7/3/2015
Ocular Side Effects of Systemic
Medications
J. Daniel Friederich, OD, FAAO
Disclosure Statement
I
do not have any relevant financial relationships with any
commercial interests
Please Silence All Mobile Devices
Learning Objectives
 Review basic eye anatomy
 Discuss potential ocular side effects and
symptoms of select systemic medications
 Review patient cases of systemic medicineinduced ocular pathology
Marsh L. “Eye Anatomy.” Schematic.
quizlet.com10 Jan. 2011. 2 Apr. 2013.
<http://www.quizlet.com>.
“The Eyes.” Schematic. webmd.com2009. 2 Apr.
2013. <http://www.webmd.com>.
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Anticoagulants
 Aspirin, Coumadin/Warfarin, Heparin,
Plavix
 Subconjunctival hemorrhage (common)
 Retinal hemorrhage (less common)
 No treatment necessary, not necessary
to discontinue anticoagulant med
 Typically recommend pt. discontinue for a
week prior to eye surgery
Subconjunctival hemorrhage
Sbconjunctival hemorrhage. Picture. 2 Apr 2015. fontanaeye.homestead.com
Anticoagulants and age-related
macular degeneration (AMD)
 “The association of aspirin use with
age-related macular degeneration.”
 Study by Liew G, et al. in Australia
 Published in JAMA Intern Med Feb. 2013
 Concluded that regular aspirin use is
associated with increased risk of
neovascular AMD
 Study received widespread headline
media coverage, generated a lot of
questions
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AMD is Broadly Classified into two Categories:
 Dry (Non-Exudative)
 Wet (Exudative)
 Dry generally
precedes wet
 Accounts for the
majority (80%) of
diagnosed AMD
cases
 Responsible for the
vast majority of
significant visual
disability with the
disease
 Occurs in 20% of dry
AMD patients
ASA/AMD JAMA Study
 Study had 2389 participants
 257 individuals (10.8%) were aspirin users
 63 of the 2389 developed neovascular AMD
 15-year cumulative incidence was 9.3% in ASA
users and 3.7% in nonusers
 No association with dry AMD
 Cannot disentangle whether this is due
to aspirin or underlying risk factors that
lead people to use aspirin
 The small (and still uncomfirmed) risk
of wet AMD is far outweighed by the
cardioprotective benefits
Anti-depressants
 Selective serotonin reuptake inhibitors
(SSRI’s)
 Dry eye and blurred/abnormal vision
 Light sensitivity
 Mydriasis/cycloplegia: pupils dilate and
focusing muscle becomes inhibited
 Double vision (diplopia)
 Effects are typically tolerable and dose
dependent
 Affecting QOL/ADL?
 Can discuss lower dose/alternate with
prescriber
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Anti-anxiety
 Xanax, Valium
 Blurred vision
 Diplopia
 Mydriasis
 Symptoms are typically manageable for
patients
 Ocular effects dose dependent
 If side effects are intolerable, contact
prescribing physician to discuss lower dose
or alternate therapy
Anti-allergy medications
 Claritin, Allegra, Zyrtec, Benadryl, etc.
 Dry eyes
 Blurred vision
 Mydriasis, loss of focusing ability
 Effects are usually tolerated
 Strong symptoms (affecting QOL/ADL)
 Depending on specific allergic indication,
can switch these patients to more localized
alternatives (i.e. Flonase, topical creams)
Levothyroxine
 Rare, but patients may experience
symptoms similar to myasthenia gravis
with excess levothyroxine
 Double vision
 Droopy eyelid (ptosis)
 Paralysis of extraocular muscles
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Medication-induced blur
Mrs. Jones is started on Xanax and Zoloft
for her anxiety and depression. She is
much happier and less anxious, but now
vision is a little blurry. We should:
A. Contact the prescribing physician and
recommend DC’ing the meds
A. Contact the prescribing physician and
recommend lowering the dose or
finding an alternate therapy
A. Monitor; no changes necessary
Medication-induced blur
Mrs. Jones is started on Xanax and Zoloft
for her anxiety and depression. She is
much happier and less anxious, but now
vision is a little blurry. We should:
A. Contact the prescribing physician and
recommend DC’ing the meds
A. Contact the prescribing physician and
recommend lowering the dose
A. Monitor; no changes necessary
Medication-induced blur
Mr. Smith is started on Xanax and Zoloft
for his depression and anxiety. His vision
becomes blurry, causing him to not be
able to participate in his beloved bingo.
