Blepharitis and Dry eyes in Aromatase Inhibitor Users Kiran Turaka, M.D. Kristin M. Hammersmith, M.D. Jennifer M. Nottage, M.D. Christopher J. Rapuano,

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Blepharitis and Dry eyes in Aromatase Inhibitor Users Kiran Turaka, M.D. Kristin M. Hammersmith, M.D. Jennifer M. Nottage, M.D. Christopher J. Rapuano, M.D. Wills Eye Institute, Philadelphia PA The authors have no financial interest in the subject matter of this e-poster in the subject matter of this e-poster

Introduction Anastrazole (Arimidex®) Aromatase inhibitor (AI), suppress estrogen synthesis from androgens Aromatase inhibitor (AI), suppress estrogen synthesis from androgens Used as an adjuvant therapy in breast/ovarian cancer treatment Used as an adjuvant therapy in breast/ovarian cancer treatment Ocular side effects of AI’s: retinal hemorrhages, visual disturbances, hemiretinal artery occlusion Androgen deficiency has been linked to meibomian gland dysfunction Picture courtesy www. medscape.com

Purpose Few studies reported the higher prevalence of moderate to severe dry eye syndrome in older women Few studies reported the higher prevalence of moderate to severe dry eye syndrome in older women None of the studies noted the prevalence of ocular surface symptoms and signs among AI users We observed that several patients who presented with dry eye symptoms were using anastrazole Investigation of an association between anastrazole and dry eye syndrome Investigation of an association between anastrazole and dry eye syndrome

Methods Retrospective chart review Retrospective chart review Computerized search of Wills Cornea Service electronic health records between from August 2008 to April 2010 for patients on Anastrazole Computerized search of Wills Cornea Service electronic health records between from August 2008 to April 2010 for patients on Anastrazole Results were compared with the age-matched controls from a published study by Schaumberg et al. 1 Results were compared with the age-matched controls from a published study by Schaumberg et al. 1 1 Schaumberg DA, Sullivan DA, Buring JE, Dana MR. Prevalence of dry eye syndrome among US women. Am J Ophthalmol 2003; 136:

Results Total patients on anastrazole: 16 Caucasian women Total patients on anastrazole: 16 Caucasian women Breast cancer: 15 (94%) Breast cancer: 15 (94%) Ovarian cancer: 1 (6%) Ovarian cancer: 1 (6%) Treatment of Primary Cancer: Treatment of Primary Cancer: Surgery:9 (56%) Surgery: 9 (56%) Chemotherapy: 4 (25%) Chemotherapy: 4 (25%) Radiotherapy: 2 (13%) Radiotherapy: 2 (13%) Mean ± SD age: 67 ± 13 years (range 50-95) Mean ± SD age: 67 ± 13 years (range 50-95)

Medical conditions Diabetes mellitus: 5 (31%) Hypertension: 5 (31%) Hyperthyroidism: 2 (13%) Hypercholesterolemia: 1 (6%) Cardiac arrhythmia: 1 (6%)

Ocular disorders at presentation and treatment* Dry eyes: 6 (38%) Glaucoma: 5 (31%) Blepharitis: 4 (25%) Fuch’s dystrophy: 4 (25%) Keratoconus: 2 (13%) PBK, ptosis (6%), fungal ulcer, chronic conjunctivitis: 1 (6%) each Tear supplement: 5 (31%) Anti-glaucoma: 5 (31%) Topical sodium Chloride: 3 (19%) No treatment: 3 (19%) Topical antibiotics: 2 (13%) Cyclosporine: 2 (13%) Anti allergic: 1 (6%) * Few patients had more than one condition at presentation and a combination of topical medications

Presenting Ocular Symptoms* Among the control population (65-69 years), dryness and irritation were found in 5.7% and 0.6% respectively. More than one symptom was found in 9.5% Among the control population (65-69 years), dryness and irritation were found in 5.7% and 0.6% respectively. More than one symptom was found in 9.5% * Few patients had more than one symptom Characteristic feature Total patients, N= 16 (%) Irritation/foreign body sensation 8 (50) Blurring vision 7 (44) Tearing 4 (25) Redness 2 (13) Prior Punctal plug use 2 (13) Asymptomatic Photosensitivity 1 (6)

Clinical Features Characteristic feature Total eyes, N= 32 (%) Blepharitis 25 (78) Decreased/poor tear film 16 (50) Superficial Punctate Keratitis 11 (34) Follicular injection 5 (17) Follicular reaction 5 (17) Corneal edema 2 (6) Iritis Ectropion/entropion 1 (3) Mean ± SD Schirmer test (median, range) mm 11 ± 5.8 (13, )

Slit lamp photograph showing blepharitis and crusts (A), and superficial punctate keratitis (B) on fluorescein staining

Treatment Tear supplement: 15 patients Tear supplement: 15 patients Lubricating ointment/gel: 3 patients Lubricating ointment/gel: 3 patients Antibiotic ointment: 3 patients Antibiotic ointment: 3 patients Punctal plugs: 2 patients Punctal plugs: 2 patients Cyclosporine (topical 0.05%): 2 patients Cyclosporine (topical 0.05%): 2 patients

Summary at the Last follow-up No. of patients at the follow up: 11 (69%) No. of patients at the follow up: 11 (69%) No of patients lost to follow up: 5 (31%) No of patients lost to follow up: 5 (31%) No of patients on Anastrazole: 10 (91%) No of patients on Anastrazole: 10 (91%) Mean ± SD follow-up: 14 ± 7.7 months (range 2-25) Mean ± SD follow-up: 14 ± 7.7 months (range 2-25) After treatment of dry eyes: After treatment of dry eyes: Improvement dry eye symptoms: 7 (64%) Improvement dry eye symptoms: 7 (64%) Persistent dry eye symptoms: 3 (27%) Persistent dry eye symptoms: 3 (27%) Mild discomfort: 1 (9%) Mild discomfort: 1 (9%) Tumor status: Tumor status: Remission of breast cancer: 9 (81%) Remission of breast cancer: 9 (81%) Remission of ovarian cancer: 1 (9%) Remission of ovarian cancer: 1 (9%) Systemic metastasis: 1 (9%) Systemic metastasis: 1 (9%)

Conclusions The prevalence of ocular surface disease appears to be higher in the patients taking anastrazole than in age- matched control population 1 The prevalence of ocular surface disease appears to be higher in the patients taking anastrazole than in age- matched control population 1 Anastrazole is likely a contributing factor to dry eye symptoms Anastrazole is likely a contributing factor to dry eye symptoms A larger scale investigation is necessary to evaluate this correlation further A larger scale investigation is necessary to evaluate this correlation further