6.1.15 Recognises adverse ocular reactions to medication.

Question 1

Antidepressants (anti-psychotics produce more severe affects)

Answer 1

• Mydriasis
• Cycloplegia - blurred vision, reduced accommodation & convergence
• Dry eye

Question 2

Antihistamines

Answer 2

• Dry eye & more staining
• Slight mydriasis - slight blurred vision

Question 3

Anti-tuberculosis e.g. Ethambutol

Answer 3

Optic neuritis, Constriction of VF

Question 4

Hydroxychloroquine

Answer 4

• Vortex keratopathy
• Bull eyes maculopathy (irreversible) - pigmentary changes/damage to macula

Question 5

Tamoxifen

Answer 5

• Crystalline retinopathy
• Whorl-like corneal opacities
• Posterior subcapuslar opacities
• VF & CV changes

Question 6

Prednisolone

Answer 6

• Steroid glaucoma (increased pressure)
• Steroid cataract - posterior subcapsular
• Corneal thinning
• Retard wound healing

Question 7

Vigabatrin

Answer 7

• Bilateral constriction of VF
• Possible optic atrophy
• Reduced VA, CV defect

Question 8

Alendronic acid

Answer 8

Eye inflammation - scleritis & keratitis

Question 9

Tamsulosin

Answer 9

• Floppy iris syndrome
• Photophobia, visual disturbance

Question 10

Sildenafil citrate (viagra)

Answer 10

Photophobia, Blurred vision, Conj hyperaemia, Ocular pain, CV defects

Question 11

Amiodarone

Answer 11

• Corneal deposits - vortex keratopathy
• Len deposits - white-yellow punctates
• Optic neuropathy - rare!

Question 12

Anti-malarials

Answer 12

e.g. Chloroquine, Mefloquine
Ocular side effects:
greyish-white corneal deposits (mainly subepithelial, whorl-like opacities)
blurred vision
pigmentary changes to retina
 “Bull’s eye maculopathy”
VF loss
 central/paracentral scotoma
Colour vision defects

Question 13

Anti-inflammatories

Answer 13

NSAIDs e.g. Diclofenac, Ibuprofen, Indometacin
Ocular side-effects:
 Dry eyes,
 transient blurred vision, refractive changes
 colour vision disturbance
 Indometacin: pigmentary changes at the macula, corneal opacities, optic neuritis
Corticosteroids – Lots! (see lectures 1 & 14)

Question 14

Hypnotics

Answer 14

Benzodiazepines e.g. Diazepam (Valium), Alprazolam (Xanax)
Ocular side-effects:
 Reduced accommodation
 EOM dysfunction
 diplopia
 allergic conjunctivitis

Question 15

Oral contraceptives

Answer 15

E.g. Ethinyloestradiol/norethisterone
Ocular side effects:
Tear quality/quantity
 Some reports of contact lens intolerance due to reduced tear secretion.
Retinal vein occlusion

Question 16

What factors determine whether an ADR will occur?

Answer 16

• Age
• Sex
• Weight
• General/ophthalmic health
• Genetics (e.g. race)
• Dosage
• Duration of medication
• Concurrent medication

Question 17

How would you recognise an ADR in practise?

Answer 17

• It would match with information you already know e.g. amiodarone causing vortex keratopathy.
  
  • You MUST rule out other possible causes of the side effect before you can be sure!
    
    • For example, if patient has started new medication & is reporting dry eyes, not reported before, then you can suspect the medication but you must also rule out other conditions/possibilities such as dry eye conditions, hormones, recent starting of CL wear, GH condition.
    • Ask if it’s worsening and exactly when it started i.e. if started very soon after medication has been taken then a likely possibility. You would also need to conduct a full dry eye assessment

Question 18

What patient groups do you need to take particular care with when considering topical medication?

Answer 18

At-risk groups such as very young or very old patients, those with renal (kidney) or hepatic (liver) impairment or patients who are pregnant or breastfeeding.

Question 19

How do you check the risk of the drugs you are instilling?

