9 Systemic side effects Flashcards
Amiodarone
Class & Indication: (2 marks)
Ocular side effects (3 marks)
Mx (2 marks)
Class: antiarrhythmic
Indications: heart arrhythmias (e.g. ventricular fibrillation,
ventricular tachycardia)
Ocular side effects:
Verticillata (vortex keratopathy) >No treatment needed. Medications should NOT be stopped.
Optic neuropathy> Refer to the original medical doctor, Refer to OMD. Consult the cardiologist regarding stopping
or altering the medication.
Anterior subcapsular lens opacities
Digoxin
Class & Indication: (2 marks)
Ocular side effects (2 marks)
Class: cardiac glycosides
Indication: atrial fibrillation
Ocular side effects: dyschromatopsia
Yellow vision (xanthopsia)
Blurred vision
warfarin
Class & Indication: (2 marks)
Ocular side effects (2 marks)
Mx: (2 marks)
Class: anticoagulant
Indication: prevention of heart attacks, strokes,
and blood clots
Ocular side effects:
Subconjunctival haemorrhages
Retinal haemorrhages
Mx:
Alert the patient’s doctor
Frequent monitoring of PT/INR (prothrombin time)
ethambutol
Class & Indication: (2 marks)
Ocular side effects: (1 mark)
Mx: (4 marks)
Class: bacteriostatic antimicrobial
Indication: Tuberculosis
Ocular side effects:
Toxic Optic Neuropathy
Management:
Regular monitoring (3-6 months) of VA, color vision, HVF, RNFL OCT
Patients with renal disease should be monitored monthly due to poor drug excretion
Educate the patient on symptoms and advise them to return immediately if noted.
Notify the GP immediately if any signs of optic neuropathy.
Hydroxychloroquine (HCQ) /chloroquine (CQ)
Class & Indication: (4 marks)
Ocular side effect: (2 marks)
Screening test: (2 marks)
Mx: (2 marks)
Class: antimalarial, anti-inflammatory
Indications: malaria, rheumatoid arthritis, SLE, Sjogren syndrome
low dose to prevent malaria
Moderate dose to relieve autoimmune diseases
High dose to treat malaria, SLE
Ocular side effects:
Bull’s eye maculopathy
Corneal deposits (verticillate)
HCQ has less side effects than CQ
Screening test:
Automated visual field (30-2 & 10-2)
SD-OCT
Additional test:
mfERG
FAF
Mx:
Discontinue medication at the earliest sign of retinopathy.
Questionable test results should be repeated to avoid
discontinuing medication unnecessarily.
Risk factors for toxic retinopathy (5 marks)
HCQ Daily dosage >5mg/kg
Renal disease
Concomitant use of Tamoxifen
Duration of use >5 yrs
Macular disease
interferons
Class & Indication: (1+3 marks)
Ocular side effects: (3 marks)
Mx: (2 marks)
Class: Immune modulator
Indication: hepatitis, multiple sclerosis, cancer
Ocular side effects:
Interferon retinopathy (retinal haemorrhages, CWS, CME)
Optic Neuropathy (rare)
Dry eye
Mx:
Close monitoring
Risk/benefit
corticosteroids
Class & Indication: (2 marks)
Ocular side effects: (3 marks)
Mx: (1 mark)
Class: anti inflammatory
Indications: SLE, RA, asthma, skin conditions,
sarcoidosis , uveitis, optic neuritis, MS, endocrine
disorders, etc.
Ocular side effects:
Cataract (PSC)
Steroid-induced glaucoma (high IOP),
(POAG, diabetes, and myopia increases risk)
Central serous chorioretinopathy
Mx:
monitor for cataract and IOP for any type of steroid usage
Tamsulosin, terazosin, doxazosin
Class & Indication: (2 marks)
Ocular side effects: (1 mark)
detail and mechanism: (4 marks)
Mx: (1 mark)
Class: α receptor antagonists
Indication: Benign prostatic hyperplasia (BPH), hypertension
Ocular side effects:
Intraoperative Floppy Iris Syndrome
Detail and mechanism:
Iris is floppy during cataract surgery
Progressive pupil constriction
Iris can prolapse into the incision
Mechanism: blocks α1 receptors on the iris dilator muscle
Mx:
If referring for cataract surgery, alert the OMD if the patient is currently using or has previously used medication in this class.
Tamoxifen
Class & Indication: (2 marks)
Ocular side effects: (4 mark)
Mx: (4 mark)
Class: selective estrogen receptor modulator (SERM)
Indication: prevent breast cancer recurrence
Ocular side effects:
Crystalline retinopathy (12%)
Cataract
Corneal verticillata
Optic Neuritis
Consult the oncologist to determine if medication should be continued.
