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45 Cards in this Set
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Factor to consider (8) |
1. Age - children and elderly are vulnerable - different metabolic rate
2. Weight - even the same dose: larger the body, the smaller the plasma level will be - fat: water ratio will be different for slim/ fat people
3. Drug - prevalence of disease - therapeutic index (TI)
4. Duration of therapy - accumulation of drug - time to clear after cessation of therapy
5. Chemical structure if drug - can reach ocular tissue through uveal or retinal circulation - neutral molecules cross lipid cell membrane better than ionised atom or molecules
6. Routine of administration - acute ocular response from injection - more chronic effects from oral administration
7. Systemic disease - water soluble excreted by kidney - lipid soluble detoxified by liver - accumulation of drug when liver/ kidney problem exist
8. Drug interaction |
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Amiodarone (5) |
1. Class: antiarrhymic
2. Indication: ventricular fibrillation 心室顫動, ventricular tachycardia 心律不整
3. Ocular side effects - Verticillata (vortex keratopathy) - bilateral golden brown corneal deposit - Anterior subcapsular lens opacity - Optic neuropathy: can be bilateral
4. Management - Verticillata: - no treatment needed - medication should not stop due to corneal deposit - Optic neuropathy: - refer to oriental medical doctor (OMD) - consult cardiologist regarding stopping or altering the medication
5. Differential diagnosis for vortex keratopathy - amiodarone - Fabry disease - chloroquine - hydroxychloroquine - indomethacin - phenothiazine - #tamoxifen |
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Fabry disease (5) |
1. X-linked genetic disorder 2. Abnormal deposit of a fatty substance (globotriaosylceramide) in blood vessel wall 3. Severe complication: stroke, heart attack, kidney disease 4. Common complication: pain in hand and feet, skin lesion (angiokeratomas), decreased sweating 5. Ocular sign: - conjunctival injection - irregular blood vessel (tortoise) - corneal opacity/ corneal verticillata (pale gray, brownish, yellowish streak in cornea) - more severe: overall hazy pattern |
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Warfarin (5) |
1. Class: anticoagulant (Category X)
2. Indication: prevent heart attack, stroke, blood clot
3. Ocular side effect - Subconjunctival hemorrhage - Retinal hemorrhage
4. Management - frequency monitoring of international normalized ratio (INR) by GP or cardiologist - INR measure time for blood clotting - normal INR: 0.8-1.2 (< 1.1) - after drug: 2-3 - alert the patient doctor of recurrent subconjunctival hemorrhage or retinal finding
5. Differential diagnosis of recurrent subconjunctival hemorrhage - valsalva 閉氣/ straining 壓力 - blood thinner (coumadin, aspirin) - herbal blood thinner (Vit E, ginger) - trauma - hypertension - diabetes - blood clotting disorder |
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Ethambutol (6) |
1. Class: bacteriostatic antimicrobial
2. Indication: tuberculosis - practitioner should wear mask - other TB drug: Isoniazid, Linezolid, Rifampicin
3. Ocular side effect - toxic optic neuropathy (dose related, reversible) - subacture, painless vision loss - dyschromatopsia (R-G colour blindness) - cecocentral scotoma - pupil bilaterally sluggish to light with no RAPD - normal optic nerve appearance early progressing to pallor
4. Typical dosage: 15mg/kg/day (risk < 1%) - high dose (25mg/kg/day) or prolonged treatment need more care
Management 1. Regular monitoring (3-6 months) of VA, color vision (D15 > Ishihara), VF, OCT 2. Patient with renal disease: monitor monthly due to poor excretion of drug 3. Educate patient on symptom and advise to return immediately if noted - the drug should be stopped immediately if symptom occur 4. Notify the GP immediately if any sign of optic neuropathy
