medication toxicities – Ask Eye Doc

Written by: Dr. Stephanie Mulick, O.D. Medication Side effects that affect the Eyes Some medication side effects can cause significant visual problems. Make sure to have your annual dilated eye exam if you are taking any of the medications listed below. MedicationsDisease/Symptom TreatedSide EffectsSymptomsBisphosphonates (Actonel, Fosamax, Boniva)bone density loss or osteoporosisepiscleritis, ocular inflammationblurred vision, ocular inflammation and red eyesCrizotinibnon-small cell lung cancerFlashes of light Light glare (trails of light) Post-flash-bulb effect (persistent light or image in one’s vision)ElmironInterstitial cystitis (bladder pain)Pigmentary MaculopathyVision loss or distortion of visionErectile dysfunction medicationsErectile DysfunctionNon-arteritic Anterior Ischemic Optic Neuropathy, Retinitis Pigmentosadecreased vision, decreased color visionEthambutol (Myambutol)pulmonary tuberculosisoptic or retrobulbar neuritisdecreased vision or peripheral vision defectsGanglioside GD2neuroblastomamydriasis (dilated pupil)difficulty focusing and light-sensitivityHydroxy-chloroquine, Chloroquine, Plaquenilarthritis, COVID-19Macular degenerationcolor vision changes, progressive visual distortion, loss of visionImatinibchronic myeloid leukemiaperiorbital edemaswelling around the eyesImmune checkpoint inhibitorsCancer treatmentRetinal detachmentflashes of light, floaters, a curtain coming over ones visionIpilimumabmetastatic malignant melanomakerato-conjunctivitis sicca, proptosis, inflammationdry eye, bulging eyes, swelling around eyesMEK (mitogen-activated protein kinase inhibitors)cancer therapyRetinal detachmentflashes of light, floaters, a curtain coming over ones visionPentosan Polysulfate sodium (PPS)chronic interstitial cystitismacular degenerationcolor vision changes, progressive visual distortion, loss of visionPlaquenil (Hydroxy-chloroquine)malaria, Rheumatoid Arthritis, LupusBulls-eye maculopathyvisual distortion or decreased visionProstaglandin Analog (latanoprost, travoprost, bimatoprost)Glaucomadry eye, darkening of pigment on the eyes and eyelids, macular edema (rare)dry eyes, red eyes, red eyelids, increased eyelash growth, visual distorition (rare)Tamoxifenbreast cancerdecreased color vision, macular edema and maculopathydistortion of vision and colorTamsulosin (Flomax)benign prostatic hyperplasiafloppy iris syndromeCan affect the pupil during Cataract surgeryTaxolsmetastatic breast cancermacular edemadecreased vision and colorThiazolidinediones (Actos, Avandia)Type 2 Diabetesmacular edemavisual distortion or decreased visionThioridazine (Mellaril)anti-psychoticsignificant retinal toxicitydecreased vision and colorTopiramate (Topamax)epilepsy and migrainesacute angle-closure glaucomaeye pain, nausea, blurred visionVandetanibnon-small cell lung cancervortex keratopathyminor decrease in vision (complete resolution after treatment) Elmiron: Elmiron (FDA approved in 1996) is used to treat interstitial cystitis, a condition that causes chronic bladder pain. An unfortunate ocular side effect of Elmiron is Pigmentary Maculopathy. Pigmentary Maculopathy is a condition that affects the area of the retina called the macula which provides us with our central vision. This condition can mimic Macular Degeneration and lead to loss of vision. The longer that a patient takes Elmiron, the more likely they will develop ocular side effects. Robin A. Vora, M.D, Amar P. Patel, M.D., and Ronald Melles M.D., ophthalmologists at Kaiser Permanente studied 91 patients that had been using Elmiron for an average of 15 years. 22 of those 91 patients showed signs of pigmentary maculopathy. It is important to diagnose Pigmentary Maculopathy early in order to preserve vision. If you are taking Elmiron make sure to have dilated retinal eye exam every year or sooner if you are experiencing symptoms of vision loss or central vision distortion. Early detection can prevent progressive vision loss due to Elmiron toxicity. If your eye doctor sees signs of Elmiron Toxicity it will be important to talk to your urologist about discontinuing the medication. Cancer treatments: Many treatments for cancer have been shown to cause ocular side effects. Biologicals have become a common treatment in oncology. During treatment, it is necessary to have an annual eye exam. Here are a few medications that can have ocular side effects during treatment that resolve when the treatment is done. CrizotinibImatinibVandetanibGanglioside GD2IpilimumabTamoxifenTaxolsMEK (mitogen-activated protein kinase inhibitorsImmune Checkpoint inhibitors Crizotinib: Crizotinib, a treatment for non-small cell lung cancer, has been found to cause ocular side effects in 42 % of patients within the first two weeks of treatment, according to the study in The Lancet Oncology Vol 12, issue 11. Crizotinib ocular side effects were minor and included: Flashes of lightLight glare (trails of light)Post-flash-bulb effect (persistent light or image in one’s vision) Imatinib: Imatinib is used to treat chronic myeloid leukemia. In a study titled Ocular side effects in chronic myeloid leukemia patients treated with imatinib, 70% of patients developed periorbital edema (swelling around the eyes) as early as 24 hours up to 1 year after the start of treatment. There have only been two cases reported of optic nerve swelling, which can lead to visual distortion. Complete resolution was noted after discontinuing treatment. Vandetanib: Vandetanib is used to treat non-small cell lung cancer, can cause vortex keratopathy occasionally resulting in a minor decrease in vision that has been shown to resolve completely with discontinuation of treatment. Ganglioside GD2 Ganglioside GD2 is used for the treatment of neuroblastoma. A small study titled “Ocular symptoms in children treated with human-mouse chimeric anti-GD2 mAb ch14.18 for neuroblastoma” found that 10 out of 85 children exhibited dilated pupils resulting in light sensitivity and difficulting focusing, which