Ocular Side Effects of Common Medications
This page discusses interactions of drugs with the eyes, ocular surface, and the vision. This is not intended to be a complete catalog of all possible ocular side effects from different medications. Instead, it lists common ocular side effects, or those which deserve special mention. Just because a drug is not listed here does not mean that it does not have any possible ocular side effects. Included are over-the-counter medications and prescription medications. Eye medications are not included here.
Read this important information before proceeding further:
These sections are not intended to replace the professional examination and diagnosis by a physician, and they are presented here purely for informational purposes. All possible diagnoses and treatment options are not covered, and the information discussed should not be taken as a recommendation to self-diagnose and self-treat a condition. A misdiagnosed or improperly treated eye condition can result in a permanent loss of vision, or a permanent loss of function of the eye or visual system. In the case of any eye problem, seek medical attention promptly. This can include emergency room treatment, as well as treatment by a medical physician or eyecare provider.
MEDICATIONS THAT CAN AFFECT THE EYE OR VISUAL SYSTEM
If the listing of medication side effects is reviewed in a medication package insert or in a publication such as the PDR (Physicians Desk Reference), side effects such as “blurred vision” and “eye redness” are commonly mentioned. However, certain medications have been found to have definite ocular side effects and may pose a risk to the eye or visual system. The listing that follows discusses these more notable cases. Again, it is not meant to be a complete list of ocular medication side effects. The list is organized alphabetically by the medication name or by the class of medication.
Isotretinoin (Amnesteem, Claravis, Sotret – generic brands of Accutane)
Many patients view this drug as a terrible toxin. Isotretinoin is commonly used to treat acne, and is known to cause dryness of mucous membranes, and the eye is included: in some cases this can be debilitating and lead to a life-time of chronic dry eye from severe meibomian gland atrophy. Symptoms of dry eye include the sensation that something is in the eye, redness, burning, and even blurred vision. Artificial tears and ointments may not help. Isotretinoin may also lead to temporary visual disturbances and trouble with night vision. Accutane has been outlawed in Europe. It has been associated with colon scarring requiring surgery. Avoid at all costs is my medical opinion.
, also known as 13-cis-retinoic acid
(and colloquially referred to by its former brand name Accutane
), is a medication primarily used to treat severe acne
. Rarely, it is also used to prevent certain skin cancers (squamous-cell carcinoma
), and in the treatment of other cancers. It is used to treat harlequin-type ichthyosis
, a usually lethal skin disease, and lamellar ichthyosis
. It is a retinoid
, meaning it is related to vitamin A
, and is found in small quantities naturally in the body. Its isomer
, is also an acne drug.
Isotretinoin is primarily used as a treatment for severe acne. The most common adverse effects are a transient worsening of acne (lasting 1-4 months), dry lips (cheilitis
), dry and fragile skin, and an increased susceptibility to sunburn
. Uncommon and rare side effects include muscle aches and pains (myalgias
), and headaches. Isotretinoin is known to cause birth defects
due to in-utero exposure because of the molecule’s close resemblance to retinoic acid
, a natural vitamin A derivative which controls normal embryonic development. It is also associated with psychiatric side effects, most commonly depression but also, more rarely, psychosis and unusual behaviours. Other rare side effects include hyperostosis, and premature epiphyseal closure, have been reported to be persistent.
In the United States, a special procedure is required to obtain the pharmaceutical. In most other countries, a consent form is required which explains these risks. Women taking isotretinoin must not get pregnant during and for 1 month after the discontinuation of isotretinoin therapy. Sexual abstinence
or effective contraception is mandatory during this period. Barrier methods by themselves (e.g., condoms
) are not considered adequate due to the unacceptable failure rates
of approximately 3%. Women who become pregnant while taking isotretinoin therapy are generally counselled to have a termination
Isotretinoin was first marketed as Accutane
by Hoffmann-La Roche
. It sold well for many years, but in 2009, Roche decided to remove Accutane from the US market after juries had awarded millions of dollars in damages to former Accutane users over inflammatory bowel disease
claims. The American College of Gastroenterologists has released a position paper stating that people with inflammatory bowel disease should not be precluded from having their acne treated with isotretinoin. It then became generic and as of 2017 was marketed under many brand names worldwide.