We should:
A. Contact the prescribing physician and
recommend DC’ing the meds
A. Contact the prescribing physician and
recommend lowering the dose or
finding an alternate therapy
A. Monitor; no changes necessary
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Medication-induced blur
Mr. Smith is started on Xanax and Zoloft
for his depression and anxiety. His vision
becomes blurry, causing him to not be
able to participate in his beloved bingo.
We should:
A. Contact the prescribing physician and
recommend DC’ing the meds
A. Contact the prescribing physician
and recommend lowering the doses
or finding an alternate therapy
A. Monitor; no changes necessary
Fosamax
*A comprehensive eye examination is
recommended due to all of the possible
side effects*
Blurred vision
Hyperemia (redness) and irritation
Anterior uveitis (iritis)
Episcleritis
Scleritis
Uve a
Choroid
NCiliary
Optic Nerve
Body
Iris
Pupil
Cornea inctiva
to
Vitreous
Sclera
Choroid
Retina
Anterior
chamber
Cornea
Pupil
Lens
Posterior
chamber
Marsh L. "Eye Anatomy." Schematic. quiz/et.com10 Jan.
2011. 2 Apr. 2015. <http://www.quiziet.com>.
Macula
Artery
(central retina
Optic
nervy
Canal of -=--.-Schtemm
Conjunctiva
"The Eyes." Schematic. webmd.com2009. 2 Apr. 2015.
<http://www.webmd.com>.
Win (central retinal)
Rectus medialis
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Scleritis
Scleritis. Picture. 2 Apr 2015. www.allaboutvision.com
Fosamax
 Patients with eye pain or vision loss
require urgent referral to an eye care
professional for treatment
 Hyperemia/irritation can be self-limiting
and decrease in intensity with time, so
in mild cases bisphosphonates can be
continued
 There is limited information on effect of
switching to a different bisphosphonate
 Severe symptoms and scleritis require
drug discontinuation for resolution
Anti-hyperlipidemia medications
 Lipitor, Zocor
 Ocular side effects are rare
 Pseudo-cystoid macular edema (CME)
 Marked decrease in vision will occur with
pseudo-CME
 Resolves after discontinuing med
 Lens opacities/cataracts
 Lid edema
 These can also occur with niacin
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Cystoid macular edema
Normal OCT
Case
 74 y/o Caucasian male
 Sensitivity to light in both eyes
 VA is 20/25 right eye and 20/30 left eye
 Had been 20/20 at last annual exam
 Anterior segment and dilated fundus
examination performed
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Whorl keratopathy
Antiarrhythmics
 Amiodarone
 Whorl keratopathy
 Appears in nearly 100% of patients taking it
longer than 6 months
 Glare and haloes, photophobia, blurred vision
 Whorl deposits typically disappear within
months of discontinuing drug
 Cataracts (less common)
 Optic nerve damage?
Amiodarone keratopathy
What percentage of patients with amiodarone
keratopathy experience visual symptoms?
A. 10%
B. 30%
C. 50%
D. 70%
E. 90%
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Amiodarone keratopathy
What percentage of patients with amiodarone
keratopathy experience visual symptoms?
A. 10%
B. 30%
C. 50%
D. 70%
E. 90%
Case
 Contacted PCP in regards to
amiodarone-induced keratopathy and
symptoms
 Agreed upon continued observation
Antiarrhythmics
 Digoxin
 Visual side effects occur in up to 25% of
patients
 Red-green color defects
 Xanthopsia: yellow-tinged vision
 Flickers and/or flashes of light
 Snowy, hazy, or clouding vision
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“Yellowing” of vision
Vegetables. Picture. 3 Apr 2014. www.flickr.com
Antiarrhythmics
 Digoxin
 Inhibits Na+, K+-ATPase for cardiac
therapeutic effect; also effects the cone
photoreceptors
 Na+, K+-ATPase plays critical role in the
production and maintenance of neural action
potentials
 Long-term inhibition of Na+, K+-ATPase by
digoxin degrades the photoreceptor polarization
 Effects are not permanent
 Visual symptoms cease after discontinuing the
drug
Marsh L. “Eye Anatomy.” Schematic.
quizlet.com10 Jan. 2011. 2 Apr. 2013.
