Accutane

--Isotretinoin

Is a form of Vitamin A, and used to treat psoriasis, cystic ance and other skin conditions

1) Optic Neuritis

2) Dry Eye

3) Decreased Night Vision

4) Transitory Myopia

- intracranial HTN (pseudotumor cerebri) - 2-3 months after treatment

-abnormal meibomain gland secretion/gland atrophy

- increase tear film osmolarity

- decrease CL tolerance

- ocular discomfort

- blepharoconjunctivitis

- keratitis

-corneal opacitieis

-decreased vision

-photophobia

-decreased dark adaptation

-myopaia

Annual eye exam certainely recommended.

-return: ocualar discomfort, redness, CL intolerance -->usually occurs in 4 weeks

- Urgent: decreased vision, HA, visual obscurrations

in 2-3 months very important for px to come in if they are experiencing blurry vision and HA -->discontinue especially if nyctalopia develops.

Amiodarone

Codarone, Pacerone

- used for anti-arrhythmia medication

1) Whorl Keratopathy

2) Optic neuroapthy

3) photophobia

Likely risk:

1) NAION

f/u every 6 months

-seek care if visual disturbances noticed

- if px is not on amiodarone -->refer for Fabry

- months for optic neuropathy to occur

- days-weeks NAION

-discontinue only if medically acceptable

dose is high. Keep dose low and corneal ADRs are not commonly seen.

>400mg/day

Avandia/Actos

rosiglitazone maleate

--for diabetes, it increases sensitivity to insulin

1) Macular Edema

DDx from CME

Contraceptives

-estrogen and/or progesterone

1) Optic Neuritis

2) Pseudotumor cerebri

3)dry eye

also

-retinal thrombosis

-cardiovascular events

Oral contraceptives / hormone replacement therapy

-more commonly side effects are in overweight women of child-bearing age

-risks outweigh the side effects -- just monitor with annual eye exams

Causes of dry eye:

- decreased tear secretion, goblet cell density decrease

-cl intolerance

Coumadin

-warfarin sodium

--preventing clot formation in atrial fibrillation and thrombosis

1) retinal and subconjunctival heme

INR stands for International Normalized Ratio. -->INR over 5 is very prone to bleeds.

INR=(PT/MNPT)^ISI.
PT is the patient's prothrombin time. MNPT is the mean normal prothrombin time. ISI is the International Sensitivity Index determined for each batch of thromboplastin reagents by manufactures.

1) Talc retinopathy (magnesium silicate)

2) Epithelial defects

-Talc is the filter in cocaine along with flour, laxatives, sugar and nocal anesthetics.

-when you crush and inject talc gets right into blood
- drug users inject 10-40 tabs per day. This is typically seen after injecting 1200 tablets
- deposits in retina, liver, kidney, spleen, granulomatous nodules in lungs
- cannot dissolve
- by the time you see the talc in the eye the patients are already very sick due to deposits elsewhere.

small, white shiny particulate emboli in the small arterioles and capillary bed usually in the fovea.

--macular edema

-venous engorgement

-FLAME HEMES

-montior for neovasc of retina and ON - if they keep using drugs

- laser photocoagulation or vitrectomy due to heme may be necessary

-Microtalc retinopathy should be monitored as open angle glaucoma --IOP measurements and use drops to prevent VF loss.

Digoxin

-digitek

For Congestive heart failure

1) R-G colour defect

2) flickering or flashes of lights, coloured spots

3)snowy, hazy or dimming vision

4)xanthopsia (yellow tinge to vision)

--all reversible upon cessation of drug use

Others:

- visual hallucinations, mydriasis, muscle paresis

Monitor their colour vision (blue-yellow) with D-15

--report to prescribing physician to consider concomitant cardiac digitalis toxicity.

Ethambutol

--myambutol

Used for tuberculosis

The effects of Ethambutol are dose related.

-->all leading to optic atrophy (reduced VA, VF defect, CV defect). It is usually retrobulbar and bilateral.

Occurs after 3 months of use.

Adults take 15-25mg/kg but total daily dose should not exceed 900-2500mg.

px recieving 25mg/kg /day -->6% optic neuroapthy

vs. 15mg/kg/day -->less than 1%

discontinue at any sign of visual effects.

Monthly exams esp for higher risk px (DM, renal failure, alcoholism, older px, children)

Consider OCT to pick up early swelling (in NFL), or chronic effects (NFL thinning)

Flomax

--tamsulosin

Used for benign prostate hypertrophy

1) loss of tone in iris dilator smooth muscle causing poor pupil dilation

--dilation/prolapse during cataract sx.

It is a selective Alpha-a1 antagonist

this will be on exam

IFIS is caused by Flomax (tamsulosin)

Mx: discontinue med before surgery to minimize degree of IFIS. methods during sx can also reduce complications.