Tetracycline, Doxycycline, Minocycline (Minocin)
These medicines are commonly used in the treatment of acne and rosacea as they help to thin oil secretions. Long term use of tetracyclines has been associated with Idiopathic Intracranial Hypertension and elevated intracranial pressure leading to headache, visual fluctuations, and double vision sometimes associated with papilledema (a swollen optic nerve head): which luckily is very rare.
Tetracyclines, when given to a young child (younger than 9) or a pregnant woman, have also been associated with discoloration of growing bones and teeth. Pigmentation of various body sites including skin, nails, bone, mouth and eyes secondary to minocycline therapy has been reported but rare. They found that pigmentation of the skin and oral mucosa is reversible on withdrawal of the drug; however, although eye pigmentation is less common, it is usually irreversible. Scleral pigmentation consisting of a blue-grey 3-5mm band starting at the limbus due to this drug has also been reported, but is rare.
Doxycycline [Doxy] (α-6 deoxy-5 hydroxytetracycline) is a long acting analogue of tetracycline that inhibits collagenase and also has antichemotactic effects which has been used in dry eye treatment for years to stabilizing the patient’s lipid layer of tear film. Doxy is a metal ion chelator and a broad spectrum antibiotic when given at a high dosage (ie, 200mg 2x/day). Doxycylcine has many properties that helps decrease inflammation at sub-antimicrobial levels (ie, very low doses that do not have an antibiotic effect).
Thus even though a low dose of Doxy does not kill bacteria, it has amazing anti-inflammatory abilities. Doxy:
1. prevents access of acyl t-RNA to the acceptor site on the mRNA-30s ribosomal subunit complex.
2. differentially inhibits the activity of members of the matrix metalloproteinase (MMP) family, inhibition of MMP synthesis, inhibition of interleukin-1 synthesis, inhibition of activated B cell function, inhibition of nitric oxide (NO) synthesis by lipopolysaccharide activated macrophages, and inhibition of collagen synthesis by cultured chondrocytes.
3. inhibits an enzyme called collagenase: which is part of a family of proteinases called matrix metalloproteinases (MMPs). MMPs are involved in a number of diseases periodontal disease, arthritis, osteoporosis and blepharitis, meibomian gland death/dysfunction.
MMPs are normally under tight regulation by the body. Any disruption of this regulation leads to pathologic breakdown of the connective tissues. Collagen is the major component of connective tissues in the body (even in the eyes as well as the bone and soft tissue such as gingiva and skin). Collagenase is synthesized and released primarily from neutrophils in response to bacterial infection and is responsible for breaking down collagen. There are several types of human MMPs.
Important MMPs include the collagenases:
a. MMP-1 (produced by fibroblasts and responsible for the normal turnover of tissues)
b. MMP-8 (produced by neutrophils)
c. MMP-13 (produced by bone cells).
In the inflammatory process, macrophages secrete cytokines (such as interleukin-1, tumor necrosis factor-alpha and prostaglandins) that stimulate the production of MMPs from neutrophils, fibroblasts, osteoclasts, and osteoblasts.
Doxycyclines, even at low doses, inhibits both the inflammatory process and connective tissue breakdown through multiple mechanisms. These mechanisms include the following:
a. direct inhibition of active MMPs
b. inhibition of the oxidative activation of pro-MMPs, reduction in the secretion of cytokines and prostaglandin synthase
c. increase in pro-anabolic collagen production.
d. inhibits the production and/or activation of the pro-inflammatory cytokine IL-1 and TNF-alpha, both of which stimulate the production of collagenase.
Thus, sub-antimicrobial doses of doxycycline hyclate 20 mg twice daily (and some studies say once daily) significantly reduce collagenase activity, while maintaining maximum plasma drug concentrations below the antimicrobial threshold of 1 mcg/mL, and are not sufficient to inhibit MMP-1 activity, and accordingly do not have undesirable effects on normal tissue turnover in other body systems.