<http://www.quizlet.com>.
“The Eyes.” Schematic. webmd.com2009. 2 Apr.
2013. <http://www.webmd.com>.
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7/3/2015
Flomax
 Loss of tone in iris dilator muscle
causing poor pupil dilation and/or
prolapse during cataract surgery
 Called “Intraoperative Floppy Iris
Syndrome” (IFIS)
 Increases chances of surgical complications
 Most surgeons ask patients to discontinue
Flomax for the 2 weeks leading up to
surgery
Intraoperative Floppy Iris
Syndrome (IFIS)
IFIS with iris prolapse
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Corticosteroids
 Prednisone
 Posterior subcapsular cataract
 Blurs vision
 Elevated intraocular pressure (IOP)
 Cannot sense or feel this; asymptomatic
 These side effects are well known
 Physicians know the risks going in, and
they’re typically outweighed by the benefits
 If significant ocular changes are occurring,
need to discuss with prescriber
 All prednisone patients require monitoring,
regardless of dosage or duration
Posterior subcapsular cataract
Posterior Subcapsular Cataract. Picture. 2 Apr 2015. medscpae.reference.com
Topamax
 Uveal effusions with ciliary body
swelling cause forward rotation of the
lens-iris diaphragm
 Acute myopia (nearsightedness) of 6-8
diopters
 Can occur within the 1st month
 Significant blurring of distance vision
 Angle closure glaucoma
 Induced by “iris bombe”
 Ocular pain, nausea, headache
 Requires urgent ophthalmological referral
for laser irodotomy
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Aqueous Inflow and Outflow
Lewis P. “Figure 1.” Schematic. aafp.org1 Apr. 1999. 11 May. 2015.<http://www.aafp.org>
Tamoxifen
 Crystalline retinopathy
 Rare (<1% of patients)
 Blurred central vision
 Reversible with discontinuation of the drug
Crystalline Retinopathy
Crystalline Retinopathy. Picture. 2 May 2015. www.reviewofophthalmology.com
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Avandia/Actos
 Macular edema
 Blurs central vision
 Diabetic macular edema can be present
secondary to elevated blood glucose
 HgA1c and the degree of other diabetic
retinopathy assists in determining whether
edema is secondary to medication vs.
uncontrolled blood glucose
Macular edema
Which medication leads to (by far) the
most referrals to the eye doctor?
A. Prednisone
B. Amiodarone
C. Fosamax
D. Plaquenil
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Plaquenil (hydroxychloroquine)
 Bull’s-eye maculopathy
 Loss of central vision
 Not reversible
 Baseline dilated eye exam needs to
performed prior to treatment
 Central visual field testing
 Color vision testing
 OCT
 Annual exams required thereafter
Bull’s-eye maculopathy
Summary
 New visual symptoms are often
secondary to systemic medications
 Careful review of a patient’s meds,
visual signs and symptoms imperative
 Consultation with prescribing physician
to help gauge necessity of and weigh
risk/benefit of med in question
 Always refer to eye care professional
with ocular pain, loss of vision
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Questions, Comments, Concerns?
Thank You!
References
1.
Fraunfelder FT, et al. Clinical Ocular Toxicology Drug-Induced Ocular Side Effects. Elsevier
2008.
2.
Santaella RM, Fraunfelder FW. Ocular adverse effects associated with systemic medications:
recognition and management. Drugs 2007;67(1):75-93.
3.
Ozturk BT, Genc E, Tokgoz M, Kerimoglu H, Genc BO. Ocular changes associated with
topiramate. Curr Eye Res 2011;36(1):47-52.
4.
Marmor MF, Carr RE, Easterbrook M, et al. Recommendations on screening for chloroquine
and hydroxychloroquine retinopathy: a report by the American Academy of Ophthalmology.
Ophthalmology. 2002 Jul;109(7):1377-82.
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