There’s Something Wrong With My Eyes!

Dianna Graves, BS Ed, COMT has no financial relationships to disclose. She is an Independent Continuing Education Consultant.

Changes Systemic Medications Color Vision: Can Cause With The Eye or Vision Bull’s Eye Maculopathy • Color Vision Ethambutol (TB medicine) can • Pigmentary Changes cause a decrease in vision, central • Lens or Cornea Keratopathies visual field defects, and decreased • Increased IOP color vision. • Retinal Toxicity *Chloroquine (Aralen phosphate) and • Nystagmus, EOM Palsy Hydroxychloroquine (Plaquenil sulfate) or Diplopia were first used to treat malaria. It was then found • Visual Acuity to be effective for rheumatoid arthritis, lupus and • Pupil Dilation other autoimmune diseases. Anti malarials can also • Dry Eyes cause whorl pattern opacities in the cornea, as well as • Hallucinations retinal pigmentary degeneration. Early macular toxicity can cause a granular pigmentation to occur. pesudovs.com springerimages.com

Chloroquine vs Viagra, Cialis or Levitra Hydroxychloroquine Chloroquine (used to treat Many users of Viagra find that malaria, RA and Lupus) tends they can’t visually distinguish to be more toxic than the differences between the Hydroxychloroquine. colors blue and green . The risk of irreversible Many more get what is known retina damage is dose dependent. Toxic macular as “blue vision”. This side effect changes are seen as a causes the patient to see Bull’s Eye maculopathy starts everything with a blue tint. The side effects are short lived and with fine, pigmentary mottling at generally peak within 1-2 the macula. hours after the drug is taken. The end result can range from reduced vision to possible blindness.

1 Digitalis

Visual disturbances can occur Digitalis (comes from a plant because they block the called Foxglove). It is an photoreceptors causing anti-arrhythmic medicine used difficulties problems with seeing blue and green. to control heart rate, especially Pilots & emergency drivers AFIB and Congestive Heart need to see yellow and green lights (and blue for runway Failure (CHF). Another Vision-simulator.tripod lights) and need to be cautioned !! common heart med is Digoxin. Digitalis toxicity can cause: anorexia, nausea, Who will have color vision changes ………??? vomiting /diarrhea, xanthopsia (yellow vision), 3 % of men taking doses of 25-50 mg

11 % taking 100 mg doses and blurry halos. 50 % of men taking 200 mg 100% of men taking 600 to 800 mg

Corticosteroids (Prednisone (Deltasone) and Lens Changes Aristocort (Triamcinolone) Cataracts can occur with phenothiazines and Corticosteroids are used to treat inflammatory antipsychotic medicines. and allergic conditions. They Chlorpromazine HCL are very effective for acute disease as well as chronic conditions (Thorazine) Thioridazine and (asthma and chronic obstructive (Mellaril) can cause also pulmonary disease (COPD). cause pigmentary changes Cataracts resulting from steroid in the cornea and conjunctiva as well as anterior use are well known and can occur subcapsular cataracts. Thorazine rarely affects with topical, systemic, and inhaled steroid use. the retina, but Mellaril may create pigment Posterior subcapsular (PSC) opacity is most frequently seen. changes than can cause a decrease in vision and color vision. quizlet.com

Prednisone

Oral, inhaled, eye drops or Cataracts are the other IV steroids are most commonly complication. The typical used for asthma or emphysema steroid induced cataract attacks. Emphysema is the gradual old.eyenews.ru destruction of the alveoli in the is a PSC cataract lungs. Prednisone is also used as and develops on the back activeforever.com an anti-inflammatory for arthritis. surface of the lens. Chronic steroid use can lead to glaucoma and/or These can occur rapidly cataracts. The glaucoma is treatable with medication and quickly become with the pressure usually returning to normal levels once visually significant. the steroids are stopped. Glare is the number one patient complaint.

