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UPDATE ON DRUGS AND THE EYE 1. LOCAL EFFECTS OF TOPICAL EYE MEDICATION UPDATE ON DRUGS AND THE EYE 1. LOCAL EFFECTS OF TOPICAL EYE MEDICATION 2. SYSTEMIC EFFECTS OF TOPICAL MEDICATION UPDATE ON DRUGS AND THE EYE 1. LOCAL EFFECTS OF TOPICAL EYE MEDICATION 2. SYSTEMIC EFFECTS OF TOPICAL MEDICATION 3. OCULAR EFFECTS OF SYSTEMIC MEDICATION OCULAR SURFACE TOXICITY • ALL PRESERVATIVES CAN BE DAMAGING OCULAR SURFACE TOXICITY • ALL PRESERVATIVES CAN BE DAMAGING • BAK IS FOUND IN MOST EYE DROPS AND IS A COMMON CAUSE OF EPITHELIAL TOXICITY ESPECIALLY WHERE MULTIPLE DAILY DROPS ARE REQUIRED ( E.G. GLAUCOMA ) OCULAR SURFACE TOXICITY • ALL PRESERVATIVES CAN BE DAMAGING • BAK IS FOUND IN MOST EYE DROPS AND IS A COMMON CAUSE OF EPITHELIAL TOXICITY ESPECIALLY WHERE MULTIPLE DAILY DROPS ARE REQUIRED ( E.G. GLAUCOMA ) • SOME TOPICAL AGENTS CAN CAUSE PUNCTATE KERATITIS E.G. TOBRAMYCIN, GENTAMICIN, ACULAR, ACYCLOVIR. EVEN DILATING DROPS CAN CAUSE THIS E.G. PRE-OP PHENYLEPHRINE OCULAR SURFACE TOXICITY • ALL PRESERVATIVES CAN BE DAMAGING • BAK IS FOUND IN MOST EYE DROPS AND IS A COMMON CAUSE OF EPITHELIAL TOXICITY ESPECIALLY WHERE MULTIPLE DAILY DROPS ARE REQUIRED ( E.G. GLAUCOMA ) • SOME TOPICAL AGENTS CAN CAUSE PUNCTATE KERATITIS E.G. TOBRAMYCIN, GENTAMICIN, ACULAR, ACYCLOVIR. EVEN DILATING DROPS CAN CAUSE THIS E.G. PRE-OP PHENYLEPHRINE • BEWARE “HIDDEN” PRESERVATIVE E.G. POVIDONE IN REFRESH BLISTER PACKS LOCAL EFFECTS OF TOPICAL MEDICATION 1. TOXIC EPITHELIOPATHY LOCAL EFFECTS OF TOPICAL MEDICATION 1. TOXIC EPITHELIOPATHY 2. ALLERGIC CONJUNCTIVITIS LOCAL EFFECTS OF TOPICAL MEDICATION 1. TOXIC EPITHELIOPATHY 2. ALLERGIC CONJUNCTIVITIS 3. SPECIFIC SIDE EFFECTS ALLERGIC CONJUNCTIVITIS • ALLERGY TO CHLORAMPHENICOL DROPS AND OINTMENT IS COMMON BUT IT CAN BE SEEN WITH OTHER ANTIBIOTICS SUCH AS SOFRAMYCIN ALLERGIC CONJUNCTIVITIS • ALLERGY TO CHLORAMPHENICOL DROPS AND OINTMENT IS COMMON BUT IT CAN BE SEEN WITH OTHER ANTIBIOTICS SUCH AS SOFRAMYCIN • I HAVE ALSO SEEN ALLERGY TO AZOPT ON OCCASIONS ALLERGIC CONJUNCTIVITIS • ALLERGY TO CHLORAMPHENICOL DROPS AND OINTMENT IS COMMON BUT IT CAN BE SEEN WITH OTHER ANTIBIOTICS SUCH AS SOFRAMYCIN • I HAVE ALSO SEEN ALLERGY TO AZOPT ON OCCASIONS • ALPHAGAN ALLERGY IS VERY COMMON AND OFTEN APPEARS AROUND 6 MONTHS PURITE AS THE PRESERVATIVE ( ALPHAGAN P ) MAY REDUCE THE INCIDENCE AS MAY COMBINING A TOPICAL β BLOCKER ( E.G. COMBIGAN ) SPECIFIC SIDE EFFECTS OF TOPICAL AGENTS PROSTAGLANDINS CAUSE CONJUNCTIVAL HYPERAEMIA, INCREASED IRIS PIGMENTATION, LASH GROWTH AND INCREASED LOWER LID SKIN PIGMENTATION INCIDENCE XALATAN < TRAVATAN < LUMIGAN SPECIFIC SIDE EFFECTS OF TOPICAL AGENTS PROSTAGLANDINS CAUSE CONJUNCTIVAL HYPERAEMIA, INCREASED IRIS PIGMENTATION, LASH GROWTH AND INCREASED