Transcript Slide 1

UPDATE ON DRUGS AND THE EYE
1. LOCAL EFFECTS OF TOPICAL EYE MEDICATION
UPDATE ON DRUGS AND THE EYE
1. LOCAL EFFECTS OF TOPICAL EYE MEDICATION
2. SYSTEMIC EFFECTS OF TOPICAL MEDICATION
UPDATE ON DRUGS AND THE EYE
1. LOCAL EFFECTS OF TOPICAL EYE MEDICATION
2. SYSTEMIC EFFECTS OF TOPICAL MEDICATION
3. OCULAR EFFECTS OF SYSTEMIC MEDICATION
OCULAR SURFACE TOXICITY
• ALL PRESERVATIVES CAN BE DAMAGING
OCULAR SURFACE TOXICITY
• ALL PRESERVATIVES CAN BE DAMAGING
• BAK IS FOUND IN MOST EYE DROPS AND IS A COMMON CAUSE OF
EPITHELIAL TOXICITY ESPECIALLY WHERE MULTIPLE DAILY DROPS ARE
REQUIRED ( E.G. GLAUCOMA )
OCULAR SURFACE TOXICITY
• ALL PRESERVATIVES CAN BE DAMAGING
• BAK IS FOUND IN MOST EYE DROPS AND IS A COMMON CAUSE OF
EPITHELIAL TOXICITY ESPECIALLY WHERE MULTIPLE DAILY DROPS ARE
REQUIRED ( E.G. GLAUCOMA )
• SOME TOPICAL AGENTS CAN CAUSE PUNCTATE KERATITIS
E.G. TOBRAMYCIN, GENTAMICIN, ACULAR, ACYCLOVIR. EVEN DILATING
DROPS CAN CAUSE THIS E.G. PRE-OP PHENYLEPHRINE
OCULAR SURFACE TOXICITY
• ALL PRESERVATIVES CAN BE DAMAGING
• BAK IS FOUND IN MOST EYE DROPS AND IS A COMMON CAUSE OF
EPITHELIAL TOXICITY ESPECIALLY WHERE MULTIPLE DAILY DROPS ARE
REQUIRED ( E.G. GLAUCOMA )
• SOME TOPICAL AGENTS CAN CAUSE PUNCTATE KERATITIS
E.G. TOBRAMYCIN, GENTAMICIN, ACULAR, ACYCLOVIR. EVEN DILATING
DROPS CAN CAUSE THIS E.G. PRE-OP PHENYLEPHRINE
• BEWARE “HIDDEN” PRESERVATIVE E.G. POVIDONE IN REFRESH BLISTER
PACKS
LOCAL EFFECTS OF TOPICAL
MEDICATION
1. TOXIC EPITHELIOPATHY
LOCAL EFFECTS OF TOPICAL
MEDICATION
1. TOXIC EPITHELIOPATHY
2. ALLERGIC CONJUNCTIVITIS
LOCAL EFFECTS OF TOPICAL
MEDICATION
1. TOXIC EPITHELIOPATHY
2. ALLERGIC CONJUNCTIVITIS
3. SPECIFIC SIDE EFFECTS
ALLERGIC CONJUNCTIVITIS
• ALLERGY TO CHLORAMPHENICOL DROPS AND OINTMENT IS COMMON
BUT IT CAN BE SEEN WITH OTHER ANTIBIOTICS SUCH AS SOFRAMYCIN
ALLERGIC CONJUNCTIVITIS
• ALLERGY TO CHLORAMPHENICOL DROPS AND OINTMENT IS COMMON
BUT IT CAN BE SEEN WITH OTHER ANTIBIOTICS SUCH AS SOFRAMYCIN
• I HAVE ALSO SEEN ALLERGY TO AZOPT ON OCCASIONS
ALLERGIC CONJUNCTIVITIS
• ALLERGY TO CHLORAMPHENICOL DROPS AND OINTMENT IS COMMON
BUT IT CAN BE SEEN WITH OTHER ANTIBIOTICS SUCH AS SOFRAMYCIN
• I HAVE ALSO SEEN ALLERGY TO AZOPT ON OCCASIONS