2 Tamsulosin (Flomax) Cornea Keratopathies & Keratitis

You need to ask your patients if • Multiple drugs can cause they have ever used Flomax corneal keratopathies, as well especially if the patient is being as lens deposits, including evaluated for cataracts. Flomax is Chloroquine, Hydroxychloroquine, used by men to treat prostate Eyeworld.org and Amiodarone. enlargement and improve urinary flow . • Whorl patterns occurs in the Women use Flomax when they have a problem with corneal epithelium. They appear spontaneous urination. The most common side effect is in nearly 100% of patients taking intra-operative floppy iris syndrome (more prone to Amiodarone for more than (6) prolapse during surgery). months. The whorls disappear within months of Even after the Flomax is discontinued, the patient is at . fabrycommunity.com a lifetime risk of IOFI syndrome. discontinuing the medication

Amiodarone Afib

Anti-arrhythmic drug suppress abnormal heart rhythms (cardiac arrhythmias ) i.e atrial fibrillation, ventricular tachycardia, and ventricular fibrillation, that can cause an irregular and rapid heart rate (up to 350 to 600 times per minute !) Used when routine Digitalis therapy fails, and tends to cause whorl like corneal deposits in as early as (6) days of treatment, but more commonly in scholarpedia.org (1) to (2) months of treatment legacy.revoptom.com

Retinal Toxicity “Talc Retinopathy” Amiodarone can also cause anterior and Numerous drugs have posterior subcapsular lens changes. been associated with Visual acuity (VA) is not usually grossly retinal toxicity, including affected (20/25-20/30). Chloroquine, Tamoxifen Patient complaints Hydroxychloroquine, and may be : Mellaril. • Glare Talc retinopathy, appears as multiple tiny, • Halos yellowish white, glistening particles. The extent • foggy vision of the talc usually corresponds with the amount and duration of illicit drug abuse and what the cocaine has been “cut” with !! pacificu.edu

3 Retinal Toxicity: Cocaine & Retinal Artifacts Tomoxifen Tomoxifen is an anti-estrogen medication Cocaine can be inhaled or injected. It also causes dilated pupils and blurry used to treat breast cancer. vision. People using cocaine have Retina toxicity presents as a "high" feeling of supremacy, increased body temperature, multiple superficial yellow increased heart rate/ blood pressure, restlessness, irritability, anxiety, paranoia, crystalline ring like and aggression. It is deposits in/near the considered a Schedule II drug - meaning it has high potential for abuse. It can also macula. be used for legitimate medical This can cause a reasons i.e. local anesthetic for some eye, ear, and throat surgeries. decrease or loss of visual acuity . quizlet.com

Cocaine dealers generally There are also reports of dilute it with an increase risk for corneal ulcers. The reason is not substances like: fully understood, except that cornstarch, talcum cocaine is a strong eye powder, sugar, flour, and anesthetic thereby causing accidental ulceration due to laxatives causing the injury, etc. Once the anesthetic effect wears off, the retina to have a “talc” eye becomes painful and blurry. retinopathy appearance. Scarring can cause eventual permanent vision loss.

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Nystagmus, EOM palsy & Intravenous Drugs Diplopia Injecting drugs directly Anticonvulsants: into the veins can also lead Drugs prescribed not only talc deposits to form in for chronic epilepsy but also for the retina. Pain. Phenytoin (Dilantin) and This can cause loss of Carbamazepine (Tegretol) are vision because the larger very commonly prescribed Wikipedia.com particles can block the and can cause nystagmus and retinal circulation when it gets lodged Nature.com glare. in a vessel. This can cause an artery occlusion Hyperglycemics: resulting in rapid loss of vision. Glipizide and Glyburides are used to treat diabetes. Excessive alcohol use

4 Chlorohydrocarbons: Medications To Treat Aerosals Depression & Bipolar Disorders Inhaling aerosols can cause: double vision, loss Lithium, Depakote ,Tegretol and Neurontin are of coordination, weakness, severe headaches, nausea / all anticonvulsant medications used to vomiting, numbness, irregular treat bipolar affective disorders, heartbeat, and suffocation. Commonly abused: paint such as manic depression. thinners, gasoline, felt markers, Drugs in this class (manic depressives) nail polish remover, glue, and other can cause downbeat jerk nystagmus household products. that may not reverse when the Aerosol sprays containing medication is stopped. “propellants” and solvents including: spray paint, Blurred vision also can sometimes occur. deodorants, hair spray, amyl nitrates and lighter fluid.