Prognosis 1. Patient may recover some vision after stopping medication 2. Some patient vision loss may be non reversible |
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Tamsulosin (4) |
1. Class: a-recptor antagonist
2. Indication: benign prostatic hyperplasia 良性前列腺增生症
3. Ocular side effects - intraoperative floppy iris syndrome - iris is floppy during cataract surgery - progressive pupil constriction - iris can prolapse into incision - mechanism: tamsulosin block a1 receptor on the iris dilator muscle - decrease response to dilating agent - risk remain even after stopped, no benefit to stopping the medication before cataract surgery
Management 1. Alert OMD if patient has tamsulosin history or current usage when refering for cataract surgery 2. Treatment for intraoperative floppy iris syndrome (IFIS) - pharmacological: atropine, epinephrine injection - mechanical devices: iris retractor hook 鈎, Malyugin ring 萬字夾 |
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Hydroxychloroquine (HCQ)/ Chloroquine (CQ) (8) |
1. Class: antimalarial
2. Indication: Malaria, Rheumatoid arthritis, SLE - chloroquine - low dose: prevent malaria - moderate dose: relieve rheumatoid arthritis, SLE - high dose: treat malaria, SLE
3. Ocular side effect - Bull‘s eye retinopathy (mainly in Caucasian) - paracentral visual field loss (mainly in Asian) - corneal deposit (verticillata) - outer retinal layer loss, esp. RPE layer loss (SD OCT foveal photoreceptor layer outer segment thinning, RPE bruchs membrane thickening) - hydroxychloroquine accumulate in RPE and remain there
4. Hydroxychloroquine has less retinal side effect than Chloroquine - usual dose 200mg or 400mg per day
5. Follow-up - recommended dosage: <=5.0 mg/kg - screening schedule - baseline exam when starting medication - annual screening after 5 years - more frequent if high dose or other risk factor - screening test - automated visual field - SD-OCT - additional test: mfERG, FFA
Risk factor 1. HCQ: >5.0mg/kg/day CQ: >2.3mg/kg/day 2. Duration of use: >5 years 3. Renal disease: subnormal glomerular filtration rate 4. Concomitant drugs: tamoxifen 5. Macular disease: may affect screening and susceptible to HCQ/ CQ
Prognosis 1. Vision loss is irreversible and there is no treatment 2. Retinopathy can progress even after the drug is stopped
Management 1. If diagnose retinopathy - discontinue medication at the earliest sign with the discussion from prescribed physician (use alternative drug) - low vision aid due to visual field loss
2. Questionable test results should be repeated to avoid discontinuing medication unnecessary |
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Hydroxychloroquine retinopathy (2) |
1. Racial difference in Visual field pattern - Asian: paracentral visual field loss - use 30-2 - Caucasian: para foveal visual field loss - use 10-2
2. SD-OCT - outer retinal layer loss, esp. RPE layer loss (SD OCT foveal photoreceptor layer outer segment thinning, RPE bruchs membrane thickening) |
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Interferon (4) |
1. Class: immune modulator 2. Indication: hepatitis, multiple sclerosis 3. Ocular side effects - interferon retinopathy (retinal hemorrhage, CWE, CME) - retinopathy is reversible with stop of treatment - optic neuropathy (rare) - dry eye 4. Management - close monitoring - risk/ benefit |
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Phenothiazine (5) |
1. Class: antipsychotic
2. Drug: chlorpromazine, thioridazine
3. Indication: schizophrenia 精神分裂症, depression, anxiety
4. Ocular side effects - anterior subcapsular cataract (stellate pattern) - posterior corneal pigment - dyschromatopsia (brown vision) - pigmentary retinopathy - nyctalopia (night blindness) - white patch area in fundus (shadow of cataract) - may have halo or glare - Bull‘s eye retinopathy - dry eye
5. Management - regular monitor - lens and cornea finding rarely decrease vision - retinopathy is rare in standard dose, high dose need monitor with fundus exam and VF |