Mild deposits can be monitored while continuing the medication.
Consider alternative tx if decreased vision due to retinal changes.
Intravitreal anti-VEGF has been used for macular edema
phenothiazines
Class & Indication: (2 marks)
Ocular side effects: (5 mark)
Mx: (3 mark)
Class: antipsychotic
indication: schizophrenia, depression, anxiety
Ocular side effects:
• anterior subcapsular cataract
• posterior corneal pigment
• dyschromatopsia
• pigmentary retinopathy
• nyctalopia
Management:
• Regular monitoring.
• Lens and cornea findings rarely decrease vision.
• Retinopathy rare at standard dose. If high dose, monitor
with fundus exam and VF.
topiramate
Class & Indication: (2 marks)
Ocular side effects: (2 mark)
Mx: (4 mark)
- Stop medication immediately
- Treat IOP with topical aqueous suppressants or oral anti-glaucoma medication.
- Cycloplegic agent to shift the lens/iris posteriorly. Avoid pilocarpine.
- There is no pupil block, so LPI is not indicated.
amantadine
Class & Indication: (2 marks)
Ocular side effects: (1 mark)
Mx: (2 mark)
Class: antiviral
Indication: Parkinson’s disease, influenza A
Ocular side effects: bilateral corneal oedema
>Longer duration and higher doses associated with
lower endothelial cell counts
Management:
Monitor endothelial cell count and morphology
Corneal oedema usually resolves with discontinuation of the drug
sildenafil (Viagra)
Class & Indication: (2 marks)
Ocular side effects: (3 mark)
Mechanism: (1 mark)
Mx: (5 mark)
Generic: sildenafil, vardenafil, tadalafil (-afil)
Class: Selective PDE-5 Inhibitor
Indication: Erectile dysfunction
Mechanism: PDE-6 is present in the retinal photoreceptors. PDE-5 inhibitors can partially inhibit PDE-6.
Ocular side effects:
Blue tint to vision (cyanopsia)
* Peak at 1 hour after the dose
* Return to normal in 4-8 hours
Photophobia
NAION? (risk factor: small C/D)
* Causal or coincidental (may be due to other systemic diseases)
* 2x higher risk
Management:
Color vision changes are transient and have no long-term negative effects.
Advise the patient to stop medication in the event of sudden vision loss.
Inform high-risk patients of the possible risk of NAION.
Manage systemic risk factors for NAION.
If NAION is experienced, stop the medication due to the increased risk of NAION in the second eye.
isotretinoin (Accutane)
Class & Indication: (2 marks)
Ocular side effects: (4 mark)
Mx: (2 mark)
Class: retinoid derivative of Vitamin A
Indication: acne
Ocular side effects:
Severe dry eye
Meibomian gland atrophy
Increase in hordeolum/chalazion
Idiopathic intracranial hypertension
Management:
Aggressive treatment of dry eye
Discontinue medication if increased ICP
5 types of Hypertension drugs
and ocular side effects for two of the drugs
ACE inhibitors (-pril)
Angiotensin II receptor blocker (-sartan)
Beta-blockers (-olol)
* Ocular side-effects: decreased tear production, dry eye, decreased IOP
Calcium channel blockers (-dipine)
Diuretics
* Ocular side-effects: decrease tear production, dry eye
statins and Niacin
class and ocular side effects:
-statins (e.g. atorvastatin, simvastain)
Ocular side effects are very rare
* Case reports of ptosis, diplopia, and ophthalmoplegia
* Reversible on discontinuation of the medication
Niacin (vitamin B3)
Ocular side effects:
* Cystoid macular oedema
* Resolves with cessation of medication
Metformin
Glyburide, Glipizide
Insulin
Class and ocular side effects:
diabetes,
Class: biguanide
* First-line medication for type 2 diabetes
* decreases hepatic glucose production, decreases GI glucose
absorption, and increases target cell insulin sensitivity
* Patients may experience refractive shifts while glucose levels stabilize.