Visual Acuity Changes: Oral Visual Acuity Changes Contraceptives Visual acuity may be The exact cause has not been proven, decreased by transient but may be associated with changes in refractive steepening of the corneal, error caused by corneal edema from hypoxia, Sulfonamides (Sulfa), and decreased tear production. antifungal agents Blurriness also can occur like when Metronidazole (Flagyl), you are pregnant! A change in the Thiazide diuretics (HCTZ), hormones (due to the artificial and Carbonic hormones you are taking) can Anhydrase Inhibitors (Acetazolamide and Dorzolamide) cause the lens to swell. for glaucoma .

Thioridazine (Mellaril) & Pupil Dilation Chlorpromazine (Thorazine) Pupil dilation can be caused by Thioridazine (Mellaril) has almost completely replaced Chlorpromazine (Thorazine) use. anticholinergic drugs (Atropine, They are both used to treat Atrovent and Detrol), antihistamines, schizophrenia and are considered antipsychotic medications. antidepressants (Lexapro, Paxil), Both these drugs have and CNS stimulants (cocaine and anticholinergic properties (blurred amphetamines). vision, decreased accommodation and mydriasis). This is often transient and dose dependent. Reduced tearing and dry eyes may also occur. Both of these drugs can cause cornea and lens changes as well.

5 Atropine Amphetamines

Atropine, and its related drugs, Amphetamine are considered also will cause pupil dilation. stimulants. Their use can lead to Scopolamine patches are a reduced focusing ability and often used to prevent a dilated pupil. Because the motion sickness, and are pupil remains dilated, there frequently used on is some risk of angle closure. The cruise ships. Passengers eye pressure suddenly elevates, often dilate their eyes by causing eye pain, redness, blurry vision or loss of vision, mistake if they apply the “rainbows” around lights, patch and then touch their nausea, and/or vomiting. eye. This leads to anisocoria and/or mydriasis.

Stimulants

A stimulant is a name given to Besides blurry vision, several groups of drugs that there can be additional tend to increase alertness and hazards regarding driving. activity. Using amphetamines The groups include amphetamines interferes with street drugs ("uppers" or "speed “) and cocaine. concentration, Amphetamines: increase heart and respiration as well as impaired vision. rates, increase blood pressure, dilate the pupils, It also increases the driver's tendencies cause blurry vision, decreased appetite, anxiety, to take risks ! and dizziness.

Pupil Constriction

Amphetamines are a Heroin is an opioid Class B drug, unless analgesic synthesized prepared for injection. from morphine, which is a derivative of the opium Then it changes it to a poppy. When used in class A drug. medicine it is typically Class B drugs carry a maximum jail used to treat severe pain, sentence of 5 years and/or an unlimited such as that resulting from Empower.com fine. Class A fines are longer ! a heart attack.

6 Dry Eyes Amitriptyline (Antidepressants)

Amitriptyline is used to treat Dry eye complaints may be symptoms of depression. It also caused by antihistamines, can be used for post-herpetic beta blockers prescribed for neuralgia. They can cause a decrease in tearing, which can high blood pressure problems lead to dry eye problems, (Atenolol,Tenormin) headaches and hallucinations. It also can lead to an inability to focus (decreased accommodation). This is a and antidepressants temporary side effect that can cause problems with (Amitriptyline and reading and/or distance vision. There may also be a risk for acute angle closure glaucoma, in those persons who Sinequan). are already at risk for this type of glaucoma. COAG patients can take this medication .

Hormone Replacement

Hormone replacement therapy (HRT) with Hormone replacement therapy (HRT) is estrogens alone or in used by an estimated 38% of combination with postmenopausal women. progesterone is a commonly In the study done by Schaumberg, et al, prescribed therapy for post-menopausal it was shown that the use of HRT was women. This use of estrogen replacements significantly related to the prevalence of and/or contraceptive agents is commonly dry eye syndrome. Schaumberg; JAMA implicated in dry eye. article/study 2001

Headaches: Hallucinations Minocycline Minocycline (brand names Minocin, Dynacin, Vectrin) Hallucinations are defined as a is a broad spectrum tetracycline derivative also used to "perception of objects with no treat severe acne. reality." They cause us to Relatively soon after starting this drug, some patients believe we are seeing or hearing something that isn't there. may develop increased intracranial pressure. Besides medications, they can When detected early enough, stopping the drug also be caused by head injuries will reverse the pressure. However, or tumors, illegal drugs (LSD), the optic nerves can be damaged by dementia ,sleep deprivation prolonged pressure elevation. and even stress.