• ALPHAGAN ALLERGY IS VERY COMMON AND OFTEN APPEARS AROUND
6 MONTHS
PURITE AS THE PRESERVATIVE ( ALPHAGAN P ) MAY REDUCE THE
INCIDENCE AS MAY COMBINING A TOPICAL β BLOCKER
( E.G. COMBIGAN )
SPECIFIC SIDE EFFECTS OF TOPICAL
AGENTS
PROSTAGLANDINS CAUSE CONJUNCTIVAL HYPERAEMIA, INCREASED IRIS PIGMENTATION,
LASH GROWTH AND INCREASED LOWER LID SKIN PIGMENTATION
INCIDENCE XALATAN < TRAVATAN < LUMIGAN
SPECIFIC SIDE EFFECTS OF TOPICAL
AGENTS
PROSTAGLANDINS CAUSE CONJUNCTIVAL HYPERAEMIA, INCREASED IRIS PIGMENTATION,
LASH GROWTH AND INCREASED LOWER LID SKIN PIGMENTATION
INCIDENCE XALATAN < TRAVATAN < LUMIGAN
PILOCARPINE CAUSES CHRONIC PUPILLARY MIOSIS WITH LONG TERM USE
SPECIFIC SIDE EFFECTS OF TOPICAL
AGENTS
PROSTAGLANDINS CAUSE CONJUNCTIVAL HYPERAEMIA, INCREASED IRIS PIGMENTATION,
LASH GROWTH AND INCREASED LOWER LID SKIN PIGMENTATION
INCIDENCE XALATAN < TRAVATAN < LUMIGAN
PILOCARPINE CAUSES CHRONIC PUPILLARY MIOSIS WITH LONG TERM USE
TOPICAL STEROID FOR LONGER THAN 3 WEEKS CAN CAUSE SECONDARY OCULAR
HYPERTENSION
SPECIFIC SIDE EFFECTS OF TOPICAL
AGENTS
PROSTAGLANDINS CAUSE CONJUNCTIVAL HYPERAEMIA, INCREASED IRIS PIGMENTATION,
LASH GROWTH AND INCREASED LOWER LID SKIN PIGMENTATION
INCIDENCE XALATAN < TRAVATAN < LUMIGAN
PILOCARPINE CAUSES CHRONIC PUPILLARY MIOSIS WITH LONG TERM USE
TOPICAL STEROID FOR LONGER THAN 3 WEEKS CAN CAUSE SECONDARY OCULAR
HYPERTENSION
30% OF THE POPULATION ARE STEROID RESPONDERS
SPECIFIC SIDE EFFECTS OF TOPICAL
AGENTS
PROSTAGLANDINS CAUSE CONJUNCTIVAL HYPERAEMIA, INCREASED IRIS PIGMENTATION,
LASH GROWTH AND INCREASED LOWER LID SKIN PIGMENTATION
INCIDENCE XALATAN < TRAVATAN < LUMIGAN
PILOCARPINE CAUSES CHRONIC PUPILLARY MIOSIS WITH LONG TERM USE
TOPICAL STEROID FOR LONGER THAN 3 WEEKS CAN CAUSE SECONDARY OCULAR
HYPERTENSION
30% OF THE POPULATION ARE STEROID RESPONDERS
WEAKER STEROIDS SUCH AS FML HAVE LESS OCULAR PENETRATION AND ARE LESS LIKELY
TO CAUSE THESE PROBLEMS
SPECIFIC SIDE EFFECTS OF TOPICAL
AGENTS
PROSTAGLANDINS CAUSE CONJUNCTIVAL HYPERAEMIA, INCREASED IRIS PIGMENTATION,
LASH GROWTH AND INCREASED LOWER LID SKIN PIGMENTATION
INCIDENCE XALATAN < TRAVATAN < LUMIGAN
PILOCARPINE CAUSES CHRONIC PUPILLARY MIOSIS WITH LONG TERM USE
TOPICAL STEROID FOR LONGER THAN 3 WEEKS CAN CAUSE SECONDARY OCULAR
