Download Common systemic medications and their ocular side effects

12/18/2012
Common systemic
medications and their ocular
side effects
Michael Maldonado, OD
Department of Surgery, Ophthalmology
Texas Tech University PLFSOM
El Paso, TX
• Objectives Discussed:
The purpose of this lecture is to
educate the Paraoptometric Assistant
on commonly prescribed systemic
medications that have a role on ocular
side effects
Basic Eye Anatomy
a) Basic Eye Anatomy
b) Optometric Assistant role
c) Work up
d) Systemic Medications
e) Questions
Basic Eye Anatomy
Anterior Segment
a)
b)
c)
d)
e)
Cornea
Sclera
Conjunctiva
Iris
Lens
Optometric Assistant Role
Many systemic drugs have reported
ocular and visual side effects that
impact patient management
Posterior Segment
a)
b)
c)
d)
Vitreous
Optic Nerve
Choroid
Retina
a) Macula
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12/18/2012
Optometric Assistant Role
As an Optometric
Assistant, it’s important to
be familiar with the
associated side effects
These can vary from
transient, mild to severe,
or may seriously threaten
vision
Optometric Assistant Role
Optometric Assistant Role
Pre-Testing Procedures:
• Case history**
• Visual acuity
• Preliminary testing techniques
•EOM’s
•Confrontation fields
•Pupils
• Color vision
• Stereo acuity
Work Up
Clinical Procedures:
• Corneal Topography
• AR/Automated Keratometry
• Tonometry
• Visual fields
• Sphygmomanometry
• Contact lenses
• Triage and first aid
• Special ocular procedures
• OCT
• Specular Microscopy
• HVF
Work Up
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The exam sequence begins with a case history**
A careful and detailed case history is critical to
reveal a patient’s medication history
This is an important part of the examination as it
can indicate what the problem may be even
before any testing is completed
HERE WE GO!
CASE HISTORY**
Chief Complaint
Visual and ocular history
General health history
ALL Medications
Allergies to medications
Family eye and medical histories
Occupational visual requirements
Recreational visual requirements
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ANTICOAGULANTS
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Indications:
ANTI-ALLERGY AGENTS
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 Alleviates allergic conditions of rhinitis, dermopathies,
 Prevents clot formation in atrial fibrillation and thrombosis
Aspirin
Coumadin (warfarin sodium)
Heparin
Plavix (clopidogrel)

Indications:
urticaria, and systemic allergies
 Claritin (Loratadine)
 Allegra (fexofenadine)
 Benadryl (Diphenhydramine HCl)

Sudafed
Singulair
Zyrtec
Ocular Side Effects:
 Mydriasis
 Dry Eye
○ Keratitis sicca
○ Contact lens intolerance
 Angle closure glaucoma or Narrow angle glaucoma
 Decreased accommodation and blurred vision
Ocular Side Effects:
 Subconjunctival and retinal hemorrhaging (less common)
 Recommend to be discontinued for a week prior to eye
surgery
ANTI-MIGRAINE AGENTS
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Indications:
ANTI-DEPRESSANTS
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Indications:
 Depression
 Migraine (off label use)
 RX for Epilepsy
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Topamax
 Ocular side effects
○ Diplopia
○ Acute Myopia 6-8 diopters ! (within 1st month)
○ Acute Closed Angle Glaucoma
○ Suprachoroidal Effusion
○ Dry Eyes
○ Sulfa Allergy
Prozac (fluoxetine)
Zoloft (sertraline)
Paxil (paroxetine)
Celexa (citalopram)
Effexor (venlafaxine hydrochloride)
Ocular Side Effects:
 Blurred vision (abnormal vision)
 Cycloplegia
 Photophobia
 Dry eye
ANTI-ANXIETY
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Indications:
 Extreme Tension and Anxiety
Xanax (Alprazolam)
Valium (Diazepam)
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Ocular Side Effects:
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Blurred Vision
Diplopia
Mydriasis
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Antiarrhythmics
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Indications:
Antiarrhythmics
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 Congestive heart failure
Amiodarone
Digoxin (Digitek)
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Vortex Keratopathy
Optic neuropathy
Change in color vision
Photophobia
Flickering vision
Anterior and posterior subcapsular lens changes
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Indications:
Ocular Side Effects
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Diuretics
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Indications:
 Treat angina including arrhythmias
11-25% of patients
Red-green color defects
Flickering or flashes of light, and colored spots
Snowy, hazy, or dimming vision
Yellow tinged vision (xanthopsia)
Antihyperlipidemics

 Thiazides or diuretics are often used to treat
Indications:
Patients with high cholesterol (Hyperlipidemia) are often
treated with antihyperlipidemic drugs
congestive heart failure and HTN
Hydrochlorothiazide (HCTZ)
LASIX
Mevacor (lovastatin)
Lipitor (atorvastatin)
Zocor (simvastatin)
Ocular Side Effects:
Pseudo-cystoid macular edema
Shows a high rate of lens opacities.
 20% experience dry eye
 Lid edema
 Blurred vision
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Ocular Side Effects:
 Dry eye by changing the tear film
 Myopic shift (rarely)
 Band keratopathy (rare)
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Avandia/Actos
Indications:
Diabetes. Increases sensitivity to insulin.
Flomax (tamsulosin)