PHENOTHIAZINE ANTIPSYCHOTIC MEDICATIONS
ALPHA-1 BLOCKER MEDICATIONS FOR BENIGN PROSTATIC HYPERTROPHY (BPH) IN MEN AND BLADDER PROBLEMS IN WOMEN
Tamsulosin (Flomax ), Dutasteride (Avodart), Finasteride (Propecia – also used for male pattern baldness), Terazosin (Hytrin), Doxazosin (Cardura), Alfuzosin (Uroxatral), Saw Palmetto (herbal)
Alpha-blocker medications, and first reported with tamsulosin (Flomax) have been associated with a condition which can occur during cataract surgery known as Intraoperative Floppy Iris Syndrome (IFIS). While any of the medications in the above list can be associated with IFIS, including the herbal medication Saw Palmetto, Flomax has the highest risk, but I have seen it occur in patients taking all of the above. In this condition, the smooth muscle dilator of the iris becomes affected, and the pupil will often not dilate well. During cataract surgery, the pupil will often spontaneously undilate making surgery progressively more difficult to perform. Iris billowing and prolapse through incision openings further complicate the surgery. IFIS can greatly increase operative time during cataract surgery and has been associated with increased risk of capsular rupture.
Stopping medications such as Flomax preoperatively has not been effective at preventing IFIS, which can still occur even years after stopping the medication. Both men and women are using this type of medication for a variety of indications, such as high blood pressure. However, if the operating surgeon is aware of the history of Flomax use (and other medications above), steps can be taken to minimize the risk or extent of IFIS during the surgery, and thus prevent complications. Surgeons have ways now to prevent IFIS from becomming a real problem during surgery. Femtosecond laser cataract surgery significantly helps prevent the increased risk of complications taking these drugs.
The American College of Physicians and the American Academy of Family Practice noted years ago:
“In a patient with a known diagnosis of cataract, prescribing physicians may wish to consider involving the patient’s cataract surgeon prior to initiating non-emergent, chronic tamsulosin or alpha blocker treatment. Options might include an eye exam or having either the patient or the prescribing MD communicate with the cataract surgeon. Patients should also be encouraged to report any prior or current history of alpha-1 antagonist use to their ophthalmic surgeon prior to undergoing any eye surgery”.
I have not seen any papers to say any of the medicines above, particularly Dutasteride (Avodart) cause dry eye symptoms and meibomian gland dysfunction, but one of my patients really feels his eye symptoms started right after he started Avodart: case of 1 thus far.
Amiodarone (Cordarone, Pacerone)
Amiodarone is an antiarrhythmic medication used to treat serious cardiac arrhythmias such ventricular tachycardia or ventricular fibrillation as well as some atrial arrhythmias. It is known to almost always lead to deposits on the cornea called “vortex keratopathy”. The surface of the cornea has a peculiar whorl-like pattern usually toward the bottom of the eye. This rarely affects the vision, but some patients describe green halos in the vision. Of more significance is the risk of bilateral optic nerve inflammation. This can occur at any time that the medication is being used. There typically is a moderate decline in vision associated with swelling of both optic nerves. This is reversible if the medication is stopped.
This risk prompted the manufacturer of amiodarone to revise the Warnings section of this medication’s prescribing information to state that optic neuritis and/or optic neuropathy have been reported in patients receiving this drug, and that the problem could develop at any time during the use of the drug. Regular ophthalmic examination is recommended for patients receiving amiodarone.
Drugs with Anticholinergic Properties:
Antihistamines: Chlorpheniramine, Hydroxyzine, Meclizine, Promethazine
Antipsychotics: Chlorpromazine, Clozapine, Thioridazine
Antispasmodics: Dicyclomine (Bentyl), Hyoscyamine, Oxybutynin
Cyclic antidepressants: Amitriptyline, Clomipramine, Desipramine, Doxepin, Imipramine, Nortriptyline
Mydriatics: Cyclopentolate, Homatropine, Tropicamide
Generally, these medications have ocular side effects of dry eye and dry mouth, pupillary dilation, and decreased accommodation (focusing ability). The focusing impairment may be especially bothersome in younger patients taking these medications. In susceptible individuals, anticholinergics can increase the risk of or worsen angle closure glaucoma.