HYPERTENSION
30% OF THE POPULATION ARE STEROID RESPONDERS
WEAKER STEROIDS SUCH AS FML HAVE LESS OCULAR PENETRATION AND ARE LESS LIKELY
TO CAUSE THESE PROBLEMS
ALPHAGAN CAUSES CONJUNCTIVAL BLANCHING AND PUPIL CONSTRICTION
SPECIFIC SIDE EFFECTS OF TOPICAL
AGENTS
PROSTAGLANDINS CAUSE CONJUNCTIVAL HYPERAEMIA, INCREASED IRIS PIGMENTATION,
LASH GROWTH AND INCREASED LOWER LID SKIN PIGMENTATION
INCIDENCE XALATAN < TRAVATAN < LUMIGAN
PILOCARPINE CAUSES CHRONIC PUPILLARY MIOSIS WITH LONG TERM USE
TOPICAL STEROID FOR LONGER THAN 3 WEEKS CAN CAUSE SECONDARY OCULAR
HYPERTENSION
30% OF THE POPULATION ARE STEROID RESPONDERS
WEAKER STEROIDS SUCH AS FML HAVE LESS OCULAR PENETRATION AND ARE LESS LIKELY
TO CAUSE THESE PROBLEMS
ALPHAGAN CAUSES CONJUNCTIVAL BLANCHING AND PUPIL CONSTRICTION
IOPIDINE CAUSES CONJUNCTIVAL BLANCHING AND ENLARGED PUPIL
SPECIFIC SIDE EFFECTS OF
INTRAVITREAL DRUGS
AVASTIN/LUCENTIS ARE ASSOCIATED WITH POSSIBLE
INCREASED RISK OF CARDIOVASCULAR ADVERSE EFFECTS
MAINLY STROKE AND MYOCARDIAL INFARCTION
SYSTEMIC EFFECTS OF TOPICAL
MEDICATION
• β BLOCKERS CAN CAUSE ASTHMA AND BRADY CARDIA
SYSTEMIC EFFECTS OF TOPICAL
MEDICATION
• β BLOCKERS CAN CAUSE ASTHMA AND BRADY CARDIA
• α BLOCKERS MAY LOWER B P
SYSTEMIC EFFECTS OF TOPICAL
MEDICATION
• β BLOCKERS CAN CAUSE ASTHMA AND BRADY CARDIA
• α BLOCKERS MAY LOWER B P
• CHLORAMPHENICOL – VERY RARE ASSOCIATION WITH APLASTIC
ANAEMIA
SYSTEMIC EFFECTS OF TOPICAL
MEDICATION
• β BLOCKERS CAN CAUSE ASTHMA AND BRADY CARDIA
• α BLOCKERS MAY LOWER B P
• CHLORAMPHENICOL – VERY RARE ASSOCIATION WITH APLASTIC
ANAEMIA
• PHENYLEPHRINE 10% MAY CAUSE TACHYCARDIA ± SYSTEMIC
HYPERTENSION ( ESPECIALLY IN ELDERLY )
SYSTEMIC EFFECTS OF TOPICAL
MEDICATION
• β BLOCKERS CAN CAUSE ASTHMA AND BRADY CARDIA
• α BLOCKERS MAY LOWER B P
• CHLORAMPHENICOL – VERY RARE ASSOCIATION WITH APLASTIC
ANAEMIA
• PHENYLEPHRINE 10% MAY CAUSE TACHYCARDIA ± SYSTEMIC
HYPERTENSION ( ESPECIALLY IN ELDERLY )
• CYCOGYL DROPS CAN BE ASSOCIATED WITH DROWSINESS AND RARELY
WITH AGITATION
SYSTEMIC EFFECTS OF TOPICAL
MEDICATION
• β BLOCKERS CAN CAUSE ASTHMA AND BRADY CARDIA
• α BLOCKERS MAY LOWER B P
• CHLORAMPHENICOL – VERY RARE ASSOCIATION WITH APLASTIC
ANAEMIA