LOWER LID SKIN PIGMENTATION INCIDENCE XALATAN < TRAVATAN < LUMIGAN PILOCARPINE CAUSES CHRONIC PUPILLARY MIOSIS WITH LONG TERM USE SPECIFIC SIDE EFFECTS OF TOPICAL AGENTS PROSTAGLANDINS CAUSE CONJUNCTIVAL HYPERAEMIA, INCREASED IRIS PIGMENTATION, LASH GROWTH AND INCREASED LOWER LID SKIN PIGMENTATION INCIDENCE XALATAN < TRAVATAN < LUMIGAN PILOCARPINE CAUSES CHRONIC PUPILLARY MIOSIS WITH LONG TERM USE TOPICAL STEROID FOR LONGER THAN 3 WEEKS CAN CAUSE SECONDARY OCULAR HYPERTENSION SPECIFIC SIDE EFFECTS OF TOPICAL AGENTS PROSTAGLANDINS CAUSE CONJUNCTIVAL HYPERAEMIA, INCREASED IRIS PIGMENTATION, LASH GROWTH AND INCREASED LOWER LID SKIN PIGMENTATION INCIDENCE XALATAN < TRAVATAN < LUMIGAN PILOCARPINE CAUSES CHRONIC PUPILLARY MIOSIS WITH LONG TERM USE TOPICAL STEROID FOR LONGER THAN 3 WEEKS CAN CAUSE SECONDARY OCULAR HYPERTENSION 30% OF THE POPULATION ARE STEROID RESPONDERS SPECIFIC SIDE EFFECTS OF TOPICAL AGENTS PROSTAGLANDINS CAUSE CONJUNCTIVAL HYPERAEMIA, INCREASED IRIS PIGMENTATION, LASH GROWTH AND INCREASED LOWER LID SKIN PIGMENTATION INCIDENCE XALATAN < TRAVATAN < LUMIGAN PILOCARPINE CAUSES CHRONIC PUPILLARY MIOSIS WITH LONG TERM USE TOPICAL STEROID FOR LONGER THAN 3 WEEKS CAN CAUSE SECONDARY OCULAR HYPERTENSION 30% OF THE POPULATION ARE STEROID RESPONDERS WEAKER STEROIDS SUCH AS FML HAVE LESS OCULAR PENETRATION AND ARE LESS LIKELY TO CAUSE THESE PROBLEMS SPECIFIC SIDE EFFECTS OF TOPICAL AGENTS PROSTAGLANDINS CAUSE CONJUNCTIVAL HYPERAEMIA, INCREASED IRIS PIGMENTATION, LASH GROWTH AND INCREASED LOWER LID SKIN PIGMENTATION INCIDENCE XALATAN < TRAVATAN < LUMIGAN PILOCARPINE CAUSES CHRONIC PUPILLARY MIOSIS WITH LONG TERM USE TOPICAL STEROID FOR LONGER THAN 3 WEEKS CAN CAUSE SECONDARY OCULAR HYPERTENSION 30% OF THE POPULATION ARE STEROID RESPONDERS WEAKER STEROIDS SUCH AS FML HAVE LESS OCULAR PENETRATION AND ARE LESS LIKELY TO CAUSE THESE PROBLEMS ALPHAGAN CAUSES CONJUNCTIVAL BLANCHING AND PUPIL CONSTRICTION SPECIFIC SIDE EFFECTS OF TOPICAL AGENTS PROSTAGLANDINS CAUSE CONJUNCTIVAL HYPERAEMIA, INCREASED IRIS PIGMENTATION, LASH GROWTH AND INCREASED LOWER LID SKIN PIGMENTATION INCIDENCE XALATAN < TRAVATAN < LUMIGAN PILOCARPINE CAUSES CHRONIC PUPILLARY MIOSIS WITH LONG TERM USE TOPICAL STEROID FOR LONGER THAN 3 WEEKS CAN CAUSE SECONDARY OCULAR HYPERTENSION 30% OF THE POPULATION ARE STEROID RESPONDERS WEAKER STEROIDS SUCH AS FML HAVE LESS OCULAR PENETRATION AND ARE LESS LIKELY TO CAUSE THESE PROBLEMS ALPHAGAN CAUSES CONJUNCTIVAL BLANCHING AND PUPIL CONSTRICTION IOPIDINE CAUSES CONJUNCTIVAL BLANCHING AND ENLARGED PUPIL SPECIFIC SIDE EFFECTS OF INTRAVITREAL DRUGS AVASTIN/LUCENTIS ARE ASSOCIATED WITH POSSIBLE INCREASED RISK OF CARDIOVASCULAR ADVERSE EFFECTS MAINLY STROKE AND MYOCARDIAL INFARCTION SYSTEMIC EFFECTS OF TOPICAL MEDICATION • β BLOCKERS CAN