glyburide, glipizide
* Class: sulfonylureas
* stimulate the pancreas to make more insulin
Insulin (e.g. Humulin, Humalog, Lantus)
* most common medication for type 1 diabetes but also used in type 2 diabetes (severe stage)
* short, intermediate, and long-acting
Levothyroxine
Carbimazole, methimazole
Class and ocular side effects:
Levothyroxine
* replaces hormone normally produced by the thyroid gland
* ocular side effects rare
* overdose causes symptoms of hyperthyroidism
Carbimazole, methimazole
* prevents the thyroid from producing excess
amounts of hormone
* Radioactive iodine – absorbed by the thyroid and causes it to shrink
5 types of antidepressants
ocular side effects
- Dry eye
- Mydriasis > photophobia (caution in narrow angle)
- Reduced accommodation
TCA/MAOI: Caution using sympathomimetics
(phenylephrine) for dilation due to the risk of
increased blood pressure
Methylphenidate (Concerta, Ritalin)
drug class and ocular side effects:
Methylphenidate (Concerta, Ritalin)
Indication: Attention Deficit Hyperactivity Disorder (ADHD)
* anticholinergic effects
* Ocular side effects: mydriasis, reduced accommodation
Benzodiazepines (“benzos”)
alprazolam, clonazepam
drug class and ocular side effects:
Central nervous system: sedatives
Benzodiazepines (“benzos”)
* alprazolam, clonazepam
* Indications: insomnia, anxiety
Ocular side-effects:
Blurred vision
Mydriasis
Reduced accommodation
Dry eye
Rare: diplopia, nystagmus
phenytoin
drug class and ocular side effects:
Central nervous system: anticonvulsant
Indication: seizure disorders
IV or oral
narrow therapeutic index
Ocular side effects:
* gaze-evoked nystagmus at therapeutic doses
* nystagmus and diplopia at toxic doses
* Stevens-Johnson Syndrome
Propofol
Ketamine
drug class and ocular side effects:
Propofol
Ocular side effects:
* decrease IOP
Ketamine
Ocular side effects:
* increase in lacrimation and salivation
* mydriasis
* increase in IOP
acetaminophen (Panadol)
hydrocodone
Aspirin
drug class and ocular side effects:
acetaminophen (Panadol)
* Pain and fever reducer
hydrocodone
* antitussive (cough suppressant) and analgesic agent
Aspirin
* Used at high doses to reduce pain, fever, and inflammation
* Used at low doses as a blood thinner
* Ocular side effects: subconjunctival or retinal hemorrhages
Ibuprofen
Indomethacin
drug class and ocular side effects:
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Ibuprofen
* Ocular side effects rare: diplopia, color vision disturbances, dry eyes
Indomethacin
* Ocular side effects: corneal verticillate, pigmentary changes in the macula
Tetracyclines
ocular side effects:
Ocular side effects:
* Intracranial hypertension
* Minocycline can cause blue sclera
be aware of optic nerve oedema
Sulfonamides
Ocular side effects:
Stevens-Johnson syndrome: Immune mediated hypersensitivity reaction
oedema of lid and conjunctiva, pseudomembranes, symblepharon
Oral contraceptives
Ocular side effects:
Common: reduced tear secretion, dry eye, CL intolerance
Rare: retinal vein occlusion, intracranial hypertension
Hormone replacement therapy (HRT)
Ocular side effects:
relieve symptoms of menopause
* Ocular side effects: dry eye
Histamine (H2) blockers (e.g. ranitidine)
Ocular side effects:
Proton pump inhibitors (e.g omeprazole)
Ocular side effects:
dry eye
OTC Allergy and Cold medication
Antihistamines (e.g cetirizine, loratadine)
Decongestants (e.g. phenylephrine, pseudoephedrine)
Ocular side effects:
Antihistamines (e.g cetirizine, loratadine)
* Used to treat allergic problems, hay fever
* Ocular side effects: dry eye
Decongestants (e.g. phenylephrine, pseudoephedrine)
* Sympathomimetics
* Ocular side effect: mydriasis
* Caution in narrow angles!!
Drugs that cause dry eye (AAABIO)
antidepressants
antihistamines
antihypertensives (e.g. beta-blockers, diuretics)
benzodiazepines
isotretinoin
oral contraceptives
Drugs that affect pupil size
Mydriasis (AABCD)
* anticholinergics
* antidepressants
* CNS stimulants
* Benzodiazepines
* decongestants
Miosis (OAP)
* opiates (e.g. heroin)
* pilocarpine
* anticholinesterase (e.g.
neostigmine for MG)
Qbrexza (glycopyrronium)
Ocular side effects:
Anticholinergic underarm wipe for hyperhidrosis
Ocular side-effects: mydriasis, blurred near vision
Drugs associated with
Intracranial Hypertension (Pseudotumor cerebri)
tetracycline antibiotics
isotretinoin
growth hormone
vitamin A
oral contraceptives
steroids
sulfa drugs
tamoxifen
Drugs that affect IOP
Increase IOP
* corticosteroids
* topiramate
Decrease IOP
* Beta-blockers
* Cannabinoids (i.e. marijuana)
* alcohol