ANTICOAGULANTS (“BLOOD THINNERS INCLUDING ANTI-PLATELET MEDICATIONS)
Aspirin, clopidogrel (Plavix), warfarin (Coumadin), heparin
Anticoagulant medications and anti-platelet medications actually have very few ocular side effects. While they generally do not cause hemorrhages on the surface of the eye (subconjunctival hemorrhages), they can prolong bleeding time make make these hemorrhages worse than they normally would be. In some cases, this type of medication should be stopped before eye surgery (possibly not cataract surgery, however, depending on the surgeon), and they usually should be stopped before eyelid surgery.
Also, a 2012 study found
that the risks for early age-related macular degeneration (AMD) and wet late AMD are associated with frequent aspirin use, and the risk increases with greater aspirin consumption.
OTC or prescription antihistamine medication including: loratadine (Claritin), pseudoephedrine (Sudafed), fexofenadine (Allegra), montelukast (Singulair), diphenhydramine (Benadryl), and cetirizine (Zyrtec)
Antihistamines are commonly found in prescription and non-prescription medications taken as pills, capsules, liquids, and effervescent tablets. They are used to relieve symptoms of allergic rhinitis, seasonal allergies, and skin allergies. They may be sold individually or in combination with other medications such as decongestants, pain medications, etc. There is often in package inserts with theses medications that the drug should not be used if one has glaucoma. However, for most people with glaucoma, antihistamines can be used safely. The most common type of glaucoma is termed “open angle glaucoma”. Antihistamines generally should have no effect with this type of glaucoma. People with “narrow angle glaucoma” may have risk of acute angle closure glaucoma wit these medications.
Common examples of these medication include Claritin (Loratadine), Sudafed, Allegra (fexofenadine), Singulair, Benadryl (Diphenhydramine), and Zyrtec. Other ocular side effects include mydriasis (pupil dilation), dry eye, Keratitis sicca, contact lens intolerance, decreased accommodation (focusing ability) and blurred vision, and the risk for angle closure glaucoma as stated above.
ANTIMALARIAL MEDICATIONS USED FOR RHEUMATOLOGICAL CONDITIONS
Hydroxychloroquine (Plaquenil) and chloroquine (Aralen)
Plaquenil (hydroxychloroquine) is often used as an anti-inflammatory medication in certain rheumatological conditions such as rheumatoid arthritis and systemic lupus erythematosis. It is a derivative chloroquine, also an antimalarial agent which has a much higher risk of toxicity. Plaquenil can rarely cause a retinal problem involving the central visual area, or macula. Retinal toxicity from Plaquenil is rare, but even if the medication is discontinued, vision loss may be irreversible and may continue to progress. Before treatment is initiated with Plaquenil, a complete ophthalmic examination should be performed to determine any baseline macular or retinal disease.
Patients in earlier stages of hydroxychloroquine retinal toxicity usually do not experience symptoms, though the rare patient may notice a blind spot near the center of the vision that causes trouble with reading as well as decreased color vision. Unfortunately, most patients usually notice symptoms only after they have become severe. In advanced cases of retinal toxicity from Plaquenil, there can be loss of visual acuity, peripheral vision, and night vision. Most documented cases of Plaquenil retinal toxicity are related to large cumulative lifetime doses over a period of many years. Toxicity is rare in the early years of use. Although it is not possible to predict which patients will develop retinal toxicity, some high-risk characteristics include patients use use a daily dose greater than 400 mg (or, in people of short stature, a daily dosage over 6.5 mg/kg ideal body weight) or total cumulative dose of more than 1,000 grams, medication use longer than five years, concomitant renal or liver disease (because the drug is cleared by both routes), underlying retinal disease or maculopathy, and age greater than 60 years.
Although retinal toxicity for Plaquenil is rare, it is recommended to have annual eye examinations with specific testing that can identify early cases of toxicity. The guidelines for monitoring for Plaquenil toxicity were revised in 2011.