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Steroid (5) |
1. Class: anti-inflammation
2. Indication: SLE, RA, Asthma, skin condition, Sarcoidosis, uveitis, optic neuritis, MS, endocrine disorder
3. Ocular side effect - cataract (PSCC) - steroid induced glaucoma (high IOP) - POAG, diabetes, myopia increase risk - idiopathic intracranial hypertension (IIH)
4. Management - regular monitoring for cataract and IOP for patient
5. Systemic side effects - acne 粉刺 - headache - sweating - nausea/ vomiting - trouble sleeping - mood change - weight gain - mood change - high blood pressure - high blood sugar - osteoporosis 骨質疏鬆症 - slow wound healing - swelling hand/ feet |
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Tamoxifen (5) |
1. Class: nonsteroidal antiestrogen
2. Indication: breast cancer
3. Ocular side effect - crystalline retinopathy (12%) - white dots at macula - Bull‘s eye retinopathy - cataract - corneal verticillata (vortex keratopathy) - optic neuritis - idiopathic intracranial hypertension (IIH)
4. Management - manage with the patient‘s oncologist to determine if the medication should be discontinued - mild deposit can be monitored - consider alternative treatment if decreased vision - intravitreal anti-VEGF for macular oedema
5. Differential diagnosis - dry AMD - Hollenhorst plaque - tamoxifen retinopathy - talc retinopathy - indicate history of intravenous drug - canthaxanthin retinopathy (tanning agent) - Bietti crystalline retinopathy |
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Topamax (topiramate) (4) |
1. Class: anticonvulsant 抗驚厥/ 鎮痙劑 (sulphonamide derivative)
2. Indication: - epileptic seizures 癲癇 - migraine - off label usage (bipolar disorder, bulimia, autism, alcohol addiction, PTSD, OCD) - Qsymia (phentermine/ topiramate) combination drug for weight loss
3. Ocular side effect i) Acute myopic shift - as topamax is temporary usage, can prescribe a cheap glass - resolve 1-2 weeks after stopped ii) Bilateral acute angle closure glaucoma - resolve within 24-48 hours with treatment - mechanism: - ciliochoroidal effusion, swelling of CB - relaxation of zonule with anterior displacement of the lens and iris - usually within the first 2 weeks of treatment/ after increasing the dosage
4. Management - stop medication immediately - treat IOP with aqueous suppressant (avoid pilocarpine) - there is no pupil block, so LPI is not indicated |
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Viagra/ Levitra/ Cialis (-afil) |
Other example: sildenafil, vardenafil, tadalafil (-afil)
1. Class: selective PDE-5 inhibitor - PDE-6: in retinal photoreceptors - PDE-5 inhibitor can partial inhibit PDE-6
2. Indication: erectile dysfunction
3. Ocular side effects i) bluish tint to vision (cyanopsia) - peak at 1 hour after dose - return to normal after 4-8 hours ii) non arthritic anterior ischaemic optic neuropathy (NAION) - causal/ coincidental - 2X higher risk to have this after the drug - associated with giant cell arteritis - visible disc swelling iii) increase light sensitivity
4. Management i) color vision change is transient and have no long term negative effect on vision ii) advice the patient to stop medication if sudden visual loss iii) inform high risk patient of possible risk of NAION - drug: interferon, sildenafil - optic disc drusen iv) manage systemic risk factor for NAION - sleep apnea syndrome (SAS) v) if NAION present, stop medication due to increased risk of NAION in second eye |
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Amantadine (4) |
Class: antiviral
Indication: 1. Influenza A 2. Parkinson's disease
Ocular side effects 1. Bilateral corneal edema 2. Lower endothelial cell counts: if longer duration and higher dose
Management 1. Monitor endothelial cell counts and morphology 2. Corneal oedema resolve with discontinuation of the drug |
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Cardiovascular drug (4) |
