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Presumed fluoxetine maculopathy
Presunta maculopatía bilateral asociada a fluoxetina
N. Moreno Benito, P.B. Blasco Palacio
, I. Rodríguez García
Corresponding author
Servicio Oftalmología, Hospital de Basurto, Bilbao, Spain
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Moreno Benito, P.B. Blasco Palacio, I. Rodríguez García" "autores" => array:3 [ 0 => array:2 [ "nombre" => "N." "apellidos" => "Moreno Benito" ] 1 => array:4 [ "nombre" => "P.B." "apellidos" => "Blasco Palacio" "email" => array:1 [ 0 => "polblascozaragoza@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:2 [ "nombre" => "I." "apellidos" => "Rodríguez García" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio Oftalmología, Hospital de Basurto, Bilbao, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Presunta maculopatía bilateral asociada a fluoxetina" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 735 "Ancho" => 2007 "Tamanyo" => 215467 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Macular OCT: alteration of the ellipsoid with disruption of this layer in both eyes. (B) Macular OCT: progressive enhancement of the reorganization of the outer retinal layers in both eyes.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The prescription of antidepressants has increased considerably in the last decade, with a preference for more current antidepressants, such as selective serotonin reuptake inhibitors (SSRIs).</p><p id="par0010" class="elsevierStylePara elsevierViewall">The ocular adverse effects described with SSRIs are: dry eye, decreased accommodation and blurred vision (especially when taking paroxetine), mydriasis, acute glaucoma due to angle closure, optic neuropathy and maculopathy (described when taking sertraline).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> No cases of maculopathy have been published to date for fluoxetine, although it shares the same mechanism of action as sertraline.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case presentation</span><p id="par0015" class="elsevierStylePara elsevierViewall">Male, 49, Caucasian, diagnosed with obsessive-compulsive disorder (OCD) who was prescribed 10 mg of fluoxetine (Prozac® ) by his psychiatrist. Fifteen days from the start of treatment he reported visual symptoms, exhibiting decreased distant visual acuity, difficulty in focusing, central scotoma in the left eye (LE), mydriasis in both eyes (BE) and decreased color saturation. The patient took the medication for 3 months, visual symptoms persisted and decided to abandon the treatment. Within 5 days of stopping treatment he began noticing improvement in symptoms.</p><p id="par0020" class="elsevierStylePara elsevierViewall">One month later, the patient attended ophthalmology consultations and underwent the following visual examination: VA BE 1.0 with correction, Goldman IOP tonometer 16/18 mmHg, anterior pole without relevant findings, normoreactive isochoric pupils, contact gonioscopy showed open angle grade IV, and in BE fundus there was a change in macular coloration (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). As for complementary tests, Ishihara 17/17 test was performed without alterations, optical coherence tomography (OCT) Heidelberg Spectralis CFNr without alterations, OCT CG without alterations, FAF-blue Heidelberg Spectralis without alterations (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), CV 24-2 Sita Fast Humphrey Visual Field testing showed no scotomas or other type of alteration and VEP within normal limits, highlighting in the macular OCT alteration of the ellipsoid in BE with disruption of this layer (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>A). In the follow-up visits, macular OCT was performed, showing a progressive improvement of the reorganization of the outer retinal layers in BE (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>B).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Regarding patient history, he was in psychiatric treatment for OCD with quetiapine 150 mg every 24 h, lormetazepam 2 mg every 24 h and had recently started fluoxetine 10 mg every 24 h. He does not present other diseases or take other treatments. Given the macular OCT findings, we questioned the patient several times about taking Popper, sildenafil and similar substances, which the patient denied. We also questioned about sunlight intake, and the patient admitted to having sunbathed in the summer months with filter 2 goggle protection, but without prolonged or direct exposure. In addition, we did not observe vitreomacular traction on OCT that could cause lesions similar to those present in this case. No cases of maculopathy have been reported with quetiapine or lormetazepam or similar drugs of the same family.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">To date, this is the only published case of maculopathy caused by fluoxetine that we are aware of. At present there are 8 published cases of sertraline-induced maculopathy,<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–4</span></a> 3 of them recently published in a case series.