An increase in photo sensisitivity is also very common.

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7 Marijuana

Using marijuana can Short-term Effects include: cause your eyes to be * Increased heart rate, body temperature, and appetite bloodshot and your * Drowsiness pupils to dilate. It also * Dry mouth and throat * Red of the eyes and reduced IOP (?) can cause hallucinations. Marijuana has been linked a decreased Marijuana has numerous ability to safely drive a vehicle due to other side effects, decreased concentration, inability to adequately perceive time/distance, including lung disease decreased reaction time, poor speed and impairment of reasoning. Stopyouraddiction.com control, inability to accurately read signs, and distraction (National Highway Traffic Safety Administration) .

Nitrous Oxide Mirapex (Parkinson’s Disease)

“ Laughing gas” Hallucinations in people that Comes in small metal cylinders are taking Mirapex is not a sold with a balloon or pipe rare side effect – some studies show up to 16.5 % of people propellant taking it have experienced It is used as an inhalant. hallucinations. Commonly, The effects it gives is a temporary loss of patients report seeing motor control, a "dissociative" psychological “snakes crawling up the walls” effect, mild hallucinations, and giddiness. Also and seeing “people in closets”. headache, dizziness, impaired judgment. Nitrous Hallucinations can also occur when using: Cimetidine (Tagamet) may be psychologically addictive. and Ranitidine (Zantac) .

Let’s Not Forget The Herbal Medications Chamomile has been used to Niacin (B3) can cause some of the treat eye disease as most severe eye reactions. Shown to lower cholesterol, it is well as insomnia, migraines, also successful in treating cardiovascular and headaches, bronchitis, fevers cerebrovascular disease. & colds, and burns. Also used to treat schizophrenia, diabetes, arthritis, hypertension, Chamomile tea has been sexual dysfunction and migraines. used topically in and around Ocular side effects show a possible the eyes to treat styes and relation to decreased vision, cystoid runny, irritated eyes. There are macular edema (CME), dry eyes, Discoloration & edema of the eyelids, as well as loss of reported cases of severe conjunctivitis eyebrows/lashes. The ocular side effects appear to be related to chamomile’s topical use. dose related.

8 Vitamin A contributes to Ginseng is used to boost the overall health of the energy and improve eyes, the skin and the to concentration. It has been associated with episodes of mucous membranes. Also frequently referred to hypertension and tachycardia, as Retinol, it can mostly be found in animal food and hypoglycemic effects in sources, as well as a number of plants that diabetics. It also can cause supply beta carotene, which is converted into insomnia, headaches and Vitamin A inside the body. Vitamin A can be nervousness. Diabetics and used for the treatment of acne. It has been heart patients should advise their doctor of use. shown that high doses of Vitamin A can cause increased intracranial hypertension.

Bilberry are similar to blueberries, St. John's Wort is commonly taken but smaller and darker, and have to reduce anxiety, depression, and a more intense flavor. Often used sleep disturbances. It also may cause damage to the lens and retina. to improve night vision. The active ingredient in St. John's Bilberry extract is thought to Wort (hypericin) has shown a potential for support blood vessel elasticity/permeability, phototoxicity due to its absorption spectrum of light in and to prevent leakage of vessels leading to the both the ultraviolet and visible light ranges thought that bilberry may be effective at leading to toxic retinal and lens effects, preventing capillary leakage in conditions such especially with outdoor sunlight exposure. People using St. John's Wort should as diabetic macular edema. There are no avoid sun exposure (not just UV exposure) for controlled studies /reports that have shown at least 2 days after taking the medication. this to be true. Allaboutvision.com

Ask for ALL the medications your patient is taking- they may be the cause of their eye problem !

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