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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 1 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 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 2 12/18/2012 ANTICOAGULANTS Indications: ANTI-ALLERGY AGENTS 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 Indications: ANTI-DEPRESSANTS Indications: Depression Migraine (off label use) RX for Epilepsy 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 Indications: Extreme Tension and Anxiety Xanax (Alprazolam) Valium (Diazepam) Ocular Side Effects: Blurred Vision Diplopia Mydriasis 3 12/18/2012 Antiarrhythmics Indications: Antiarrhythmics Congestive heart failure Amiodarone Digoxin (Digitek) Vortex Keratopathy Optic neuropathy Change in color vision Photophobia Flickering vision Anterior and posterior subcapsular lens changes Indications: Ocular Side Effects Diuretics 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 Ocular Side Effects: Dry eye by changing the tear film Myopic shift (rarely) Band keratopathy (rare) Avandia/Actos Indications: Diabetes. Increases sensitivity to insulin. Flomax (tamsulosin) Benign prostate hypertrophy 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 “Floppy Iris Syndrome” 4 12/18/2012 Video Tamoxifen citrate 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 Synthroid (Levothyroxine) 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. 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 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 5 12/18/2012 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: Bull’s-eye maculopathy 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 Prednisone Indications: To treat inflammatory and allergic conditions. Some examples include Lupus, rheumatoid arthritis, and other immune-mediated conditions They are very effective for acute disease states as well as chronic conditions Ocular Side Effects: Posterior subcapsular cataract Elevated IOP* Exacerbation of herpetic keratitis Papilledema Corticosteroids Cataracts resulting from steroid use are well known and occur with topical, systemic, and nasal administration. 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 6 12/18/2012 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 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 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. 7