Weir REP, Whitehead DEJ, Zaidi FH, et al. Pupil blown by a puffer. Lancet 363: 2004, 1853.

Woelfle J, Zielen S, Lentze MJ. Unilateral fixed dilated pupil in an infant after inhalation of nebulized ipratropium bromide. J Pediatr 136: 423–424, 2000.

Generic name: Salbutamol (albuterol).

Proprietary names: Accuneb, Proventil, Proair, Ventolin, Vospire.

Primary use

This sympathomimetic amine is primarily used as a broncho­ dilator in the symptomatic relief of bronchospasm.

Ocular side effects

Systemic administration – nebulizer

Certain

1. Decreased vision

2. Eyelids or conjunctiva

a.Erythema

b.Blepharoconjunctivitis

c.Edema

d.Angioneurotic edema

e.Urticaria

3. Mydriasis – may precipitate angle-closure glaucoma 4. Ocular pain

Probable

1. Visual hallucinations

Clinical significance

Oral salbutamol has no reported adverse ocular effects. This beta- ­agonist only has significant ocular side effects if delivered via a nebulizer with the drug coming into direct contact with the eye. Methods to prevent ocular contact will completely prevent all ocular effects. Salbutamol can cause mydriasis and may increase intraocular pressure in predisposed narrow angles. This drug is often given also in nebulized form with ipratropium and will induce angle-closure glaucoma by its parasympathetic inhibitory effect. In a study by Kalra and Bone (1988), both salbutamol and ipratropium were administered simultaneously via nebulizers without eye protection and all patients with narrow angles had an increase in intraocular pressure. Transient angle closure occurred in 50% of them. This effect was completely prevented when protective eye goggles were worn. Contact of this drug with the eye and eyelids may occasionally cause transitory irritation and or ocular pain. Visual hallucinations have only been reported in children.

References And Further Reading

Basoglu OK, Emre S, Bacakoglu F, et al. Glaucoma associated with metereddose bronchodilator therapy. Respir Med 95: 844–845, 2001.

Goldstein JB, Biousse V, Newman NJ. Unilateral pharmacologic mydriasis in a patient with respiratory compromise. Arch Ophthalmol 15: 806, 1997.

Kalra L, Bone MF. The effect of nebulized bronchodilator therapy on intra­ ocular pressures in patients with glaucoma. Chest 93: 739–741, 1988.

Khanna PB, Davies R. Hallucinations associated with the administration of salbutamol via a nebulizer. BMJ 292: 1430, 1986.

Packe GE, Cayton RM, Mashhoudi N. Nebulised ipratopium bromide and salbutamol causing closed-angle glaucoma. Lancet 2: 691, 1984.

Rho DS. Acute angle-closure glaucoma after albuterol nebulizer treatment. Am J Ophthalmol 130: 123–124, 2000.

Shurman A, Passero MA. Unusual vascular reactions to albuterol. Arch Intern Med 144: 1771, 1984.

Class: Diuretics

Generic names: 1. Bendroflumethiazide; 2. chlorothiazide; 3. chlortalidone; 4. hydrochlorothiazide; 5. hydroflumethiazide; 6. indapamide; 7. methyclothiazide; 8. metolazone; 9. polythiazide; 10. trichlormethiazide.

Proprietary names: 1. Naturetin-5; 2. Diuril;

3. Thalitone; 4. Esidrix, Microzide, Oretic; 5. Saluron; 6. Lozol; 7. Enduron; 8. Zaroxolyn; 9. Renese; 10. Metahydrin, Naqua, Trichlorex, Trichlormas.

Primary use

These thiazides and related diuretics are effective in the maintenance therapy of edema associated with chronic congestive heart failure, essential hypertension, renal dysfunction, cirrhosis, pregnancy, premenstrual tension and hormonal imbalance.