1. Hypertension (AABCD) - ACE inhibitor (-pril 飄) - Angiotensin 2 receptor antagonist (-sartan 撒旦) - Beta blocker (-olol) - Calcium channel blocker (-dipine di 飄) - Diuretic
2. Cholesterol - -statin (category X) - Niacin (vitamin B3)
3. Antiarrhythmic drug - amiodarone
4. Cardiotonic drug - digoxin 大哥 (yellow vision) - increase efficiency and improve the contraction of heart muscle - increase blood circulation |
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Cardiovascular drug - hypertension (5) |
1. Angiotensin converting enzyme (ACE) inhibitor (-pril 飄) - e.g. lisinopril (category D) - reduce vasoconstriction by blocking production of angiotensin 2 - allowing blood vessel to expand - side effects: dry cough, dizziness, hyperkalemia 高鉀血症, confusion - monitor hypertensive retinopathy
2. Angiotensin 2 receptor blocker (-sartan 撒旦) - e.g. losartan - prevent angiotensin 2 from binding receptor sites on blood vessel - increase vasodilation - treat hypertension - monitor hypertensive retinopathy
3. Beta blocker (-olol) - e.g. netoprolol, atenolol - for hypertension, angina 心絞痛, cardiac arrhythmia - lower blood pressure, reduce heart rate and cardiac output, depressed AV conduction - decrease tear production - decrease IOP (non selective beta blocker)
4. Calcium channel blocker (-dipine di 飄) - e.g. amlodipine - hypertension, angina - block calcium from entering smooth muscle cells of heart and blood vessel to reduce contractive force of heart and increase vasodilation - monitor hypertensive retinopathy
5. Diuretic - increase urine production by kidney, removing water and sodium from the body which reduce total blood volume - 3 types: thiazide, potassium sparing, loop diuretic |
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Cardiovascular drug - cholesterol lowering agent (2) |
1. - statins (- vastin) - e.g. simvastatin (Zocor), atorvastin (Lipitor) - ocular side effects: rare
2. Niacin (vitamin B3) - cystoid macular oedema (rare) - resolve with stop of medication |
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Cardiovascular drug - cardiotonic drug (Digoxin 大哥) (3) |
Digoxin 大哥 1. Extracted from foxglove (digitalis) plant 毛地黃屬植物
2. Indication: heart failure, atrial fibrillation
3. Ocular side effects i) dyschromatopsia - yellow tinted vision (xanthopsia) - colored border of object ii) flickering vision, blurred vision iii) diplopia, mydrasis |
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Endocrine drug (2) |
1. Diabetes medication - biguanide - sulfonylureas - insulin
2. Thyroid medication - hypothyroidism - hyperthyroidism |
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Endocrine drug - diabetes medication (3) |
1. Biguanide - e.g. Metformin 文科 - first line medication for type 2 diabetes - function: - decrease hepatic glucose production - decrease GI glucose absorption - increase target cell insulin sensitivity - ocular side effects - experience refractive shift - side effects: nausea, diarrhea
2. Sulfonylureas - e.g. Glyburide, Glipizide - stimulate the pancreas to make more insulin
3. Insulin - e.g. Humulin, Humalog, Lantus - most common medication for type 1 and also used in type 2 - short, intermediate, long-acting |
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Endocrine drug - thyroid medication (2) |
1. Hypothyroidism - Levothytoxine - replace hormone normally produced by thyroid gland - ocular side effect: rare - overdose cause symptom of hyperthyroidism
2. Hyperthyroidism (- mazole) - e.g. Carbimazole, Methimazole - prevent thyroid from producing excess amount of hormone - e.g. radioactive iodine: absorbed by thyroid and cause it to shrink |
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Central nervous system (6) |
1. Antidepressant 2. CNS stimulant (ADHD) 3. Hypnotics 4. Anticonvulsant 5. Phenothiazine 6. Topiramate |
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Central nervous system - Antidepressant (5) |
