Bilateral central retinal artery occlusion following paclitaxel therapy

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A recently published report associated the development of central retinal artery occlusion (CRAO) with the use of paclitaxel to treat breast cancer, reported first author Harsh H. Jain, MBBS, DNB. He and his colleagues from the National Institute of Ophthalmology, Pune, India, and Future Vision Eye Care, Mumbai, India, advised that clinicians be vigilant regarding the effects of paclitaxel to ensure that ocular symptoms are recognized early. The researchers reported their case in JAMA Ophthalmology.

They explained that while development of CRAO in association with paclitaxel therapy is “exceedingly rare,” CRAO is considered an emergency situation. The drug has been reported previously to cause neuropathy and hypersensitivity reactions in breast cancer patients.² CRAO also has been reported to occur in patients with systemic lupus erythematosus, antiphospholipid antibody syndrome, and giant cell arteritis.³

Case report

The patient was a 66-year-old woman undergoing chemotherapy with paclitaxel (80 mg/m² weekly) for stage 3 breast cancer. About 6 hours following the second cycle of paclitaxel, acute, painless loss of vision occurred bilaterally.

Her medical history included rheumatoid arthritis, but it was not treated.

Following the vision loss, the best-corrected visual acuities in the right and left eyes were, respectively, 20/600 and 20/400; cherry-red spots were present in the macula on optical coherence tomography consistent with bilateral CRAO.

Testing was negative for lupus, and the prothrombin time and D-dimer and fibrinogen levels were normal. The erythrocyte sedimentation rate and C-reactive protein levels were normal despite a positive test for rheumatoid factor. She also had no significant atherosclerotic disease and no intracranial vasculopathy or embolic phenomena. The low-density lipoprotein and total cholesterol levels were mildly elevated, and an electrocardiogram was normal.

Treatment included immediate paracentesis and ocular massage bilaterally, followed by hyperbaric oxygen therapy the next day. She was prescribed 75 mg of aspirin and 20 mg of atorvastatin daily.

One week after the ophthalmic episode, the vision in the left eye increased to 20/60, but the vision in the right eye was 20/400. The CRAO was seen to have resolved in both eyes on imaging, but ischemia and a partial cherry-red spot in the right eye persisted. Two months after vision loss, the vision in both eyes improved to 20/60.

The authors theorized that the “strong temporal association with chemotherapy, with CRAO occurring within hours of paclitaxel administration as the sole agent, suggests paclitaxel to be the most probable cause, especially in the absence of other thrombotic events, normal hypercoagulability markers, absence of systemic vasculitis symptoms, or prior vasculitic manifestations.”

In commenting on the vision loss potentially linked to paclitaxel, Dr. Jain and colleagues said, “The drug’s vascular toxic effects, including endothelial damage and vasospasm, are plausible mechanisms for CRAO,⁴particularly in a patient with predisposing factors such as malignancy and chronic inflammation. Das et al⁵ reported a case of bilateral ischemic retinopathy after the sixth cycle of paclitaxel-cyclophosphamide chemotherapy for breast cancer in a 72-year-old Indian woman. Paclitaxel has also been implicated in causing cardiac ischemia in 1 patient following administration for cervical cancer.⁶ Interestingly, we also saw mild hyperreflectivity in the retinal outer layers, likely from ischemic stress involving the photoreceptors and pigment epithelium, as described by Ng et al.⁷

“This case highlights the need for vigilance during paclitaxel therapy, as early recognition of ocular symptoms and prompt multidisciplinary care are crucial,” the authors concluded.

References

1. Jain HH, Naaz R, Sagar T, et al. Bilateral central retinal artery occlusion after paclitaxel in breast cancer. JAMA Ophthalmol. 2025; published online May 29. doi:10.1001/jamaophthalmol.2025.1379

2. Al-Mahayri ZN, AlAhmad MM, Ali BR. Current opinion on the pharmacogenomics of paclitaxel-induced toxicity. Expert Opin Drug Metab Toxicol. 2021;17:785-801. doi:10.1080/17425255.2021.1943358

3. Chandran K, Shenoy SB, Kulkarni C, Mathew NR. Bilateral simultaneous central retinal artery occlusion (CRAO) in a patient with systemic lupus erythematosus (SLE). Am J Ophthalmol Case Rep. 2020;19:100833.

4. Stähli BE, Camici GG, Steffel J, et al. Paclitaxel enhances thrombin-induced endothelial tissue factor expression via c-Jun terminal NH2 kinase activation. Circ Res. 2006;99:149-155. doi:10.1161/01.RES.0000233379.92010.fd

5. Das A, Ranjan R, Shah PK, Narendran V. Paclitaxel- and/or cyclophosphamide-induced severe ischaemic retinopathy. Clin Exp Ophthalmol. 2020;48:1113-1115. doi:10.1111/ceo.13854

6. Higami S, Tanaka Y, Deguchi T, Shiraishi M, Shiki Y. Acute ST-segment elevations following paclitaxel administration for uterine cervical cancer: a case report and literature review. Cardiooncology. 2022;8:22. doi:10.1186/s40959-022-00148-9

7. Ng WY, Wong DW, Yeo IY, Han DC. Cystoid macular edema in acute presentation of central retinal artery occlusion. Case Rep Ophthalmol Med. 2012;2012:530128.