Intraoperative Floppy Iris Syndrome

--this is a "Certain" OADR

--flaccid iris stroma billows on irrigation

--iris prolapse toward incisions

--intraoperative miosis

Fosamax

--Alendronate/bisphosphanates

Used for Osteoporosis treatment and prevention

1) Blurry vision

2)hyperemia

3)anterior uveitis

4) episcleritis

5)scleritis

Bisphosphonates treat people who are really sick and need the drug (Paget's disease, hypercalcemia)

sxs occur 6-48 hours after injection.

-resolve upon discontinuation of tx.

How to Mx?

Persistent decreased VA or pain (scleritis/episcleritis) -->give NSAID

Anterior uveitis -->intensive topical therapy or systemic meds.

But discontinuation may be required for inflammation to resolve -->especially for Scleritis.

Interferons

-Intron A/Avonex/Pegasys

Used for hepatitis and MS

1) Ocular Pain

2) Conjunctivitis

3) CWS

4) optic neuritis

5)pronounced Dry eye

Levothyroxine

--Synthroid

Used to replace thyroxin not produced by thyroid

1) Diplopia

2)Ptosis

3)paralysis of EOM

Collaborate with endocrinologist in case dose should be adjusted to balance T-level control, and reduce side effects.

Other side effects

--eyelid hyperemia,

--pseudotumor cerebri

ALL reversible upon discontinuation of Tx.

Lipitor/Zocor

--atorvastatin/simvastatin

Used to control hyperlipidemia

1) Pseudo-cystoid Macular Edema

Commonly in med 30-50.

Effects can also be seen in Niacin therapy (to lower cholesterol)

Phenothiazines

--Thorazine, Mellaril

Used for Depression and Anxiety, schizophrenia

1) Night Blindness - Nyctalopia

2) Brown Vision

3) Anterior Subcapsular Cataract

4) Salt and Pepper Fundus

Based on dosing around 800 mg/day increases risk of toxicity.

Phenothaizines

-effects begin in 30-90 days

Phenothiazines, Pepper fundus, Psychotic, Pigmentary changes!

Certain - pigmentary changes

- RPE and Choroidal atrophy

Reduced VA, colour vision distrubances and dark adaptation issues.

f/u DFE every 2-4 months initially

- then every 6 months depending on dose/duration

sxs often preceed fundus changes, once this happens discontinue. Progression may occur even when drug is stopped.

Plaquenil

--Hydroxychloroquine

Used for Malaria Rx, Rheumatoid Arthritis, Lupus

1) Bull's Eye Maculopathy

2) Corneal Deposits (whorl)

What does OD do?

- baseline HVF-10

-give Amsler grid

-test colour vision

--Then yearly thereafter

Hydroxychloroquine has much less risk of OADRS than chloroquine (Aralen).

Chloroquine-->toxicity with cumulative dose of 300g

Hydroxychloroquine -->used chronically 2x200mg tabs per day. Lower risk.

Bulls eye-->starts with 6/18-->6/60 --> CF

--Stopping the drug does not necessarily stop progression of disease.

Corneal deposits -->often does not change mx of the patient.

Prednisone

--Steroids

Used for Lupus, RA, other Immune-conditions

1) Posterior Subcapsular Cataracts

2) High IOP

When do you monitor?

- 20-80mg/day, intravitreal injections, implants

- delayed epithelial wound healing, PSC, decreased resistance to infection, decrease tear lysozyme, hyperemia, translucent blue sclera, increased IOP, mypia, exophthalmos, intracranial HTN, diplopia, EOM paresis, eyelid ptosis, CSR

Mx:

- f/u depending on dose and duration

- every 6 months for cataract formation

-IOP monitoring depends on type, route, dose, duration  -- if it becomes elevated taper off steroids. If px is on lowest dose possible use anti-glaucoma agents to lower IOP.

Prozac/Antidepressant

-Fluoxetine/SSRI

1) Dry Eye

2) Blurred Vision

3) Mydriasis

4) Photophobia

5) Diplopia

6) conjunctivitis

7)Ptosis

Tamoxifen Citrate

--Nolvadex

Used for Breast Cancer

1) Crystalline Retinopathy

--central VF defect since they affect Macula.

Normal dose is 20mgday-->low risk.

5% of px 1-2 years after beginning Tx.

Other OADRs

- PSC

-CV decrease

-cataract

-VF changes

-Optic Neuritis

Topamax

--topiramate

Used for Seizures and off label for migraine headaches

1) acute myopia

2) bilateral angle closure glaucoma

Ultrasonography shows choroidal effusion, choroidal detachment, ciliary body edema.

Occurs 3-14 days after starting drug. Examine within 2 weeks.

Stop medication

-treat with hyperosmotics, cycloplegics, topical IOP lowering meds

Viagara/Levitra/Cialis

--Sildenafil

Used for ED

1) Blue tinge to vision (cyanopsia)

2) NAION

3) Macular Edema

Occurs in 11% of px on 100mg doses.

Viagara Mx

-those with previous NAION or PR should not be on this drug.

CV and light percept changes are transient and occur due to blood [conc]. Anyone who experiences this should be advised to stop taking Viagara. They occur 15-30 mins after ingestion, peak at 60mins.

NAION --also associated with the men who take Viagara (not just the drug)risk is small --only a possible Risk.