Answer 19

• Consider if a drug will interact with another e.g. phenylephrine may interact with systemically administered monoamine-oxidase inhibitors and anti-hypertensive drugs.
• Check Van hericks & IOPs before & after dilation
• Ensure awareness to px that they may not be able to drive for few hours if mydriatic used
• Check corneal integrity if needed
• You should ask the patient if they:
  have experienced adverse reactions to eye drops in the past
  have a history of drug-induced adverse incidents
  have any relevant medical conditions
  take any systemic drugs.
• You should check:
  that you are administering the correct drug and dosage
  the expiry date.
• You should record all drugs used, including the batch number and expiry date, on the patient record.

Question 20

What should you explain to the px before instilling any drugs?

Answer 20

1. why you are instilling the drug
2. what effects the drops might have
3. how long the effects might last
4. the side effects they might experience
5. if you are dilating their pupils, that they might not be able to drive and must not undertake
6. any activity which is not advised after dilation, and for how long
7. if you are using anaesthetic drops, that they should avoid wearing contact lenses for an
8. appropriate period of time after anaesthesia
9. what to do if they experience an adverse reaction.

Give them a drug leaflet

Question 21

What advice is given for if the px experience an ADR?

Answer 21

• You should tell the patient to attend the local Accident and Emergency department if you are not available to deal with any emergency or adverse reaction that may arise following the instillation of the drug
• Ensure to tell the patient what ADRs may occur
• You should inform the patient’s GP of any suspected adverse reaction
• In MOST situations, the ADR will be mild & can be seen routinely by GP & whatnot. In these cases, DO NOT tell the px to stop using the medication or lower the dosage. You have NO RIGHT to do so. If you do, you’re legally liable for any further consequences as a result. YOU MUST advise px not to stop using until seen by relevant medical professional i.e. doctor. MAKE SURE to record this in the notes!

Question 22

Reporting Schemes

Answer 22

• You should use reporting schemes for adverse drug reactions . There are two reporting schemes, operated by the MHRA. These are:
  1. the yellow card scheme which covers systemic adverse reactions to ocular medicines and ocular reactions to systemic medication
  2. the Medical Devices Reporting Form which covers adverse incidents mainly relating to contact lenses and care products, including contact lens comfort drops

Question 23

How to report?

Answer 23

• Online form - www.mhra.gov.uk/yellowcard
• On paper –
  
  • complete a paper Yellow Card form post to: FREEPOST YELLOW CARD
  • Yellow Cards forms are in the back pages of the BNF & MIMS

Question 24

What to report?

Answer 24

The side effect(s).
Info about the px
The name of the drug
Your name and address

Question 25

Reporting guidelines:

Answer 25

- All suspected ADRs for new medicines - (newer drugs are identified by the black triangle ▼ symbol in the BNF and MIMS) - All serious suspected ADRs for established medicines - including unlicensed medicines, herbal remedies, and medicines used off-label - (i.e. “medically significant”, fatal, life-threatening, disabling, incapacitating, resulting in prolonged hospitalisation or congenital abnormalities.) They advise that if unsure, report anyway.

Question 26

What if a patient had an angle closure attack after dilation?

Answer 26

Where the IOP is 40mmHg or higher and the patient is not vomiting, give a single dose of oral acetazolamide (Diamox) 500mg (not slow release formulation). (NB: Diamox may be hazardous in an elderly frail patient.) Then refer as an emergency to ophthalmologist. (In view of potential unwanted effects of this treatment, patient should be accompanied by a carer or relative) Otherwise just refer as emergency if no drug available

Question 27

What if patient had severe corneal melt after local anaesthetic use?

Answer 27

Emergency referral. Px should wear eye protection getting to appt

Question 28

HRT – hormone replacement therapy

Answer 28

Studies show can make dry eye worse – 15% elevation in clinically diagnosed dry eye

Question 29

Prostaglandin Analogues (topical)

Answer 29

* Bimatoprost (Lumigan), latanoprost (Xalatan) * Ocular irritation * Conj hyperaemia * Iris hyperpigmentation * Increase in lash length, thickness & pigmentation * Increase in lid skin pigmentation * CMO - RARE * AU – RARE

Question 30

Steroids (long term over 10mg daily = chronic dose = risks higher)

Answer 30

* Prednisolone * Dexamethasone * Increase in IOP * Cataract * Exophthalmos *

Question 31

Anti-rheumatic / malarial

Answer 31

* Blurred vision * Bull’s eye Maculopathy