Alendronate sodium (Fosamax), pamidronate (Aredia), risedronate sodium (Actonel), tiludronate disodium (Skelid), zoledronic acid (Zometa) and etidronate disodium (Didronel)
The class of medications known as bisphosphonates is used to increase bone density in patients with osteoporosis, myeloma bone disease, Paget’s disease, metastatic cancer to bone, and in other conditions. These include Aredia (pamidronate), Fosamax (alendronate sodium), Actonel (risedronate sodium), Skelid (tiludronate disodium), Zometa (zoledronic acid) and Didronel (etidronate disodium).
Although rare, cases of orbital inflammation, uveitis and scleritis occurred shortly after the medication was started. The ocular side effects are reversible if the medication is stopped. In addition, other patients taking the medication experienced blurred vision, ocular pain, conjunctivitis and bilateral anterior uveitis. Although all cases of blurred vision, ocular pain, conjunctivitis and uveitis resolved during treatment, no instances of scleritis abated unless the medication was discontinued.
Intravenous (or intravitreal) cidofovir is primarily used for the treatment of cytomegalovirus (CMV) retinitis usually found in AIDS patients, but it is also an effective antiherpetic agent, particularly against acyclovir-resistant strains. CMV retinitis is a common opportunistic infection associated with AIDS and occurs in 20% – 40% of individuals with AIDS and requires lifelong maintenance therapy. Studies have shown that IV cidofovir causes anterior uveitis in 26% t- 44% of patients with previously treated retinitis. Patients can be asymptomatic at the time of diagnosis with no abnormal findings on slit-lamp examination, but because the exact incidence of anterior uveitis is still unknown, all patients receiving cidofovir should be followed by careful eye examination for evidence of uveitis. Studies have demonstrated that IV cidofovir followed by oral probenecid results in fewer cases of uveitis. If anterior uveitis develops with cidofovir use, prompt treatment with topical steroids with or without stopping cidofovir can effectively resolve symptoms.
Prednisone, hydrocortisone, prednisolone, methylprednisolone, triamcinolone acetonide, desonide, fluocinonide, betamethasone, dexamethasone, dexamethasone sodium phosphate, fluocortolone, fluticasone propionate, beclomethasone dipropionate, budesonide, flunisolide
Brand names include: Orasone, Deltasone, Solu-medol, Decadron, Kenalog, Flovent (inhaled), Advair (inhaled), Qvar (inhaled), Pulmicort (inhaled), Azmacort (inhaled), Aerobid (inhaled)
Steroids are commonly used for a wide variety of conditions including asthma, allergies, skin conditions, arthritis and other rheumatological conditions, post-surgical, brain tumors, traumatic brain injury, optic neuritis, giant cell arteritis, lupus, adrenal insufficiency, and more. Steroids can be given by many different routes, including inhaled, nasal spray, oral, topical, intravenously, intramuscularly, and into joints. The eye can be affected by any steroid through any route of administration.
The two major complications of steroid use are usually found with chronic use as opposed to a short term administration such as found in a dose pack. However, ocular complications can also occur with very high doses of steroids, especially those given IV. Cataract is a common complication of chronic steroid used, including nasal spray steroid use for allergies. The type of cataract is often the posterior subcapsular type, and often leads to symptoms very early in the course of development. This type of cataract often requires surgery even in the earliest stages. It can develop rapidly, with the vision often declining in a matter of weeks to months.
The second major complication is a steroid related rise in eye pressure, also known as being a “steroid responder”. This usually requires at least 2 weeks of continuous steroid use, and is reversible if the steroid is discontinued. The rise in pressure can be very high but if often asymptomatic. It may be more common in people already being treated for glaucoma. If a person has glaucoma or has a history of steroid related eye pressure problems, they should consult with an ophthalmologist for monitoring of eye pressure if steroid treatment is being contemplated.
Finally, some cases of central serous retinopathy have been associated with steroid use. This condition is usually self-limited and reversible.