 Benign prostate hypertrophy
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Indications:
Ocular Side Effects:
Macular edema
Ocular Side Effects:
 Loss of tone in iris dilator smooth muscle
causing poor pupil dilation/prolapse during
cataract surgery
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“Floppy Iris Syndrome”
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12/18/2012
Video
Tamoxifen citrate
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Indications:
 Breast cancer and reducing the incidence of breast cancer
among high-risk women
http://www.youtube.com/watch?v=
Te9wPFtWk6M

Ocular Side Effects:
○ Crystalline retinopathy
○ Treatment involves withdrawal of the drug as it is reversible
○ Ocular complications are rare (0.6%)
HORMONES
HORMONES
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Synthroid (Levothyroxine)
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Indications:
 Replaces thyroxin not produced by thyroid. In patients with reduced
thyroid function, its given for management of thyroxine levels. Synthetic
hormones are commonly prescribed for replacement therapy.
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Oral Contraceptives
estrogen or progesterone
Ocular Side Effects:
Diplopia
Visual Hallucinations
Ptosis
Paralysis of EOM
Hyperemia
Pseudotumor Cerebri (PTC)
*Side effects disappear with discontinuation of drug*
Oral Contraceptives
estrogen or progesterone
Indications: Pregnancy prevention
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Ocular Side Effects:
Dry Eye
Contact Lens Intolerance
Optic neuritis
Macular Edema
TIA (Transischemic attacks)
Pseudotumor cerebri
Microvascular complications like artery and venous occlusions are reported.
May be related to changes in retinal vasculature, enhanced platelet
adhesiveness, or increase in fibrinogen and clotting factors
Comments: retinal thrombosis, cardiovascular events
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DERMATOLOGIC AGENTS
Accutane (isoretinoin)
Indications:
This retinoid (a form of vitamin A) is used to treat psoriasis, cystic acne,
and various other skin conditions.
Ocular Side Effects:
 Deficiency of the normal lipid layer in the tear film
 Keratitis
 Pseudotumor cerebri
 Optic neuritis
 Night blindness
 Retinotoxicity
Antimalarials
Plaquenil (hydroxychloroquine)
Indications:
Treats malaria, rheumatoid arthritis, and lupus erythematosis
Ocular Side Effects:
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Bull’s-eye maculopathy
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Corneal deposits
This bull’s-eye maculopathy starts as fine pigmentary mottling within the macular area.
The end result can range from reduced vision to possible blindness
Comments:
A baseline exam should be performed before the patient starts treatment.
Eye exam including Fundus Photos, HVF-10 (red-white), OCT, Amsler grid, and color vision.
Fundus photos are excellent for documentation and useful for detecting subtle changes in pigmentation*
Along with artificial tears, treatment includes decreasing the dosage or
discontinuing the medication.
Annual eye exam recommended
ANNUAL EXAM!!
Corticosteroids
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Prednisone
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Indications:
To treat inflammatory and allergic conditions. Some examples include
Lupus, rheumatoid arthritis, and other immune-mediated conditions
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They are very effective for acute disease states as well as chronic
conditions
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Ocular Side Effects:
Posterior subcapsular cataract
Elevated IOP*
Exacerbation of herpetic keratitis
Papilledema
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Corticosteroids
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Cataracts resulting from steroid use are well
known and occur with topical, systemic, and nasal
administration.
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The etiology is unknown, but these drugs may
react with amino groups of crystalline lens fibers
causing protein complexes to aggregate
Corticosteroids
Fosamax
(alendronate/bisphosphonates)

If significant changes are noted, the
prescribing physician should be informed to
weigh the risk versus benefit of steroid
treatment.
Indications:
Osteoporosis treatment/prevention in men and women
normalization of the rate of bone turnover, significant increase in BMD
(bone mineral density) of the spine, hip, wrist and total body, and significant
reductions in the risk of vertebral (spine) fractures, wrist fractures, hip
fractures, and all non-vertebral fractures

*Steroid use is increases IOP. The incidence is
greater with topical versus systemic
administration
Ocular Side Effects:
 Blurred vision
 Hyperemia
 Anterior uveitis
 Episcleritis
 Scleritis

Careful evaluation of each patient, regardless
of duration or dosage is important
Comments: A dilated exam is recommended due to the multiple side
effects that may occur
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Interferons
(Intron A/Avonex/Pegasys)

Indications:
Used to treat hepatitis (HCV) & MS

Ocular Side Effects:
Ocular pain
Conjunctivitis
Cotton wool spots
Optic neuritis
Pronounced dry eye
ERECTILE DYSFUNCTION
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Indications:
 “Peepee not working” aka ED.
 It inhibits phosophodiesterase-5 (PDE-5) which results in vasodilation of
smooth muscle.
Viagra
Cialis
Staxyn
Stendra
Levitra
 Ocular Side Effects:
 Visual disturbances
 NAION
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Comments: Dilated Eye exam prior to treatment and 2-4
weeks after treatments
 Macular edema
 Blocks hyperpolarization of photoreceptors
 11% of patients on 100mg perceive a blue haze up to four hours
Summary
Many systemic drugs have reported ocular and
visual side effects that impact patient management
As an Optometric Assistant, It is important to be
familiar with the associated side effects which can
be mild and transient or may seriously threaten
vision
 A careful and detailed case history is important to
reveal a patient’s medication history
 The ocular and visual side effects from a patient’s
systemic medication can range from mild to severe.
 These side effects may or may not be serious
enough to warrant discontinuing treatment.
 Recognition of ocular and visual side effects is
important for prompt management to prevent and
minimize serious complications
 Familiarity with medications improves by routinely
paying attention to concomitant medications.
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