Corneal deposits and Achilles tendonitis

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

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This is a unique relationship in arthritis.

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1.Fluoroquinolone antibiotics. These antibiotics have been associated with spontaneous rupture of the Achilles tendon as well as corneal deposits.

BMC Ophthalmol. 2003; 3: 10.
Published online 2003 October 6.
Copyright © 2003 Reviglio et al; licensee BioMed Central Ltd. This is an Open Access article: verbatim copying and redistribution of this article are permitted in all media for any purpose, provided this notice is preserved along with the article's original URL.

Effect of topical fluoroquinolones on the expression of matrix metalloproteinases in the cornea
Victor E Reviglio,1 Melinda A Hakim,1 Jae K Song,1 and Terrence P O'Brien 1
1Ocular Microbiology and Immunology Laboratory, Refractive Surgery Research Laboratory, The Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, USA
Corresponding author.
Victor E Reviglio:; Melinda A Hakim:; Jae K Song:; Terrence P O'Brien:
Received April 23, 2003; Accepted October 6, 2003.

Matrix metalloproteinases play an important role in extracellular matrix deposition and degradation. Based on previous clinical observations of corneal perforations during topical fluoroquinolone treatment, we decided to evaluate the comparative effects of various fluoroquinolone eye drops on the expression of matrix metalloproteinases (MMPs) in cornea.

Eighty female Lewis rats were divided into two experimental groups: intact and wounded corneal epithelium. Uniform corneal epithelial defects were created in the right eye with application of 75% alcohol in the center of the tissue for 6 seconds. The treatment groups were tested as follows: 1) Tear drops: carboxymethylcellulose sodium 0.5 % (Refresh, Allergan); 2) Ciprofloxacin 0.3% (Ciloxan, Alcon); 3) Ofloxacin 0.3%(Ocuflox, Allergan); 4) Levofloxacin 0.5%(Quixin, Santen). Eye drops were administered 6 times a day for 48 hours. Rats were sacrificed at 48 hours. Immunohistochemical analysis and zymography were conducted using antibodies specific to MMPs-1, 2, 8 and 9.

MMP-1, MMP-2, MMP-8 and MMP-9 expression were detected at 48 hrs in undebrided corneal epithelium groups treated with the topical fluoroquinolones. No statistical difference was observed in quantitative expression of MMPs among ciprofloxacin 0.3%, ofloxacin 0.3%, levofloxacin 0.5%. When the artificial tear group and the fluoroquinolone groups with corneal epithelial defect were compared, increased expression of MMPs was observed as a result of the wound healing process. However, the fluoroquinolone treated group exhibited high statistically significantly levels of MMPs expression.

Our study provides preliminary evidence that topical application of fluoroquinolone drugs can induce the expression of MMP-1, MMP-2, MMP-8 and MMP-9 in the undebrided corneal epithelium compared to artificial tear eye drops.

Keywords: Fluoroquinolones, Levofloxacin, Ciprofloxacin, Ofloxacin, Matrix metalloproteinases, Cornea

Kahn F, Christensson B.[A rapid development of Achilles tendon rupture following quinolone treatment]Lakartidningen. 2004 Jan 15;101(3):190-1. Swedish. No abstract available. PMID: 14763088 [PubMed - indexed for MEDLINE]

6 [No authors listed]Antibiotics: Achilles' heel of the Achilles' tendon.Harv Health Lett. 2004 Jan;29(3):7. No abstract available. PMID: 14734287 [PubMed - indexed for MEDLINE]

7 Pouzaud F, Bernard-Beaubois K, Thevenin M, Warnet JM, Hayem G, Rat P.In vitro discrimination of fluoroquinolones toxicity on tendon cells: involvement of oxidative stress.J Pharmacol Exp Ther. 2004 Jan;308(1):394-402. Epub 2003 Oct 20. PMID: 14569066 [PubMed - indexed for MEDLINE]

8 Rodriguez-Vera FJ, Pereira Vega A, Pujol de la Llave E.[Tendinitis by quinolones: treatment and drug class effect in two new cases]Rev Clin Esp. 2004 Jan;204(1):35-6. Spanish. No abstract available. PMID: 14746761 [PubMed - indexed for MEDLINE]

9 Burkhardt O, Kohnlein T, Pap T, Welte T.Recurrent tendinitis after treatment with two different fluoroquinolones.Scand J Infect Dis. 2004;36(4):315-6. PMID: 15198194 [PubMed - indexed for MEDLINE]

2.Patients with famililal hyperlipidemia (an abnormality of cholesterol metabolism) may develop deposits of cholesterol in the tendons(called xanthomas) along with a peculiar ring around the iris of the eye called arcys senilis.

This combination is usually found in patients who have the trait for this problem inherited from both parents. This is called Homozygous Familial Hyperlipidemia.

These patients may have cutaneous xanthomas at birth or by early childhood.

Several types of xanthomas are usually apparent in the first decade of life, and they include (1) planar xanthomas (on hands, elbows, buttocks, or knees), which are diagnostic for the homozygous state and are distinct from other cutaneous xanthomas because of their yellow-to-orange color; (2) tuberous xanthomas (on hands, elbows, or knees); and (3) tendon xanthomas (especially on the extensor tendons of the hands or Achilles tendon).

Children may have corneal arcus. While common in older adults with normal cholesterol levels, corneal arcus is highly unusual in children, and this finding should prompt a workup for this disorder.

Aortic stenosis - narrowing of the aortic valve due to cholesterol deposits may also be present.

3.Fabry’s disease, a glycogen storage disease- another metabolic disease- is also associated with corneal deposits and Achilles tendon issues. In the bones and joints, there are distal interphalangeal joint contractures, lymphedema, bone formation at tendon insertion sites, joint and bone erosions, bone pain, and avascular necrosis of the bone. In the eyes, corneal opacities similar to those observed during hydroxychloroquine therapy.

4.Patients with rheumatoid arthritis, psoriatic arthritis, Reiter’s disease and other forms of inflammatory arthritis who were treated with high doses of gold salts or hydroxychloroquine could possibly experience both corneal deposits as well as Achilles tendonopathy.

For more information on tendonitis, visit our sister site Tendonitis and PRP

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