• PHENYLEPHRINE 10% MAY CAUSE TACHYCARDIA ± SYSTEMIC
HYPERTENSION ( ESPECIALLY IN ELDERLY )
• CYCOGYL DROPS CAN BE ASSOCIATED WITH DROWSINESS AND RARELY
WITH AGITATION
• ATROPINE DROPS MAY ALSO CAUSE SYSTEMIC SIDE EFFECTS ESPECIALLY
IN YOUNG CHILDREN
LOCAL OCULAR EFFECTS OF SYSTEMIC
DRUGS
•
PLAQUENIL:
–
AVIDLY BOUND TO RPE AND CAN CAUSE MACULAR TOXICITY
LOCAL OCULAR EFFECTS OF SYSTEMIC
DRUGS
•
PLAQUENIL:
–
•
AVIDLY BOUND TO RPE AND CAN CAUSE MACULAR TOXICITY
PREDNISONE:
– CAN BE ASSOCIATED WITH PSCC AND NUCLEAR SCLEROTIC CATARACT
LOCAL OCULAR EFFECTS OF SYSTEMIC
DRUGS
•
PLAQUENIL:
–
•
•
AVIDLY BOUND TO RPE AND CAN CAUSE MACULAR TOXICITY
PREDNISONE:
– CAN BE ASSOCIATED WITH PSCC AND NUCLEAR SCLEROTIC CATARACT
FLOMAXTRA:
–
–
–
–
DIFFICULT CATARACT SURGERY
LOSS OF IRIS TONE
POOR PUPIL DILATATION
PROGRESSIVE MIOSIS DURING OP
LOCAL OCULAR EFFECTS OF SYSTEMIC
DRUGS
•
PLAQUENIL:
–
•
•
PREDNISONE:
– CAN BE ASSOCIATED WITH PSCC AND NUCLEAR SCLEROTIC CATARACT
FLOMAXTRA:
–
–
–
–
•
AVIDLY BOUND TO RPE AND CAN CAUSE MACULAR TOXICITY
DIFFICULT CATARACT SURGERY
LOSS OF IRIS TONE
POOR PUPIL DILATATION
PROGRESSIVE MIOSIS DURING OP
ANTICHOLINERGICS E.G. TRYPTANOL ANTI SPASMODICS:
–
–
CAN PRECIPITATE AACG IN PREDISPOSED INDIVIDUALS
CONFUSES DOCTORS AS THE TYPE OF GLAUCOMA IS NOT SPECIFIED IN
PRODUCT INFORMATION
LOCAL OCULAR EFFECTS OF SYSTEMIC
DRUGS
•
PLAQUENIL:
–
•
•
PREDNISONE:
– CAN BE ASSOCIATED WITH PSCC AND NUCLEAR SCLEROTIC CATARACT
FLOMAXTRA:
–
–
–
–
•
•
AVIDLY BOUND TO RPE AND CAN CAUSE MACULAR TOXICITY
DIFFICULT CATARACT SURGERY
LOSS OF IRIS TONE
POOR PUPIL DILATATION
PROGRESSIVE MIOSIS DURING OP
ANTICHOLINERGICS E.G. TRYPTANOL ANTI SPASMODICS:
–
–
CAN PRECIPITATE AACG IN PREDISPOSED INDIVIDUALS
CONFUSES DOCTORS AS THE TYPE OF GLAUCOMA IS NOT SPECIFIED IN
PRODUCT INFORMATION
–
–
RARE ASSOCIATION WITH ACUTE GLAUCOMA
LOW SERUM K⁺ / BLOOD DISORDERS
DIAMOX:
LOCAL OCULAR EFFECTS OF SYSTEMIC
DRUGS
•
PLAQUENIL:
–
•
•
PREDNISONE:
– CAN BE ASSOCIATED WITH PSCC AND NUCLEAR SCLEROTIC CATARACT
FLOMAXTRA:
–
–
–
–
•
•
•
AVIDLY BOUND TO RPE AND CAN CAUSE MACULAR TOXICITY
DIFFICULT CATARACT SURGERY
LOSS OF IRIS TONE
POOR PUPIL DILATATION
PROGRESSIVE MIOSIS DURING OP
ANTICHOLINERGICS E.G. TRYPTANOL ANTI SPASMODICS:
–
–