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The changes found in the macular OCT of the present case are almost identical to those reported in the sertraline maculopathy cases by Javidi et al.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The latter, together with the fact that sertraline and fluoxetine share the same mechanism of action, suggests that we may be dealing with maculopathy caused by SSRIs. In June 2019, the European Medicines Agency (EMA) added new adverse reactions of sertraline: maculopathy, vision of spots in front of the eyes, irregular pupils, visual disturbances and partial loss of vision, among others.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In view of the unusual case, possible pathologies presenting the same characteristics were ruled out in the OCT, which were phototoxicity, taking Popper, taking sildenafil and similar, and, finally, vitreomacular traction. The OCT ruled out this last option, and in the exhaustive anamnesis performed on the patient, he denied the intake of the aforementioned substances and prolonged exposure to laser or unprotected sunlight.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Although more case series and research are needed to ensure that both sertraline and fluoxetine can cause maculopathy, the temporal sequence of events and the subjective and objective improvement of the lesions after cessation of treatment indicate that they are a likely cause. Therefore, health care professionals should be attentive to ophthalmological symptoms for which patients treated with SSRIs consult and even ask about their appearance during follow-up visits. The case presented has been reported to the Spanish Agency of Medicines and Health Products (AEMPS).</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflict of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">No conflicts of interest were declared by the authors.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Informed consent</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors have obtained informed consent for the publication of the images.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres2214466" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1856569" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2214465" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1856570" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case presentation" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of interest" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Informed consent" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2024-01-19" "fechaAceptado" => "2024-03-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1856569" "palabras" => array:6 [ 0 => "Fluoxetine" 1 => "Maculopathy" 2 => "Disruption" 3 => "SSRIs" 4 => "OCT" 5 => "Outer retinal layer" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1856570" "palabras" => array:6 [ 0 => "Fluoxetina" 1 => "Maculopatía" 2 => "Disrupción" 3 => "ISRS" 4 => "OCT" 5 => "Capas externas de la retina" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">To report a unique case of a patient who developed simultaneous bilateral maculopathy presumed from intake of fluoxetine. The optic coherence tomography (OCT) macular showed a subfoveal disruption in the outer retinal layer in both eyes (OU), higher in the left one (OS). Although reported cases of serotonin recapture inhibitors (SSRIs) Maculopathy so far have been caused by sertraline, fluoxetine shares the biological mechanism, and OCT findings and ocular symptoms are the same as published. We should be aware with ocular symptoms in patients that take fluoxetine.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Presentamos el caso único de un paciente con maculopatía bilateral tras la toma de fluoxetina. En la tomografía de coherencia óptica (OCT) macular se observa una disrupción en la capa de elipsoides a nivel subfoveal en ambos ojos (AO), mayor en ojo izquierdo (OI). Aunque los casos reportados de maculopatía por Inhibidores de la recaptación de serotonina (ISRS) hasta ahora han sido causados por sertralina, la fluoxetina comparte el mismo mecanismo de acción y los hallazgos en la OCT macular del paciente presentado y sus síntomas coinciden con los publicados en los casos de maculopatía por sertralina. Por ello debemos estar atentos a los síntomas oftalmológicos que pudieran tener los pacientes que están en tratamiento con fluoxetina y realizarles una exploración oftalmológica.</p></span>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 377 "Ancho" => 755 "Tamanyo" => 50646 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Macular coloration changes.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 373 "Ancho" => 755 "Tamanyo" => 61247 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">FAF autofluorescence Heidelberg Spectralis without alterations.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 735 "Ancho" => 2007 "Tamanyo" => 215467 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Macular OCT: alteration of the ellipsoid with disruption of this layer in both eyes. 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