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Diabetic retinopathy and interferon- ribavirin therapy

Diabetic retinopathy and interferon- ribavirin therapy. SM 9/10/1960 Joslin ID#: 238275. Presentation. Age/Gender : 47 y/o Female Ethnicity : Afro-American Occupation : Counseling DM/Type/Duration : DM 2 x 17 yrs A1C/Date : 5.7% (3/08 – 1mo) PCP/Endo : William Sullivan

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Diabetic retinopathy and interferon- ribavirin therapy

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  1. Diabetic retinopathy and interferon-ribavirin therapy SM 9/10/1960 Joslin ID#: 238275

  2. Presentation Age/Gender : 47 y/o Female Ethnicity : Afro-American Occupation : Counseling DM/Type/Duration : DM 2 x 17 yrs A1C/Date : 5.7% (3/08 – 1mo) PCP/Endo : William Sullivan Insulin/Oral Agents : Insulin + Oral Agents Last Eye Exam : 11/2007 (5 months) Medical history : Chronic Hep C / HTN / Depression

  3. Presentation Chief Complaint : DR f/up, no visual changes Brief History : 47 y/o female that comes for mod NPDR f/up @ 6mo Review of systems : Neuro: Burning sensation in toes Psych: Depression + eating disorder Past Ocular history : mod NPDR (1/06 – 11/07) Past Surgical history : N/A Medications : Peginterferon + Ribavirin (aprox. 7/07)

  4. VA and Ancillary Tests Visual Acuity and Refraction OD +0.25 sph 20/32 +1.75 ADD 20/25 OS -0.25 sph 20/20 +1.75 ADD 20/25 Ancillary Tests Pupils PERRL, No RAPD OU EOMs F/S OU Confrontation Full OU Amsler Normal OU IOP 14 OD / 14 OS

  5. External and Anterior Segment Exam OD OS External Normal OU Conjunctiva Melanosis OU Cornea Clear OU AC Deep and Quiet OU Iris Normal OU Lens NS trace OU

  6. Posterior Segment Exam OD: H/Ma (≥2A x 4Q), VB (=1Q), IRMA, No Vit Heme, No NVD, NVE (<½DA). Cotton wool spots. C/D=0.3, No ME. OS: H/Ma (≥2A x 4Q), VB (=1Q), IRMA, No Vit Heme, No NVD, NVE (<½DA). Cotton wool spots. Large area RPE hypopig at 4:00, flat. C/D=0.3, No ME.

  7. OD4/1/08

  8. OD4/1/08

  9. OD4/1/08

  10. OD4/1/08

  11. OD4/1/08

  12. OD4/1/08

  13. OD4/1/08

  14. OS4/1/08

  15. OS4/1/08

  16. OS4/1/08

  17. OS4/1/08

  18. OS4/1/08

  19. OS4/1/08

  20. OS4/1/08

  21. Previous Photos(8 months before)

  22. OD7/24/07

  23. OS7/24/07

  24. Diagnosis • Proliferative Diabetic Retinopathy <HRC OU • Poor glycemic control??? • Depression associated with eating disorders • HA1c during 1/05 to 6/07  8.6 – 10.4 range • Early worsening of tight control??? • HA1c from 10.4 to 5.5 in 5 months • Interferon + Ribavirin Tx??? • Started around 7/07 (9 months before) • Multifactorial???

  25. Interferon + Ribavirin combination therapy is FDA approved for Chronic Hepatitis C Interferon Immunomodulating agent with direct antiviral activity in cell culture. Antiproliferative properties. Antiangiogenic activities. Ribavirin Orally active synthetic guanosine analog that inhibits both DNA and RNA virus replication in vitro. Theoretical immunomodulating actions. Alone has no effect on the HCV.

  26. Interferon associated retinopathy CWS, retinal hemes and microvascular abnormalities Posterior pole and around the ON head Transient Association of therapy with development of retinal ischemic changes Risk factors – are still unclear Monotherapy  DM and age Comb therapy  DM, HTN and response to tx

  27. References Chiaki O, Hiroshi Y, Yoshihiko N, et al. Risk factors for retinopathy associated with interferon α-2b and ribavirin combination therapy in patients with chronic hepatitis C. World J Gastroenterol 2006 June 21; 12(23): 3756-3759. Schulman JA, Liang C, Kooragayada LM, et al. Posterior Segment Complications in Patients with Hepatitis C Treated with Interferon and Ribavirin. Ophthalmology 2003; 110:437-442.

  28. Conclusion Ocular side effects are well recognized complications of interferon and ribavirin therapy for hepatitis C. Risk factors  DM and HTN Hypothesis – Ischemic mechanisms?? Deposition of immune complexes followed by lymphocyte infiltration in capillaries Increase leukocyte adherence to the endothelium High circulating levels of plasma-activated complement 5 (potent intravascular aggregator or platelets)

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