[indices] Cellcept and flying [3]

["Dr S Toovey" <toovey@travelclinic.co.za>]

Dear all

The guiding principle in certifying aviators fit to fly is whether they may
be prone to sudden incapacitation. 

Having had a transplant (which organ?) alone could affect ability to fly.
Common adverse effects recorded in patients taking mycophenolate include
nausea, vomiting, leukopaenia, anorexia, abdominal pain, diarrhoea, and
anaemia. All of the other factors mentioned above (and these are only some of them) are problems make it difficult to see how the safety of the aircraft,its occupants, and those on the ground could be assured.

With regard to mycophenolate and vision, an association with macula oedema
and loss of vision is reported.

The following was presented at the Deutsche Ophthalmologische Gesellschaft
Berlin 2002 meeting.
Bilateral Visual Loss following Administration of Mycophenolate Mofetil: A
Case Report

1Kube T., 1Hansen L. L., 2Lagrhze W., 
1Albert-Ludwigs-Universitdt, Augenklinik (Freiburg)
2Albert-Ludwigs-Universitdt Freiburg, Augenklinik (Freiburg)

Purpose: Mycophenolate mofetil is a relatively new immunosuppressive drug
which is frequently used after organ transplantation. We herein report the
first case of bilateral visual loss after administration of mycophenolate
mofetil. 
Method: Case report of a 52-year old patient who was referred to us by the
medical department with bilateral visual loss in October 2001. Suffering
from dilative cardiomyopathy, the patient underwent a heart transplantation
one year ago, which was followed by a course of cyclosporine and
azathioprine. At the end of September 2001, elevated uric acid levels
prompted a change from azathioprine to mycophenolate mofetil in order to
initiate a therapy with allopurinol. 
Results: At the initial presentation visual acuity was decreased to 0.5 OD
and 0.63 OS. Furthermore, a bilateral hyperopia of 1.75 dpt had developed.
Visual field examination revealed a bilateral relative central scotoma. The
macula was indistinct but gray, and fluorescein and indocyanine-green (ICG)
angiography demonstrated a small cystoid macula edema (CME). The central
scotoma diminished within the next four weeks, visual acuity, however, did
not recover. Multifocal electroretinogram (mf-ERG) examination, performed
eight weeks after initial presentation showed extended bilateral functional
deterioration. Therapy with acetazolamide led to a reduction of the macular
edema, visual acuity and photoreceptor function however did not recover. 
Conclusions: The present case demonstrates that the use of mycophenolate
mofetil may result in cystoid macular edema and loss of photoreceptor
function. Moreover, it underlines the importance of angiography and mf-ERG,
especially when a CME is not clearly detectable by routine ophthalmoscopy,
as it was the case in our patient. Pathogenesis and prevalence of the
observed side effects of mycophenolate mofetil are as yet unknown and
warrant further studies. 

Dr Stephen Toovey 
MBBCh, CTM, FACTM, FFTM
Aviation medical examiner