There are hundreds of drugs that can affect vision. Some can cause temporary blurriness or dryness, others can cause a permanent loss of vision.
There are many drugs that can cause eye fluctuations but these are the most common.
Let me start though with ones that can rarely cause a loss of vision.
Hormones
Birth Control Pills & Hormone replacement therapy (HRT) with estrogens alone or in
combination with progestins is a commonly medicines. The use of estrogen replacements and
contraceptive agents is commonly implicated in dry eye. The exact
cause-and-effect relationship is unknown, but may be associated with a
decreased aqueous component of the precorneal tear film.
A great deal of information is available
about hormone replacement therapy in post-menopausal women. A colleague of mine from Harvard, Debra A.
Schaumberg, Sc.D., O.D., M.P.H., and colleagues reported a 69% increase
in dry eye symptoms in women who were taking estrogen compared to the
control group. Additionally, the study reported that women
who were taking a progesterone or progesterone combination also
experienced a 29% increase in dry eye symptoms over women not on HRT.
This report, based on observations on
25,000 post-menopausal women, showed evidence of a significant increased
risk of dry eye syndrome and severity of dry eye symptoms in women
taking estrogen. Because this risk has been shown to increase with
longer durations of estrogen use, patients on HRT with estrogens should
be monitored for dry eye problems.
Rarely birth control and hormones will cause a vein or artery occlusion in the eye, brain, and/or heart. I have seen more than 20 women with this long term devastation and all women should know that though rare, it is a risk.
Sildenafil, sold as Viagra:
Viagra and other trade names, is a medication used to treat erectile dysfunction and pulmonary arterial hypertension. Its effectiveness for treating sexual dysfunction in women has not been demonstrated. The Wiki page excerpt below does not mention the risk of loss of vision from an non-arteritic ischemic optic neuropathy: basically a loss of oxygen to the optic nerve.
I have now diagnosed this condition in 8 men and it is devastating. Two of the men only used Viagra once when the sudden loss of vision happened a few hours later. One of the men immediately noted a loss of vision but came in about 8 hours later with 20/20 vision and a pale nerve (the optic nerve should look pink). He noticed a darkening of his peripheral vision first. The visual field showed a peripheral superior temporal scotoma and a normal central vision. I had to tell him that this vision was going to slowly decrease from 20/20 to much worse and there would be nothing we can do to stop this unfortunate process. Sure enough he came back with Count Fingers vision at 3 feet. He is devastated! He will never take Viagra again. All these patients did have a “disc at risk” in the other eye. So now I tell all my patients with “discs at risks” to check out the risks at: https://drcremers.com/2016/07/disc-at-risk-what-you-need-to-know-if.html
Some patients will notice a blur in their vision or a darkening of their vision without a permanent loss of vision. This is likely a warning sign. Also dryness or reflex tearing is a side effect of Viagra.
Wiki page: Common side effects include headaches and heartburn, as well as flushed skin. Caution is advised in those who have cardiovascular disease. Rare but serious side effects include prolonged erections, which can lead to damage to the penis, and sudden-onset hearing loss. Sildenafil should not be taken by people who take nitrates such as nitroglycerin (GTN), as this may result in a severe and potentially fatal drop in blood pressure.
Sildenafil acts by inhibiting cGMP-specific phosphodiesterase type 5 (PDE5), an enzyme that promotes degradation of cGMP, which regulates blood flow in the penis.
Pfizer scientists
Andrew Bell, David Brown, and Nicholas Terrett originally discovered
sildenafil as a treatment for various cardiovascular disorders. Since becoming available in 1998, sildenafil has been a common treatment for erectile dysfunction; its primary competitors are tadalafil (Cialis) and vardenafil (Levitra). https://en.wikipedia.org/wiki/Sildenafil
Let’s break them the rest down:
Hypertensive Agents
1. Beta blockers drugs are used to treat angina
pectoris, essential hypertension, myocardial infarctions and migraine
headaches. Because beta blockers reduce lysozyme levels and
immunoglobulin A, these drugs can decrease aqueous production from the lacrimal gland and lead dry eye symptoms in some patients. Some patients can also have corneal anesthesia (lack of corneal sensitivity), decreased tear film break-up times, and eye irritation, and redness.
2. Thiazides or diuretics are often
prescribed to treat congestive heart failure. This drug class causes
decreased lacrimation, which may induce dry eye complaints.
Hydrochlorothiazide (HCTZ) is a commonly used diuretic and can produce
changes in the precorneal tear film, inducing a dry eye. Furosamide and HCTZ/triamterene are other common medications in this class.
3. Note: Beta blocker eye drops like timolol can sometimes cause irregular heart beat, worsening of asthma symptoms, depression, decreased libido, and mask a diabetic’s low sugar status, and dry eyes. If you are taking such a drop and have such side effects, let your eyeMD know.
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| Lissamine green staining of conjunctiva and cornea in dry eye. |
Antihistamines and Decongestants
Medications that block histamine receptors alleviate allergic
conditions of allergic conjunctivitis, rhinitis, uticaria, dermatitis and systemic allergies. The
drugs in this class reduce mucous and aqueous production from the lacrimal gland, which cause
dry eye complaints. Their activity may also decrease the
aqueous component of the precorneal tear film as well.
