRI
  • Stroke
  • Hypertensive encephalopathy
  • Reversible cerebal vasoconstriction (Call-Fleming) syndrome
  • Non-convulsive status epilepticus
  • Dural venous sinus thrombosis
  • Encephalitis
  • Posterior ischemic optic neuropathy
  • Occult retinopathy
  • Pituitary apoplexy
  • Anticipate this common side effect
  • Refer urgently to ophthalmologist or emergency room
  • Medication must be promptly discontinued and blood pressure lowered
  • These measures will lead to recovery within days, but...
  • If PRES has persisted for too long, stroke may occur, producing permanent occipital blindness, so...
  • Diagnosis is urgent!