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THIOTHIXENE-INDUCED TOXIC MACULOPATHY Grace Lim, OD Nadia Zalatimo, OD, FAAO Manchester VAMC, NH Abstract: Thiothixene is an antipsychotic medication similar to piperazine phenothiazines. Antipsychotic agents are retinotoxic and can produce blur, dyschromatopsia, constricted fields, abnormal ERG, nyctalopia, and pigment retinopathy. Regular eye examinations are important to identify early maculopathy. Outline: I. Case History a. Pt demographics: 62 year old white man b. Chief complaint: Decreased vision OS>OD c. Ocular history: Unremarkable d. Medical history: Schizophrenia, Hypertension, Hyperlipidemia Nicotine Dependency, Backache e. Medications: Thiothixene HCL 25mg, Lisinoprl 20mg, Nicotine Polacrilex 2mg, as needed f. Social history: Long history of smoking II. Pertinent Clinical Findings a. Clinical: Distance visual acuity: OD 20/40, OS 20/200, No improvement on pinhole Pupils: 3mm OD, OS, round, reactive, No APD Color vision: OD 9/14, OS 10/14 with Ishihara plates Biomicroscopy: Unremarkable OD, OS Goldmann Applanation Tonometry: OD:16.0 mmHg, OS:18.0 mmHg @ 1:00pm Dilated fundus examination: Lens: Trace Nuclear sclerosis OU Vitreous: Clear OU Optic Nerve: 0.25 with healthy rim tissue OD, OS Macula: OD: Juxtafoveal atrophy with hyperpigmentation involving the fovea OS: Diffuse, atrophic RPE changes No hemorrhage, fluid, exudate OD, OS Vessels: 2/3 A/V OU Periphery: flat and intact 360 degree OU b. Fundus photographs of macula OD, OS, as described above c. Fundus fluorescein angiography: Extensive RPE window defects with late staining OD, OS d. OCT: Extensive RPE window defects with no fluid OD, OS III. Differential diagnosis a. Primary: Toxic Maculopathy secondary to thiothixene b. Others: Gyrate atrophy, Bietti’s crystalline dystrophy, choroideremia, Age Related Macular Degeneration IV. Diagnosis and discussion a. Toxic Maculopathy secondary to thiothixene The fundus presentation of uniform, bilateral, diffuse pigmentary maculopathy in the context of a 30 year history of thiothixene use which was suggestive of toxicity. The patient has been treated for schizophrenia with thiothixene for more than 30 years. Further testing with FFA and OCT showed characteristic changes from medication toxicity. Such changes will be discussed and visually presented. V. Treatment, management a. Discontinuation of thiothixene was recommended b. Smoking cessation was advised c. ARED supplementation without beta carotene was recommended d. Daily monitoring with Amsler grid in each eye was recommended e. Blood pressure and cholesterol control was stressed f. Eye examination every 6 months was recommended g. Bibliography: Ryan, S.J. “Drug Toxicity of the Posterior Segment.” Retina, 4th ed., vol. 2, Philadelphia; Elsevier/Mosby, 2006:1839-1856. Gass, J. Donald. “Thioridazine (Mellaril) Retinopathy.” Stereoscopic Atlas of Macular Diseases: diagnosis and treatment. 4th ed., vol 2, St. Louis; Mosby, 1997:779 Toler, S.M. Oxidative stress plays an important role in the pathogenesis of drug-induced retinopathy. Exp.Biol.Med. (Maywood). 229:607-615, 2004. Toler, S.M. Invited review: fluphenazine augments retinal oxidative stress. J Ocul Pharmacol Ther. 21(4):259-265, 2005. Fornaro, P., Calabria, G.,Corallo, G., et al. Pathogenesis of degenerative retinopathy induced by thioridazine and other antipsychotics: A dopamine hypothesis. Doc. Ophthalmol. 105:41-49, 2002. Lee, M.S., and Fern, A.I. Fluphenazine and its toxic maculopathy. Ophthalmic Res. 36:237-239, 2004. Shah, G.K., Auerbach, D.B., Augsburger, J.J., Savino, P.J., Acute Thioridazine retinopathy. Arch Ophthalmol. 116(6):826-827, 1998. Borodoker, N., Del Priore, L.V., Carvalho, C.A., Yannuzzi, L.A., Retinopathy as a result of long-term use of Thioridazine. Arch Ophthalmol. Vol. 120:994-995, 2002. Blair, J.R., Mieler, W. F., Retinal toxicity associated with commonly encountered systemic agents. Int Ophthalmol Clin. 35(4):137-156, 1995. Kempen, J.H. Drug-induced maculopathy. Int Ophthalmol Clin. 39(4):67-82, 1999. VI. Conclusion: Optometrists should consider toxic maculopathy in patients taking antipsychotic medications in the phenothiazine-class. Such patients should have regular eye examinations including fundus photography to identify early toxic retinal changes and prevent vision loss from toxic maculopathy. Patients taking phenothiazine-related medications should be educated about potential retinal toxicity and advised to monitor for vision changes regularly with the amsler grid.