completely resolved upon discontinuation of treatment. Ipilimumab: Ipilimumab is used to treat metastatic malignant melanoma. Side effects can include dry eye, proptosis, and swelling of the extraocular muscles which can mimic Grave’s disease (click here for my post on Grave’s disease). All of these side effects can be treated in conjunction with the treatment of Ipilimumab. Studies are still being conducted to rule out other ocular side effects from the use of Ipilimumab. Tamoxifen: Tamoxifen is a treatment for breast cancer. Ocular side effects can include decreased color vision, macular edema and maculopathy, leading to distortion of vision and color. Taxols (Paclitaxel): Taxols are used to treat metastatic breast cancer. Due to the ocular side effects of macular edema it is very important to have an annual dilated eye exam. If you experience decrease vision and changes in color perception let your doctor know right away. MEK (mitogen-activated protein kinase inhibitors): MEK, a type of cancer treatment has been shown to have a side effect of retinal detachment. If you experience flashes of lights, significant floaters (wispy shadows in your vision) or a curtain coming over your vision go into the nearest eye doctor immediately. With all these medications having an annual dilated eye exam is extremely important. Immune checkpoint inhibitor: Immune checkpoint inhibitor is another Cancer treatment that can lead to retinal detachment. Again if you exhibit flashes, floaters or a curtain over your vision, visit your nearest eye doctor. Thioridazine (Mellaril): Thioridazine is an antipsychotic medication used to treat schizophrenia. Significant retinal toxicity has been shown with the use of this medication leading to a decrease in visual acuity and changes in color perception. Prostaglandin Analogs (PGA): Prostaglandin Analogs such as latanoprost, travoprost, and bimatoprost are used to glaucoma; used as a once a day eye drop to help reduce eye pressure and decrease the risk for glaucomatous damage to the optic nerve. The side effects of Prostaglandin analogs are dry eye, red eyes or eyelids, darkening of pigment on the eyes and eyelids, increased eyelash growth, and rarely reported macular edema. Dry eye treatment can help with these side effects (review my post on dry eye treatment). These eye drops will be prescribed by your eye doctor and regular eye exams will be necessary to keep glaucoma well controlled. The side effect of eyelash growth led to several companies producing eyelash growth serums with prostaglandin analogs. These serums do help with eyelash growth but can still cause red eyes and eyelids and increase pigment of the eyes and eyelids as well as dry red eyes. Thiazolidinediones (Glitazones): Actos and Avandia are examples of Thiazolidinediones or TZD (also known as Glitazones) which are used in the treatment of Type 2 Diabetes. The documented side effects include edema, weight gain, increased appetite, macular edema, increased risk for bone fracture, increase LDL cholesterol and heart failure. Diabetics should have regular yearly dilated eye exams which would allow the Doctor to evaluate for potential side effects of macular edema. Keep in mind that macular edema is a risk factor for Diabetes even if not treated with TZD. According to the ACCORD Eye Study, the largest study on ocular side effects from the use of Thiazolidinediones (TZD) found no association between the use of TZD and Diabetic Macular edema. If you have Diabetes make sure to continue with regular Dilated eye exams to ensure early detection of Diabetic Retinopathy and early treatment for the best visual outcomes. Plaquenil (Hydroxychloroquine): Plaquenil has been used for the prevention and treatment of malaria. More recently Plaquenil has been used to treat auto-immune diseases such as Rheumatoid arthritis and Lupus. Plaquenil has been found to cause maculopathy which can cause loss of central vision slowly over time. Plaquenil toxicity is dependent on the dose and duration. The longer someone is taking Plaquenil, the more likely for ocular toxicity. Again, early detection is key. The sooner your eye doctor sees signs of maculopathy the better the prognosis for maintaining a good quality of vision. Specific tests should be done annually by your eye doctor including a Dilated eye exam and visual field exam. Bisphosphonates: Bisphosphonates are used to treat conditions that cause loss of bone density such as osteoporosis. If you are using Bisphosphonates (such as Actonel, Fosamax, Boniva, Reclast, Aredia and Didronel) and experience ocular side effects such as blurred vision, ocular inflammation and red eyes, schedule an appointment with your eye doctor for evaluation. Erectile dysfunction medications: Vardenafil, Tadalafil, and Sildenafil are frequently prescribed for the treatment of erectile dysfunction (ED). Potential ocular symptoms associated with ED medications include: blurry visionlight sensitivitydifficulty telling colors like blue and green aparthaving a blue-green tinge to your visiondecreased color visionA sudden decrease in vision A slow progressive decrease in vision If you take ED medication and experience any of the above symptoms schedule an eye exam immediately. You may be at higher risk for complications if you have a family history or have been diagnosed with Retinitis Pigmentosa or if you have diabetes, high blood pressure or heart disease. Tamsulosin (Flomax): Flomax is used to treat benign prostatic hyperplasia. It is extremely important to let your eye doctor know if you are taking this medication prior to cataract surgery due to the potential of floppy iris syndrome that can increase the complexity and lead to potential damage to intraocular structures during cataract surgery. Conclusion: Every medication can cause a potential side effect. Some are more serious than others. Knowing the ocular side effects of systemic medications and having regular eye exams can help prevent potential vision loss or other serious repercussions.