1. Tricyclic Antidepressant (TCA) - first line drug - increase norepinephrine and serotonin - e.g. Amitriptyline
2. Monoamine Oxidase Inhibitor (MAOI) - dangerous dietary and drug interaction - e.g. Isocarboxazid
TCA/ MAOI - anticholinergic effect (mydriasis, cycloplegic) - caution in narrow angle - caution using sympathomimetic (phenylephrine) for dilation - risk of increased blood pressure
3. Selective Serotonin Reuptake Inhibitor (SSRI) - increase in serotonin - newer drug - e.g. Fluoxetine (Prozac), Sertraline (Zoloft) - antidepressant with fewer side effects - blurred vision, photophobia, dry eye, mydriasis - caution in narrow angle
4. Serotonin and norepinephrine Reuptake Inhibitor (SNRI)
5. Atypical Antidepressant - Wellbutrin: no side effects |
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Central nervous system - CNS stimulant Methylphenidate (Concerta, Ritalin) |
1. Methylphenidate (Concerta, Ritalin) - Attention Deficit Hyperactivity Disorder (ADHD) 過度活躍症 - mydriasis, reduced accommodation |
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Central nervous system - hypnotics 安眠藥 (3) |
1. Indication: insomnia 失眠
2. e.g. Barbiturates - ocular side effects: ptosis, EOM problem or nystagmus e.g. Benzodiazepine (Category D) - ocular side effects: blurred vision (due to loss of accommodation)
3. Benzos - e.g. Alprazolam, Diazepam - sedative 鎮靜劑, hypnotics, short term anti-anxiety - side effects are reversible - blurred vision - decrease accommodation and mydriasis - decrease tear production - abnormal EOM movement: diplopia, nystagmus |
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Central nervous system - anticonvulsant 抗驚厥 (2) |
1. Phenytoin (Dilantin) - gaze evoked nystagmus at therapeutic dose - diplopia at toxic dose - Stevens Johnson syndrome
2. Medication for general anaesthesia a) Ketamine - increase in lacrimation and salivation - mydriasis - increase in IOP - nausea and vomiting b) Propofol (異丙酚) - 是一種短效的、靜脈注射鎮靜性藥物 - Michael Jackson dead |
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Analgesic/ Anti-inflammatory drug (4) |
1. Aspirin - NSAID - promote bleeding by inhibiting platelet aggregation - patient with excess bleeding may need to use alternative
2. Naproxen - NASID - for rheumatoid arthritis, ankylosing spondylosis and acute gout - rare ocular side effects - blurred vision - optic neuritis - whorl-like corneal opacity - dry eye - corneal ulcer
3. Ibuprofen - NASID - for RA, reduction of fever, relief of pain - transient blurred vision - rare: diplopia, colour vision distribance (R-G colour deficiency), myopia, dry eyes
4. Indomethacin - NSAID - RA, ankylosing spondylosis - vortex keratopathy - transient blurred vision, diplopia |
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Antibiotic (2) |
1. Sulfonamide - Steven-Johnson syndrome - immune medicated hypersensitivity reaction - oedema of lid and conjunctiva
2. Tetracycline - photosensitivity (UV protection) - idiopathic intracranial hypertension (IIH) - GI tract irritation - bone growth depression - teeth discoloration - Minocycline: vestibular toxicity, blue sclera, irreversible papilledema |
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Hormone agent (2) |
1. Oral contraceptive - may cause migraine - may reduce tear secretion - CL intolerance - rare: retinal vein occlusion and IIH
2. Hormone replacement therapy - relieve symptom of menopause - e.g. Premarin |
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Dermatological agent Isotretinoin (5) Tetracycline/ Minocycline/ Doxycycline (3) |
Isotretinoin (Roaccutane)
Indication: for acne
Ocular side effects: 1. Change in Rx 2. Blepharoconjunctivits 3. Decrease meibomian glands function - deficiency of lipid layer - increase tear evaporation 4. Decrease CL tolerance 5. IIH
Tetracycline/Minocycline/Doxycycline 1. Indication: acne 2. Usage: low dose for regulating fatty acid secretion 3. Side effects: increase in intracranial pressure (IIH) |