CAUSE ASTHMA AND BRADY CARDIA SYSTEMIC EFFECTS OF TOPICAL MEDICATION • β BLOCKERS CAN CAUSE ASTHMA AND BRADY CARDIA • α BLOCKERS MAY LOWER B P SYSTEMIC EFFECTS OF TOPICAL MEDICATION • β BLOCKERS CAN CAUSE ASTHMA AND BRADY CARDIA • α BLOCKERS MAY LOWER B P • CHLORAMPHENICOL – VERY RARE ASSOCIATION WITH APLASTIC ANAEMIA SYSTEMIC EFFECTS OF TOPICAL MEDICATION • β BLOCKERS CAN CAUSE ASTHMA AND BRADY CARDIA • α BLOCKERS MAY LOWER B P • CHLORAMPHENICOL – VERY RARE ASSOCIATION WITH APLASTIC ANAEMIA • PHENYLEPHRINE 10% MAY CAUSE TACHYCARDIA ± SYSTEMIC HYPERTENSION ( ESPECIALLY IN ELDERLY ) SYSTEMIC EFFECTS OF TOPICAL MEDICATION • β BLOCKERS CAN CAUSE ASTHMA AND BRADY CARDIA • α BLOCKERS MAY LOWER B P • CHLORAMPHENICOL – VERY RARE ASSOCIATION WITH APLASTIC ANAEMIA • PHENYLEPHRINE 10% MAY CAUSE TACHYCARDIA ± SYSTEMIC HYPERTENSION ( ESPECIALLY IN ELDERLY ) • CYCOGYL DROPS CAN BE ASSOCIATED WITH DROWSINESS AND RARELY WITH AGITATION SYSTEMIC EFFECTS OF TOPICAL MEDICATION • β BLOCKERS CAN CAUSE ASTHMA AND BRADY CARDIA • α BLOCKERS MAY LOWER B P • CHLORAMPHENICOL – VERY RARE ASSOCIATION WITH APLASTIC ANAEMIA • PHENYLEPHRINE 10% MAY CAUSE TACHYCARDIA ± SYSTEMIC HYPERTENSION ( ESPECIALLY IN ELDERLY ) • CYCOGYL DROPS CAN BE ASSOCIATED WITH DROWSINESS AND RARELY WITH AGITATION • ATROPINE DROPS MAY ALSO CAUSE SYSTEMIC SIDE EFFECTS ESPECIALLY IN YOUNG CHILDREN LOCAL OCULAR EFFECTS OF SYSTEMIC DRUGS • PLAQUENIL: – AVIDLY BOUND TO RPE AND CAN CAUSE MACULAR TOXICITY LOCAL OCULAR EFFECTS OF SYSTEMIC DRUGS • PLAQUENIL: – • AVIDLY BOUND TO RPE AND CAN CAUSE MACULAR TOXICITY PREDNISONE: – CAN BE ASSOCIATED WITH PSCC AND NUCLEAR SCLEROTIC CATARACT LOCAL OCULAR EFFECTS OF SYSTEMIC DRUGS • PLAQUENIL: – • • AVIDLY BOUND TO RPE AND CAN CAUSE MACULAR TOXICITY PREDNISONE: – CAN BE ASSOCIATED WITH PSCC AND NUCLEAR SCLEROTIC CATARACT FLOMAXTRA: – – – – DIFFICULT CATARACT SURGERY LOSS OF IRIS TONE POOR PUPIL DILATATION PROGRESSIVE MIOSIS DURING OP LOCAL OCULAR EFFECTS OF SYSTEMIC DRUGS • PLAQUENIL: – • • PREDNISONE: – CAN BE ASSOCIATED WITH PSCC AND NUCLEAR SCLEROTIC CATARACT FLOMAXTRA: – – – – • AVIDLY BOUND TO RPE AND CAN CAUSE MACULAR TOXICITY DIFFICULT CATARACT SURGERY LOSS OF IRIS TONE POOR PUPIL DILATATION PROGRESSIVE MIOSIS DURING OP ANTICHOLINERGICS E.G. TRYPTANOL ANTI SPASMODICS: – – CAN PRECIPITATE AACG IN PREDISPOSED INDIVIDUALS CONFUSES DOCTORS AS THE TYPE OF GLAUCOMA IS NOT SPECIFIED IN PRODUCT INFORMATION LOCAL OCULAR EFFECTS OF SYSTEMIC DRUGS • PLAQUENIL: – • • PREDNISONE: – CAN BE ASSOCIATED WITH PSCC AND NUCLEAR SCLEROTIC CATARACT FLOMAXTRA: – – – – • • AVIDLY BOUND TO RPE AND CAN CAUSE MACULAR TOXICITY DIFFICULT CATARACT SURGERY LOSS OF IRIS TONE POOR PUPIL DILATATION PROGRESSIVE MIOSIS DURING OP ANTICHOLINERGICS E.G. TRYPTANOL ANTI SPASMODICS: – – CAN