Annals of Medicine and Surgery

Myopia in dermatological patients: There is more than meets the eye

--Manuscript Draft--

Manuscript Number:

Article Type: Short communication

Corresponding Author: Bisma Shaikh

Jinnah Sindh Medical University
PAKISTAN

First Author: Bisma Shaikh

Order of Authors: Bisma Shaikh

Moosa Ashfaq

Aayat Ellahi

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Cover Letter

To,
Riaz Agha,
Editor-in-Chief,
Annals of Medicine and Surgery
18th February 2023
Dear Editor,
I wish to submit my short communication entitled “Myopia in dermatological patients:
There is more than meets the eye” for consideration in your prestigious Annals of Medicine
& Surgery. We believe this manuscript is appropriate for publication because it emphasizes
effect of oral Isotretinoin therapy on myopia (nearsightedness) and raises awareness
amongst dermatologists and ophthalmologists. Myopia is currently the most widespread
cause of blindness in East Asian nations, and it will be prevalent in more countries in the
future. Hence, it is crucial to understand the scope and risk factors that will assist in disease
diagnosis, treatment, and prevention.
We have no conflicts of interest to report, and no funding has been made. I affirm that all of
the authors read and approved the manuscript and the contribution of each author has
been listed. Please forward all correspondence regarding this manuscript to me. This paper
has not been published and is not currently being considered for publication in another
journal. The author's instructions were carefully read and followed.
We shall look forward to hearing from you at your earliest convenience.
Sincerely,
Bisma Shaikh
Jinnah Sindh Medical University
bisma.shaikh1321@gmail.com
Title Page (including author details)

Myopia in dermatological patients: There is more than meets the eye

Authors and Affiliations

1) Bisma Shaikh
bisma.shaikh1321@gmail.com
Jinnah Sindh Medical University

2) Moosa Ashfaq
Moosanl30@gmail.com
Jinnah Sindh Medical University

3) Aayat Ellahi
Aayatellahi1@gmail.com
Jinnah Sindh Medical University

Corresponding Author:

Bisma Shaikh
Jinnah Sindh Medical University
Address: Kurrie Road, Clifton, Karchi, Karachi City, Sindh
Email: bisma.shaikh1321@gmail.com
Phone number: +923490211960
Manuscript without author details

Isotretinoin (13-CIS-RETINOIC ACID) is a synthetic counterpart of Vitamin A prescribed to

patients when diagnosed with treatment-resistant nodular and cystic acne vulgaris (1). It

functions by altering DNA transcription, affecting different stages of the cycle such as

differentiation and apoptosis, resulting in decreased size and production of sebaceous glands and

becoming an effective inhibitor of sebum secretion. (2, 3) This medication is beneficial in

treating and preventing the recurrence of resistant nodular and cystic acne, with a success rate of

approximately 90% (3). However, there is a widespread recognition that many medicines have

effects, some favorable and some of which are critical. According to a recent review, 3.4% of

patients taking Isotretinoin experienced ophthalmologic side effects. (4)

One of its reported side effects is myopia, an eye disorder that enables visual images to focus in

front of the retina, affecting the vision of distant objects. Early research did not clearly describe

the association of myopia in patients treated with Isoretinoin. However, a study highlighted that

13-cis-retinoic acid, an active constituents in Isotretinoin, activates metalloproteinase 9 resulting

in the degeneration of the cornea, making it a primary factor contributing to the development of

myopia. (3) According to a clinical trial on male acne patients given retinoid, such as Isoretinoin,

the development of the sclera and the differentiation of fibroblast into myofibroblast are both

impacted by a decrease in Transforming growth factor-beta (TGF-B), which occurs as myopia

develops. Myopia is brought on by an increase in collagen and a decrease in the production of

scleral collagen as a result of low TGF-B levels. (5)

Interestingly, the Food and Drug Administration (FDA) and the World Health Organization

(WHO) received 1741 reports of ocular adverse event. Out of approximately 2400 events with

Ocular Adverse Events, 3.57% reported refractive change with short sightedness is the most

common type of refractive error (1, 6). Furthermore, in a 2020 pilot study, forty-seven patients

with acne vulgaris were treated with Isotretinoin, while the rest were healthy controls. The

results concluded that Isotretinoin consumption for six months resulted in increased myopia and

axial length (2) Moreover, a female patient in her late 20s underwent laser-assisted in situ

keratomileusis (LASIK) to correct her myopia but only experienced a recurrence of

nearsightedness and blurred vision after being prescribed oral Isotretinoin therapy daily to treat

her chronic inflammatory acne vulgaris. (3). Similarly, while on oral Isotretinoin therapy for

acne, a 28-year-old woman also presented with a rare case of elevated intraocular pressure (IOP)

with transient bilateral angle closure and the myopic shift. However, IOP returned to normal two

weeks after ceasing oral Isotretinoin. (4) Lastly, a patient in his early 20’s was presented with

nodulocystic acne with a history of 10 years of stable myopia. He was prescribed 0.3 mg/kg oral

Isotretinoin for his acne. After two weeks, the patient began to notice blurred vision, which

worsened over time, and his myopia increased in both eyes (7).

Surprisingly, lack of health engagement regarding possible side effects and usage instructions of

Isotretinoin makes it difficult for an early diagnosis and can raise the possibility of negative

consequences(8). Due to this, the ophthalmologists and the dermatologists are unaware of this

side effect and fail to take a comprehensive history of previous eye complaints before prescribing

this drug. Considering this, it is important to prevent patients from developing extreme myopia.

T cater to this problem, public policies and therapies must be developed. For instance,

dermatologists should only prescribe oral therapy of Isotretinoin when required and confirm any
past surgical history of LASIK treatment. Additionally, a follow-up should be practiced

throughout Isotretinoin oral therapy. If a patient experiences ocular issues following oral

Isotretinoin treatment, a consultation should be considered necessary as it would help with an

early diagnosis and treatment of Isotretinoin ocular adverse effects.

References

1. Fraunfelder FT, Fraunfelder FW, Edwards R. Ocular side effects possibly associated with

isotretinoin usage. Am J Ophthalmol. 2001;132(3):299-305.

2. Yasar E, Gurlevik U, Kemeriz F, Atalay E. Effect of isotretinoin on myopia and axial

length: a pilot study. Cutan Ocul Toxicol. 2020;39(4):385-8.

3. Qureshi K, Tariq J, Chaudhry MS, Pasha F. Oral Isotretinoin Resulting in Recurrence of

LASIK-Treated Myopia: A Rare Side Effect. Cureus. 2021;13(8):e16884.

4. Park YM, Lee TE. Isotretinoin-induced Angle Closure and Myopic Shift. J Glaucoma.

2017;26(11):e252-e4.

5. Zhu X, Xu B, Dai L, Wang Z, Feng L, Zhao J. Association between TGF-β gene

polymorphism and myopia: A systematic review and meta-analysis. Medicine (Baltimore).

2022;101(30):e29961.

6. Pan CW, Ramamurthy D, Saw SM. Worldwide prevalence and risk factors for myopia.

Ophthalmic Physiol Opt. 2012;32(1):3-16.

7. Saraswat A. Sudden irreversible worsening of myopia with isotretinoin treatment. Indian

J Dermatol Venereol Leprol. 2011;77(5):611-2.

8. Jarab AS, Al-Azzam S, Almutairi S, Mukattash TL. Patients' Knowledge and Information

Needs about Isotretinoin Therapy Use in Jordan. Int J Clin Pract. 2022;2022:9443884.