Common Culprits:
1. Benadryl
(diphenhydramine, McNeil Consumer)
2. Chlor-Trimeton (chlorpheniramine,
Schering)
3. Claritin (loratadine,
Schering).
4. Less likely to cause eye dryness but still can: (H1
selective) antihistamines like:
a. Zyrtec (cetirizine, McNeil Consumer)
b. Clarinex (desloratadine, Merck)
c. Allegra (fexofenadine,
Sanofi-Adventis)
These H1 selective antihistamines do not cause as much side effects as earlier generation antihistamines.
Antihistamines are combined with
anticholinergics in many over the counter medications, such as cold preparations,
sedatives, antidiarrheals and nasal decongestants.
Antidepressants
Antidepressants commonly cause dry eye symptoms. They also cause blurred
vision, reflex tearing, and dilated pupils in some patients.
Common culprits:
1. Zoloft
(sertraline, Pfizer)
2. Paxil (paroxetine, GlaxoSmithKline).
3. Tricyclic
antidepressants—Elavil (amitriptyline, Merck), Endep (amitriptyline,
Roche), Adapin (doxepin, Lotus Biochemical), Sinequan (doxepin,
Pfizer)—produce many anticholinergic side effects: the classic anti-cholinergic effects are colloquially described as
“Blind as a bat, mad as a hatter, red as a beet, hot as Hades (or hot as a hare), dry as a bone, the bowel and bladder lose their tone, and the heart runs alone.”
For the eye, this mean, these drugs can make the eye super dry.
If a patient has narrow angles, it can cause angle closure: see https://drcremers.com/2013/04/narrow-angles-risk-for-glaucoma.html
Since these
medications are being prescribed to a broader and younger population
than in the past, which means there is an increased likelihood that your
patients will display dry eye side effects.
Antipsychotic Medications
1. Phenothiazines are prescribed to manage schizophrenia.
2. Mellaril
(thioridazine, Mutual Pharmaceutical) is the best known of this class
and has almost completely replaced Thorazine (chlorpromazine,
GlaxoSmithKline) in the management of the condition. Both drugs decrease
aqueous secretion, and symptoms are transient and dose dependent.
Pain Relievers
Ibuprofen, is a common pain medication, can cause dry eye in
addition to blurred vision, refractive changes, diplopia and color
vision changes, especially when the higher dosages (up to 800mg) are
prescribed. Darvocet-N (propoxyphene napsylate and acetometaphin, USP) reportedly decreases tear secretion. Lortab (hydrocodone and acetaminophen, USP) combinations can also produce a dry eye.
Dermatologic Medications
Dermatologists sometimes prescribe Accutane (isoretinoin, Genpharm)
for the treatment of severe acne. Even though Roche
Pharmaceuticals removed Accutane from the market in 2009, generic
versions of the drug may still be available by prescription.
Isotretinoin (13-cis-retinoic acid) is a form of vitamin A that reduces the amount of oil released by oil glands in the skin.
Vitamin A and its synthetic derivatives are collectively known as
retinoids and are used to treat severe recalcitrant nodular acne, acne
vulgaris and severe recalcitrant psoriasis, and to induce remission of
leukemia. Isoretinoin has been shown to be secreted in
tears by the lacrimal gland and has been associated with causing
meibomian gland dysfunction—producing dry eye complaints, contact lens
discomfort, blepharoconjunctivitis, transient blurring of vision and
acute, transient refractive changes––especially myopic shifts. This synthetic medication affects the overproduction of skin lipids.
Decreased meibomian gland function also impacts the production of the
lipid layer of the precorneal tear film, leading to tear film
instability and enhanced surface evaporation, which results in dry eye
syndrome.
Dry eye complaints will disappear after
medication use is discontinued, although it may take several months for
the complaints to wane. Approximately 20% of previously successful
contact lens wearers may need to decrease their wearing time, use
preservative-free lubricating eye drops or discontinue contact lens wear
while on this medication.
Gastrointestinal Medications
This medication class includes the proton pump inhibitors:
1. Prevacid
(lansoprazole, Takeda),
2. Prilosec (omeprazole, Procter & Gamble),
3. Nexium (esomeprazole magnesium, AstraZeneca),
4. Zantac (ranitidine,
GlaxoSmithKline) and
5. Tagamet (cimetidine, GlaxoSmithKline).
6. Proton pump
inhibitors have caused dry eye complaints, although this information
does not appear in their individual package inserts.
7. H2 receptor
antagonists, like all antihistamines, can cause dry eye symptoms.
Chemotherapy Medications
Many chemotherapeutic drugs likely destroy meibomian glands and damage the lacrimal gland. I will try to do more research on this and post the research. This is based on my observations of Lipiview after Chemo.
A major drug in this class is Cytoxan (cyclophosphamide,
Bristol-Myers Squibb), which is also used to treat ocular cicatricial
pemphigoid and primary Sjögren syndrome. As many as 60% of patients
taking cyclophosphamide have developed dry eye.