Deseroxamine (also known as desferrioxamine mesylate, Desferal, DFO, DFOA)
Deferoxamine is a chelating agent used to remove excess iron from the body. It acts by binding free iron in the bloodstream and enhancing its elimination in the urine. By removing excess iron, the agent reduces the damage done to various organs and tissues, such as the liver. Deferoxamine is used to treat acute iron poisoning, especially in small children. Repeated treatment with this agent is also frequently necessary to treat hemochromatosis, a disease of iron accumulation that can be either genetic or acquired. Acquired hemochromatosis is common in patients with certain types of chronic anemia (e.g. thalassemia and myelodysplastic syndrome) who require many blood transfusions, which can greatly increase the amount of iron in the body. Deferoxamine is also used to treat aluminum toxicity in certain patients.
Deferoxamine can cause toxicity to the retina. Retinal toxicity may develop acutely or after chronic administration. Therefore, patients should have a baseline ophthalmological examination before starting on this medication and be advised to report any visual symptoms immediately. Eye examinations should be repeated every three months while on treatment. Symptoms of retinal toxicity include complaints of blurred vision, poor night vision, poor color vision, or peripheral visual field loss. These symptoms typically precede ophthalmic signs by weeks to months. Once signs have appeared, visual dysfunction is largely irreversible. Retinal findings of toxicity include speckled pigmentation and narrowed arterioles typical of damage to the retinal pigment epithelium and photoreceptors.
Other ocular side-effects include cataracts, retrobulbar optic neuritis, pigmentary retinopathy, bull’s eye maculopathy and vitelliform maculopathy. The pigmentary retinopathy usually involves the macula and less commonly the peripheral retina. It is unclear whether ocular toxicity is dose-dependent or not, but dosages higher than 50 mg/kg/day are at increased risk for developing systemic toxicity. All patients on desferoxamine treatment should have baseline visual acuities, color vision, visual fields, and ERG if available.
Digitalis (Digoxin, Lanoxin and many other brand names)
Digoxin (first extracted from the foxglove plant, Digitalis lanata) is used primarily for the treatment of cardiac conditions such as atrial fibrillation, atrial flutter, and congestive heart failure. The drug can be difficult to maintain at effective but nontoxic levels. Visual abnormalities are among the first and most common signs of digoxin toxicity, occurring in 7% to 20% of adults on the medication. Patients most frequently complain of decreased acuity, xanthopsia (yellow colored vision), chromatopsia (abnormal coloration of objects), photopsias (sparkles of light in the vision), photophobia (light sensitivity), and blind spots near the center of the vision. The retina is believed to be the main site of digoxin toxicity. All visual disturbances disappear days to weeks after digoxin is discontinued, however, digoxin toxicity can have life-threatening complications including heart block if not treated promptly.
ERECTILE DYSFUNCTION MEDICATIONS
Sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis)
PDE5 inhibitors sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis) are prescription drugs which are taken orally for erectile dysfunction. Ocular side effects can include pupillary dilation, redness, dryness, blurred vision, and a temporary bluish discoloration to the vision. The Academy of Ophthalmology cautions the use of this drug in individuals with retinitis pigmentosa, macular degeneration, and diabetic retinopathy. There have now been many cases of vision loss secondary to ischemic optic neuropathy reported. I have seen about 10 patients have sudden loss of vision permanently from Viagra.
Ethambutol (Myambutol or EMB)
This drug is widely used to treat mycobacterial disease, including tuberculosis. If it is not taken at safe doses, it is can be toxic to the optic nerve. The damage typically occurs slowly and progressively in both eyes, and it is usually irreversible. Patients are typically treated with doses up to 25 mg/kg/day, especially shortly after diagnosis. Safer doses may be 15 mg/kg/day or less. Patients with kidney disease may be at higher risk for toxicity. Regular eye examinations should be performed in patients on this medication because the treatment of mycobacterial infections is usually very lengthy.
