Branch Retinal Vein Occlusion During Fingolimod Treatment in a Patient With Multiple Sclerosis

Abstract

Fingolimod (FTY720; Novartis) is a new oral drug that acts as a superagonist of the sphingosine-1-phosphate-1 receptor on thymocytes and lymphocytes, sequestering these cells in lymph nodes (1). This medication has been shown to be effective in the management of multiple sclerosis (2,3). The most frequent adverse events reported with fingolimod are nasopharyngitis, influenza, and headache, but cases of arterial vasospasm (4) and reversible cystoid macular edema (5) have also been described. A 47-year-old woman with a 9-year history of multiple sclerosis, who had been treated with fingolimod for the past 6 years, complained of sudden visual loss in her left eye. Visual acuity was 20/20 in the right eye and 20/40 in the left eye. Anterior segment evaluation was unremarkable. The right fundus was normal while a superotemporal branch retinal vein occlusion was noted in the left eye (Fig. 1). Spectral-domain optical coherence tomography (SD-OCT) revealed the presence of intraretinal cystic changes and thickening of the superior nasal macula with foveal involvement (Fig. 2A). The central foveal thickness measured 396 μm. Fluorescein angiography showed the blocking effect of the intraretinal hemorrhages and an area of delayed choroidal filling (Fig. 2B). There was no evidence of retinal vasculitis. Fingolimod was discontinued, and an intravitreal injection of ranibizumab (Lucentis; Novartis) was administered. A thorough evaluation for a coagulation disorder was conducted, but no significant abnormality was detected. The presence of cardiovascular risk factors, such as smoking, arterial hypertension, or diabetes, was also excluded.FIG. 1: Left fundus showing a superotemporal branch retinal vein occlusion.FIG. 2: A. SD-OCT reveals superotemporal macular thickening (top) with intraretinal cystic spaces (bottom). B. Top, fluorescein angiography is consistent with a superotemporal branch retinal vein occlusion and an area of delayed choroidal filling (arrows); bottom, choroid fills late in the angiogram.Three weeks later, vision was 20/20 in the left eye and the SD-OCT showed normalization of the foveal contour without cystic spaces and a mild superonasal macular thickening (Fig. 3).FIG. 3: Three weeks after an intravitreal injection of ranibizumab, there was a near-complete resolution of retinal edema.We are not aware of any previous reports of retinal vein occlusion in patients treated with fingolimod. Although we cannot prove a causal relationship between fingolimod and retinal vein occlusion, we believe that this drug should be considered in the diagnostic algorithm of patients with this retinal vascular disorder. Roberto Gallego-Pinazo, MD Enrique España-Gregori, MD Bonaventura Casanova, MD Diamar Pardo-López, MD Manuel Díaz-Llopis, PhD, MD New University and Polytechnic Hospital La Fe and University of Valencia Valencia, Spain [email protected]