CAN PRECIPITATE AACG IN PREDISPOSED INDIVIDUALS
CONFUSES DOCTORS AS THE TYPE OF GLAUCOMA IS NOT SPECIFIED IN
PRODUCT INFORMATION
–
–
RARE ASSOCIATION WITH ACUTE GLAUCOMA
LOW SERUM K⁺ / BLOOD DISORDERS
–
CME AND LID OEDEMA
DIAMOX:
GLIVEC:
PLAQUENIL TOXICITY
THIS DRUG IS FAIRLY SAFE
HIGHER RISK SEEN IN THE FOLLOWING:
PLAQUENIL TOXICITY
THIS DRUG IS FAIRLY SAFE
HIGHER RISK SEEN IN THE FOLLOWING:
1. DOSE > 6.5mg/Kg OF IDEAL BODY WEIGHT
PLAQUENIL TOXICITY
THIS DRUG IS FAIRLY SAFE
HIGHER RISK SEEN IN THE FOLLOWING:
1. DOSE > 6.5mg/Kg OF IDEAL BODY WEIGHT
2. DURATION OF TREATMENT > 10 YEARS
PLAQUENIL TOXICITY
THIS DRUG IS FAIRLY SAFE
HIGHER RISK SEEN IN THE FOLLOWING:
1. DOSE > 6.5mg/Kg OF IDEAL BODY WEIGHT
2. DURATION OF TREATMENT > 10 YEARS
3. LIVER OR KIDNEY DISEASE ( REDUCED DRUG EXCRETION )
PLAQUENIL TOXICITY
THIS DRUG IS FAIRLY SAFE
HIGHER RISK SEEN IN THE FOLLOWING:
1. DOSE > 6.5mg/Kg OF IDEAL BODY WEIGHT
2. DURATION OF TREATMENT > 10 YEARS
3. LIVER OR KIDNEY DISEASE ( REDUCED DRUG EXCRETION )
4. ? COINCIDENT MACULAR DISEASE E.G. DRUSEN
MONITORING PLAQUENIL
1. DISTANCE AND NEAR V A
MONITORING PLAQUENIL
1. DISTANCE AND NEAR V A
2. COLOUR VISION ( B/Y PLATES )
MONITORING PLAQUENIL
1. DISTANCE AND NEAR V A
2. COLOUR VISION ( B/Y PLATES )
3. AMSLER
MONITORING PLAQUENIL
1. DISTANCE AND NEAR V A
2. COLOUR VISION ( B/Y PLATES )
3. AMSLER
4. ? BLUE ON YELLOW FIELDS
MONITORING PLAQUENIL
1. DISTANCE AND NEAR V A
2. COLOUR VISION ( B/Y PLATES )
3. AMSLER
4. ? BLUE ON YELLOW FIELDS
5. ERG/EOG IF > 5 YEARS CONTINUOUS TREATMENT
Which of the following ocular side
effects is not associated with
Flomaxtra?
A. Poor pupil dilatation
B. Iris flaccidity during cataract surgery
C. Progressive miosis during cataract surgery
D. Ocular hypertension
Which of the following eye drop
preservatives is most likely to cause
corneal epithelial toxicity?
A. Purite
B. Polyquaternium
C. Benzalkonium Chloride
D. Povidone
Which of the following is not a side
effect of topical or systemic
B Blockers?
A. Brady cardia ( slow pulse )
B. Asthma
C. BP lowering
D. High BP
Which of the following is not a known
side effect of topical prostaglandins?
A. Conjunctival hyperaemia
B. Lash growth
C. Lid pigmentation
D. Pupillary constriction