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Gastrointestinal Tract Histamine (H2) blocker |
1. Cimetidine (Tagamet), Ranitidine (Zantac) - Histamine (H2) Blocker - Indication: duodenal and gastric ulcer - dry eye
2. Omeprazole (-prazole) - Proton Pump Inhibitor (PPI) - indication: duodenal, gastric ulcer, gastroesophageal reflux disease (GERD) - dry eye
3. Antimuscarinic drug (systemic parasympatholytic) - relieve GI spasm, peptic ulceration and irritable bowel syndrome - ocular side effects: mydriasis and cycloplegia |
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Respiratory system (3) |
1. Bronchodilator and corticosteroid - asthma
2. Antihistamine - hay fever - oral antihistamine: Cetirizine (Zyrtec), Loratadine (Clarityne)
3. Antimuscarinic/ sympathomimetic: dilate respiratory tract |
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Cetirizine (Zyrtec), Loratadine (Clarityne) (4) |
1. Oral antihistamine 2. Treat allergic problem 3. Reduce aqueous layer of tear 4. Increase corneal and conjunctival staining |
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Allopurinol (4) |
1. Treat gout 痛風 2. Xanthine oxidase Inhibitor 3. Reduce production of iris acid 4. Increase risk of cataract |
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Cold and cough mixture Promethazine (4) |
1. Antihistamine with anticholinergic effect 2. With codeine 3. Blurred vision, decreased accommodation, mydriasis, decrease lacrimation 4. Contraindicated in narrow angle |
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Drug decreasing tear production (7) |
1. Antidepressant - SSRI 2. Antihistamine (oral) - Cetirizine (Zyrtec), Loratadine (Clarityne) 3. Antihypertensive - beta-blocker, diuretic 4. Benzodiazepine 安眠 5. Isotretinoin 皮膚 6. Oral contraceptive 7. Phenothiazine (chlorpromazine) |
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Drug affecting pupil Mydrasis (3) Miosis (2) |
Mydrasis 1. Anticholinergic - Promethazine (for cold) (anticholinergic with antihistamine) 2. CNS stimulant (e.g. amphetamine, cocaine) - MAOI, SSRI, methylphenidate 3. CNS depressant (Barbiturates, Benzodiazepine)
Miosis 1. Opiates 鴉片(heroin, morphine, codeine) 2. Anticholinerase (neostigmine for MG) |
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Drug affecting cornea and lens (6) |
1. Amiodarone 2. Phenothiazine 3. Chloroquine/ Hydroxychloroquine 4. Indomethacin 5. Steroid 6. Tamoxifen |
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Drug affecting IOP (3) |
1. Steroid 2. Beta blocker 3. Cannabinoids 大麻 (marijuana) |
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Drug affecting posterior segment (6) |
1. Amiodarone 2. Phenothiazine (chlorpromazine) 3. Chloroquine, hydroxychloroquine 4. Ethambutol, isoniazid, rifampicin 5. Oral contraceptive 6. Tamoxifen |
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Caution in Narrow Angle (8) |
1. Anti-anxiety medication - Topamax (topiramate) 2. Antidepressant - TCA, MAOI, SSRI 3. Antihistamine (may induce dilation) - Cetirizine (Zyrtec), Loratadine (Clarityne) 4. Asthma and COPD medication (Antimuscarinic or sympathomimetic drug: cause mydriasis) 5. Cold remedies 感冒病 - Promethazine 6. GI medication (may induce dilation) - Histamine (H2) blocker (Cimetidine, Ranitidine) 7. Nausea medication 8. CNS Stimulant for ADHD - Methylphenidate (Concerta, Ritalin) |
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Drug associated with intracranial hypertension (pseduotumor cerebri) (8) |
1. Tetracycline antibiotic 2. Isotretinoin 3. Growth hormone 4. Vitamin A 5. Oral contraceptive 6. Steroid 7. Sulfa-based drug 8. Tamoxifen |
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Drug induced refractive shift (5) |
1. Topamax (topiramate) 2. Isotretinoin (for acne) 3. Ibuprofen (NSAID): myopia 4. Metformin (DM) 5. Sulfonamide: myopia |
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Drug cause cataract (5) |
1. Steroid 2. Amiodarone 3. Tamoxifen 4. Allopurinol 5. Phenothiazine |