Medications Discussed Include: ciprofloxacin (Cipro), levofloxacin (Levaquin), norfloxacin, gatifloxacin, moxifloxacin
Oral use of fluoroquinolones, and most specifically Cipro, have been associated with an increased risk of acute retinal detachment in current users of the medication. A large study published in 2012 found an 4.5 fold increased risk of retinal detachment in patients using oral fluoroquinolones compared to patients not using the medication. Most patients in the study were taking the oral fluoroquinolone for respiratory or genitourinary infections, the retinal detachment occurred within 5 days of starting the medication. The authors hypothesized that fluoroquinolones might alter the vitreous of the eye leading to the detachments, possibly in a similar way that fluoroquinolone use has been associated with an increased risk of Achilles tendon rupture.
GILENYA (FOR MULTIPLE SCLEROSIS)
Gilenya is a relatively new medication for the treatment of multiple sclerosis. Gilenya can cause macular edema (swelling in the central visual part of the retina), generally within 3-4 months of starting treatment. Macular swelling can cause symptoms similar to those that occur with an attack of optic neuritis, or may not be noticed at all. It is recommended the patient has an eye examination before starting treatment and then three to four months later. The patient should monitor their vision for any changes such as blurriness or shadows in the center of the vision, a blind spot in the center of the vision, sensitivity to light, or changes in color vision. There may be an increased risk of macular edema when Gilenya is used in diabetics or in people with a history of uveitis (inflammation within the eye).
Interferon-α is used to treat various illnesses including chronic hepatitis B and C infection, renal cell carcinoma, leukemia, lymphoma, AIDS-related Kaposi’s sarcoma, malignant melanoma, and hemangiomatosis. Interferon can lead to retinal damage anywhere from 2 weeks to 3 months after the medication is started. The retinopathy is typically characterized by cotton wool spots and retinal hemorrhages near the optic nerves. Retinal complications may or may not be dose-dependent, and usually resolve spontaneously or disappear when the drug is discontinued. Most patients with interferon retinopathy are asymptomatic; however, vision loss may occur and can be irreversible in some patients even after discontinuation of therapy. Branch retinal artery and vein occlusion, central retinal vein occlusion, branch retinal artery occlusion, CME, and optic disc edema have all been associated with interferon therapy and can cause irreversible vision loss. Patients with diabetes or hypertension or who are taking interferon or high interferon doses are more likely to experience interferon retinopathy and should be closely monitored when taking this drug. Controlling associated hypertension alone may be enough to quiet the retinopathy without the need to discontinue interferon treatment.
ISOTRETINOIN (ACCUTANE IS NO LONGER AVAILABLEMedications Discussed Include: chlorpromazine (Thorazine), thioridazine (Mellaril), trifluoperazine (Stelazine)
These psychiatric medications, taken in large dosages can lead to pigmentation of the conjunctiva, cornea, and eyelids. Blurred vision and dry eye are common symptoms related to use. With longer term use, a pigmentary retinal degeneration can also occur when can lead to visual loss. Cataract is also possible.
Rifabutin is a derivative of rifampin, and is an oral antimycobacterial antibiotic that is used as a prophylactic agent against Mycobacterium avium infections in patients who are HIV positive or otherwise immunocompromised. Rifabutin has been associated not only with a characteristic hypopyon anterior uveitis, but also with other forms of uveitis such as intermediate uveitis, panuveitis, and retinal vasculitis, which have been recently reported. Dosage and duration are significant risk factors for rifabutin-induced uveitis. Medications such as clarithromycin and ritonavir can exacerbate rifabutin-associated uveitis through inhibition of hepatic cytochrome P450 enzymes.This uveitis responds to intensive topical corticosteroids therapy and discontinuation of rifabutin.
Rifampin (also rifampicin, Rifadin)
Rifampin is usually used to treat Mycobacterium infections, including tuberculosis and leprosy. The medication is intensely red, which can cause certain bodily fluids, such as urine and tears, to become orange-red in color, a benign side effect which can be frightening if it is not expected and prepared for. The color change of the urine is the most striking, occurring for a few hours after taking a dosage. The discoloration of sweat and tears is not directly noticeable, but sweat may stain light clothing orange, and tears may permanently stain soft contact lenses.