Ocular side effects

Systemic administration

Certain

1. Decreased vision

2. Myopia (Fig. 7.6d)

3. Problems with color vision

a.Objects have yellow tinge (chlorothiazide)

b.Large yellow spots on white background 4. Eyelids or conjunctiva

a.Allergic reactions

b.Conjunctivitis – non-specific

c.Photosensitivity

d.Urticaria

e.Purpura

5. Visual hallucinations

6. Choroidal effusion

7. Increased anterior-posterior lens diameter

8. Shallow anterior chambers

9. Acute glaucoma

Probable

1. Retinal edema

2. Decreased lacrimation

3. Decreased intraocular pressure – minimal

4. Paralysis of accommodation

Possible

1. Eyelids or conjunctiva

a.Lupoid syndrome

b.Erythema multiforme

c.Stevens-Johnson syndrome

d.Lyell’s syndrome

e.Toxic epidermal necrolysis

2. Subconjunctival or retinal hemorrhages secondary to druginduced anemia

Clinical significance

Ocular side effects due to these diuretics occur only occasionally and are usually transitory. It appears that most of these agents can cause transitory myopia. There are many different possible mechanisms involved in causing myopia. One is a change directly related to the crystalline lens and ciliary body, i.e. spasm of accommodation, altered sodium-chloride metabolism, ciliary body edema, inhibition of fluid by the lens or change in lenticular index

agents renal and vascular Cardiac, • 6Stionec

of refraction. The second mechanism is related to changes in the media or sclera, i.e. changes in the refractive index of the media or stretching of the sclera (Jampolsky and Flom 1953). Blain et al (2000), using angiography, showed diffuse choroidal thickening during indapamide induced myopia. Some of the mechanisms proposed for inducing myopia are probably the cause of inducing angle-closure glaucoma. There are well-documented cases of unilateral or bilateral ciliary body edema or effusions, which produce anterior rotation of the ciliary body at the scleral spur, allowing laxity of the lens zonule and forward displacement of the irislens diaphragm. This increases the anterioposterior diameter of the lens, allowing for a shallowing of the anterior chamber with a resultant narrow angle. The cause of the ciliary body edema is unknown; however, Geanon and Perkins (1995) described a case they felt was due to a hypersensitivity reaction. Krieg and Schipper (1996) showed that prostaglandins and eicosanoids are involved. The management of this type of glaucoma is the same as with topiramate. Sponsel and Rapoza (1992) reported a posterior subcapsular cataract after indapamide therapy, but made no statement as to causation. Miller and Moses (1978) described a case of transient oculomotor nerve palsy associated with thiazide-induced glucose intolerance. Thiazide diuretics can also cause hypercalcemia, which may result in band keratopathy.

When thiazide diuretics are used in combination with carbonic anhydrase inhibitors, one should be alert for signs of hypokalemia. These diuretics are photosensitizers and Hartzer et al (1993) showed that in tissue culture hydrochlorothiazide will interact with UV-A radiation to produce toxic synergistic effects

on human RPE cells. de la Mamierre et al (2003), in a case control study, concluded that drug-induced phototoxicity (thiazide diuretics in long-term treatment) may be involved in causing more severe neovascularization in age-related macular degeneration.

References And Further Reading

Ashraf N, Locksley R, Arieff AI. Thiazide-induced hyponatremia associated with death or neurologic damage in outpatients. Am J Med 70: 1163, 1981.

Beasley FJ. Transient myopia during trichlormethiazide therapy. Ann Ophthalmol 12: 705, 1980.

Bergmann MT, Newman BL, Johnson NC Jr. The effect of a diuretic (hydrochlorothiazide) on tear production in humans. Am J Ophthalmol 99: 473, 1985.

Birch J, et al. Acquired color vision defects. In: Congenital and Acquired Color Vision Defects, Pokorny J et al. (eds), Grune & Stratton, New York, p 243–350, 1979.

Blain P, Paques M, Massin P, et al. Acute transient myopia induced by indapamide. Am J Ophthalmol 129: 538–540, 2000.

de la Marnierre E, Guigon B, Quaranta M, et al. Phototoxic drugs and agerelated maculopathy. J Fr Ophtalmol 26: 596–601, 2003.

Geanon JD, Perkins TW. Bilateral acute angle-closure glaucoma associated with drug sensitivity to hydrochlorothiazide. Arch Ophthalmol 113: 1231–1232, 1995.

Grinbaum A, Ashkenazi I, Avni I. Drug induced myopia associated with treatment for gynecological problems. Eur J Ophthalmol 5(2): 136–138, 1995.

Hartzer M, et al. Hydrochlorothiazide: increased human retinal epithelial cell toxicity following low-level UV-A irradiation. ARVO Invest Ophthalmol Vis Sci Annual Meeting Abstract (Issue), 3633–3640, May 1993.

Jampolsky A, Flom B. Transient myopia associated with anterior displacement of the crystalline lens. Am J Ophthalmol 36: 81–89, 1953.