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Coulter DM. et al. reported a temporary visual impairment after
taking Celecoxib, a new selective cyclooxygenase (COX)-1 inhibitor. A
possible mechanism for the visual impairment may be the inhibition of
prostaglandin synthesis, which usually increases blood flow and decreases
platelet aggregation by decreasing thromboxane A2 (TXA2) and prostaglandin
H2 (PGI2) [1]. This effect may also explain an elevated incidence of
myocardial infarction in patients taking rofecoxib compared to standard
NSAID therapy as reported in the Vioxx Gastrointestinal Outcomes research
(VIGOR) trial [2]. We recently reported a patient who developed a central
retinal vein occlusion (CRVO) taking rofecoxib [3]. In this report we
describe a second patient who developed branch retinal vein occlusion
(BRVO) after taking rofecoxib.
A 69-years year old white female with severe OA started treatment with
25mg rofecoxib daily for her increasing hip pain. On the second day she
noticed unwellness and marked deterioration of her vision right eye and
her visual acuity decreased to 20/400. Ophthalmic examination
demonstrated dilated and tortuous retinal veins and numerous flame-shaped
hemorrhages in the superior hemisphere. Intravenous angiography disclosed
almost no perfusion of the superior retinal vein consistent with a BRVO.
She had no other risk factors for ocular or systemic thrombosis and did
not take any other drug.
BRVO are among the most common vascular retinal diseases and occur usually
at the crossing of the arteriolar and venous vessels. Because retinal
vessels have no collaterals, any occlusion induces non-drainage of blood
in the corresponding area leading to ischemia and decreased vision.
Rofecoxib may induce imbalance of TXA2 and PGI2, and therefore trigger
spontaneous thrombosis at predisposed locations. Knockout mice, lacking
PGI2 receptors, developed after an intravasal injury an increased TXA2
biosynthesis and thrombus formation[4].
Although the precise role of COX-2 and its relation prostaglandins remains
to be elucidated; it is know that selective COX-2 inhibitors modulate the
vascular hemostasis. Based on relatice large number of reports with visual
distrubance associated with the use of COX-inhibitors, we agree with
Coulter’s conclusion, that the safety of rofecoxib needs to be
closely monitored concerning acute or permanent visual disturbances.
references
1. Coulter DM, Clark DWJ, Savage RL. Celecoxib, rofecoxib, and acute
temporary visual impairment. BMJ 2003;327:1214-1215.
2. Bombardier C, Laine L, Reicin A. et al. Comparison of upper
gastrointestinal toxicity of rofecoxib and naproxen in patients with
rheumatoid arthritis. VIGOR Study Group. N Engl J Med 2000;343:1520-1528.
3. Meyer CH, Gähler R. Central retinal vein occlusion (CRVO) in a patient
with rheumatoid arthritis treated with rofecoxib. Lancet 2002;360:110.
4. Cheng Y, Austin SC, Rocca B. et al. Role of prostacyclin in the
cardiovascular response to thromboxane A2. Science 2002;296:539-41.
Competing interests:
None declared
Editorial note The patient whose case is described has given her signed informed consent to publication.
Competing interests:
No competing interests
18 February 2004
Carsten H. Meyer
Department of Ophthalmology Philipps-University Marburg, Germany
Retinal vein occlusion in patients treated with rofecoxib (VIOXX)
Coulter DM. et al. reported a temporary visual impairment after
taking Celecoxib, a new selective cyclooxygenase (COX)-1 inhibitor. A
possible mechanism for the visual impairment may be the inhibition of
prostaglandin synthesis, which usually increases blood flow and decreases
platelet aggregation by decreasing thromboxane A2 (TXA2) and prostaglandin
H2 (PGI2) [1]. This effect may also explain an elevated incidence of
myocardial infarction in patients taking rofecoxib compared to standard
NSAID therapy as reported in the Vioxx Gastrointestinal Outcomes research
(VIGOR) trial [2]. We recently reported a patient who developed a central
retinal vein occlusion (CRVO) taking rofecoxib [3]. In this report we
describe a second patient who developed branch retinal vein occlusion
(BRVO) after taking rofecoxib.
A 69-years year old white female with severe OA started treatment with
25mg rofecoxib daily for her increasing hip pain. On the second day she
noticed unwellness and marked deterioration of her vision right eye and
her visual acuity decreased to 20/400. Ophthalmic examination
demonstrated dilated and tortuous retinal veins and numerous flame-shaped
hemorrhages in the superior hemisphere. Intravenous angiography disclosed
almost no perfusion of the superior retinal vein consistent with a BRVO.
She had no other risk factors for ocular or systemic thrombosis and did
not take any other drug.
BRVO are among the most common vascular retinal diseases and occur usually
at the crossing of the arteriolar and venous vessels. Because retinal
vessels have no collaterals, any occlusion induces non-drainage of blood
in the corresponding area leading to ischemia and decreased vision.
Rofecoxib may induce imbalance of TXA2 and PGI2, and therefore trigger
spontaneous thrombosis at predisposed locations. Knockout mice, lacking
PGI2 receptors, developed after an intravasal injury an increased TXA2
biosynthesis and thrombus formation[4].
Although the precise role of COX-2 and its relation prostaglandins remains
to be elucidated; it is know that selective COX-2 inhibitors modulate the
vascular hemostasis. Based on relatice large number of reports with visual
distrubance associated with the use of COX-inhibitors, we agree with
Coulter’s conclusion, that the safety of rofecoxib needs to be
closely monitored concerning acute or permanent visual disturbances.
references
1. Coulter DM, Clark DWJ, Savage RL. Celecoxib, rofecoxib, and acute
temporary visual impairment. BMJ 2003;327:1214-1215.
2. Bombardier C, Laine L, Reicin A. et al. Comparison of upper
gastrointestinal toxicity of rofecoxib and naproxen in patients with
rheumatoid arthritis. VIGOR Study Group. N Engl J Med 2000;343:1520-1528.
3. Meyer CH, Gähler R. Central retinal vein occlusion (CRVO) in a patient
with rheumatoid arthritis treated with rofecoxib. Lancet 2002;360:110.
4. Cheng Y, Austin SC, Rocca B. et al. Role of prostacyclin in the
cardiovascular response to thromboxane A2. Science 2002;296:539-41.
Competing interests:
None declared
Editorial note
The patient whose case is described has given her signed informed consent to publication.
Competing interests: No competing interests