PRECIPITATE AACG IN PREDISPOSED INDIVIDUALS CONFUSES DOCTORS AS THE TYPE OF GLAUCOMA IS NOT SPECIFIED IN PRODUCT INFORMATION – – RARE ASSOCIATION WITH ACUTE GLAUCOMA LOW SERUM K⁺ / BLOOD DISORDERS DIAMOX: LOCAL OCULAR EFFECTS OF SYSTEMIC DRUGS • PLAQUENIL: – • • PREDNISONE: – CAN BE ASSOCIATED WITH PSCC AND NUCLEAR SCLEROTIC CATARACT FLOMAXTRA: – – – – • • • AVIDLY BOUND TO RPE AND CAN CAUSE MACULAR TOXICITY DIFFICULT CATARACT SURGERY LOSS OF IRIS TONE POOR PUPIL DILATATION PROGRESSIVE MIOSIS DURING OP ANTICHOLINERGICS E.G. TRYPTANOL ANTI SPASMODICS: – – CAN PRECIPITATE AACG IN PREDISPOSED INDIVIDUALS CONFUSES DOCTORS AS THE TYPE OF GLAUCOMA IS NOT SPECIFIED IN PRODUCT INFORMATION – – RARE ASSOCIATION WITH ACUTE GLAUCOMA LOW SERUM K⁺ / BLOOD DISORDERS – CME AND LID OEDEMA DIAMOX: GLIVEC: PLAQUENIL TOXICITY THIS DRUG IS FAIRLY SAFE HIGHER RISK SEEN IN THE FOLLOWING: PLAQUENIL TOXICITY THIS DRUG IS FAIRLY SAFE HIGHER RISK SEEN IN THE FOLLOWING: 1. DOSE > 6.5mg/Kg OF IDEAL BODY WEIGHT PLAQUENIL TOXICITY THIS DRUG IS FAIRLY SAFE HIGHER RISK SEEN IN THE FOLLOWING: 1. DOSE > 6.5mg/Kg OF IDEAL BODY WEIGHT 2. DURATION OF TREATMENT > 10 YEARS PLAQUENIL TOXICITY THIS DRUG IS FAIRLY SAFE HIGHER RISK SEEN IN THE FOLLOWING: 1. DOSE > 6.5mg/Kg OF IDEAL BODY WEIGHT 2. DURATION OF TREATMENT > 10 YEARS 3. LIVER OR KIDNEY DISEASE ( REDUCED DRUG EXCRETION ) PLAQUENIL TOXICITY THIS DRUG IS FAIRLY SAFE HIGHER RISK SEEN IN THE FOLLOWING: 1. DOSE > 6.5mg/Kg OF IDEAL BODY WEIGHT 2. DURATION OF TREATMENT > 10 YEARS 3. LIVER OR KIDNEY DISEASE ( REDUCED DRUG EXCRETION ) 4. ? COINCIDENT MACULAR DISEASE E.G. DRUSEN MONITORING PLAQUENIL 1. DISTANCE AND NEAR V A MONITORING PLAQUENIL 1. DISTANCE AND NEAR V A 2. COLOUR VISION ( B/Y PLATES ) MONITORING PLAQUENIL 1. DISTANCE AND NEAR V A 2. COLOUR VISION ( B/Y PLATES ) 3. AMSLER MONITORING PLAQUENIL 1. DISTANCE AND NEAR V A 2. COLOUR VISION ( B/Y PLATES ) 3. AMSLER 4. ? BLUE ON YELLOW FIELDS MONITORING PLAQUENIL 1. DISTANCE AND NEAR V A 2. COLOUR VISION ( B/Y PLATES ) 3. AMSLER 4. ? BLUE ON YELLOW FIELDS 5. ERG/EOG IF > 5 YEARS CONTINUOUS TREATMENT Which of the following ocular side effects is not associated with Flomaxtra? A. Poor pupil dilatation B. Iris flaccidity during cataract surgery C. Progressive miosis during cataract surgery D. Ocular hypertension Which of the following eye drop preservatives is most likely to cause corneal epithelial toxicity? A. Purite B. Polyquaternium C. Benzalkonium Chloride D. Povidone Which of the following is not a side effect of topical or systemic B Blockers? A. Brady cardia ( slow pulse ) B. Asthma C. BP lowering D. High BP Which of the following is not a known side effect of topical prostaglandins? A. Conjunctival hyperaemia B. Lash growth C. Lid pigmentation D. Pupillary constriction