Scopolamine (Scopolamine Patch)
This is a patch often placed behind the ear to help relieve motion sickness, or sea-sickness. Scopolamine is a potent pupillary dilating agent, with the pupillary dilation lasting 3 to 5 days. When used normally, this ocular side effect is not usually seen, or is minimal. However, if the patch is broken open or cut, and the contents are inadvertently rubbed into the eyes, this pupil dilation could occur. A loss of focusing ability also occurs with the dilation. If this inadvertent complication occurs, the dilating effect has to wear off on its own.
Sertraline is used to treat major depressive disorders, post-traumatic stress disorder, panic and anxiety disorder, and obsessive-compulsive behavior disorder. Patients taking this medication may experience reduced focusing ability (accommodation), and some patients may have a need for reading glasses (presbyopia) in excess of what would normally be expected based on age alone. Patients may also experience abnormal extraocular muscle movement patterns, leading to double vision. Patients may also experience foreign-body sensation.
Tamoxifen is a commonly used estrogen receptor modulator used in the management of breast cancer. Currently, it is used to treat early and advanced stages of estrogen-receptor–positive breast cancer in pre- and postmenopausal women. Intraretinal crystalline deposits, corneal deposits, macular edema (swelling), and localized retinal pigmentary changes, along with decreased visual acuity (VA), have been linked with tamoxifen doses greater than 60 mg/m2 per day. The macular toxicity of tamoxifen may also predispose to macular hole formation.
Upon eye examination, crystalline deposits are most commonly within the parafoveal area of the macula. The frequency of ocular toxicity with long-term low-dose tamoxifen use is rare, generating controversy over the requirements for regular ophthalmic screenings in patients using low-dose tamoxifen. Discontinuation of tamoxifen usually improves vision and edema but has no effect on the crystalline deposits.
Topamax is used as an antiseizure medication, to treat migraine, and to treat bipolar disorder among other conditions. An ocular syndrome has been identified characterized by acute myopia and secondary angle closure glaucoma. Symptoms have typically occurred within the first month of therapy, with patients reporting an acute onset of decreased visual acuity and/or ocular pain. Eye examination shows myopia, redness, shallowing of the anterior chamber and elevated ocular pressure, with or without pupil dilatation. Supraciliary effusion may displace the lens and iris anteriorly, secondarily causing angle closure glaucoma. If patients develop this syndrome, the primary treatment to reverse symptoms is discontinuation of Topamax as rapidly as possible, according to the judgment of the treating physician. In contrast to primary narrow angle glaucoma, which is rare under 40 years of age, secondary angle closure glaucoma associated with Topamax has been reported in pediatric patients as well as adults. Patients taking Topamax should be told to seek immediate medical attention if they experience blurred vision or periorbital pain.
Amitriptyline (Elavil), doxepin, nortriptyline, desipramine, clomipramine
This class of medication used for depression can have several ocular side effects. They can cause a decrease in tearing, which can lead to dry eye problems. They also can lead to a decrease in focusing ability (accommodation). This temporary effect may cause difficulty with reading or even distance vision. Finally, these medications may lead to acute angle closure glaucoma, in those persons at risk for this type of glaucoma. Most people with glaucoma have “open angle” glaucoma, and would not have a problem with taking these medication. Sometimes consultation with an ophthalmologist might be required to determine if there is a risk for angle closure glaucoma by performing a test in the office called gonioscopy. A small lens is placed on the eye after anesthetic eye drops, and the part of the eye at risk for glaucoma can be examined directly.
Supplemental Vitamin A
Vitamin A has a reputation for being beneficial to the eye. The retina does need a normal amount of vitamin A to properly function, and this amount can be obtained with a well balanced diet without supplements. Large dosages of vitamin A have NOT been shown to help to preserve vision in conditions which cause retinal degeneration (such as retinitis pigmentosa). Excessive vitamin A intake can be harmful, as it is stored by the body. One condition that can be caused by a large intake of vitamin A (or of foods containing a large amount of vitamin A such as cod liver oil and liver) is “pseudotumor cerebri”, which is an increase in the pressure of the fluid around the brain (increased intracranial pressure). This can cause visible swelling of the optic nerve within the eye, as well as symptoms of headache and visual disturbances.