2.Pupils

a.Mydriasis

b.Decreased or absent reaction to light

3.Retinal or macular

a.Edema

b.Degeneration

c.Pigmentary changes (Fig. 7.1h)

d.Exudates

e.Vasodilatation followed by vasoconstriction

f.Absence of foveal reflex

g.Abnormal ERG, EOG, VEP or critical flicker fusion

4.Visual sensations

a.Distortion due to flashing lights

b.Distortion of images secondary to sensations of wave

5.Optic nerve

a.Papilledema

b.Atrophy

6.Problems with color vision

a.Color vision defect, red-green or blue-yellow defect

b.Objects have red or green tinge

7.Visual fields

a.Scotomas

b.Constriction

8.Eyelids or conjunctiva

a.Allergic reactions

b.Edema

c.Photosensitivity

d.Angioedema

e.Purpura

f.Urticaria

9.Night blindness

10. Visual hallucinations

Probable

1. Myasthenia gravis (aggravates)

a.Diplopia

b.Ptosis

c.Paresis of extraocular muscle

Possible

1. Subconjunctival or retinal hemorrhages secondary to druginduced anemia

2. Eyelids or conjunctiva

a.Erythema multiforme

b.Stevens-Johnson syndrome

Conditional/Unclassified

1. Myopia – transitory

2. ERG changes

3. Granulamatous uveitis

4. Angle-closure glaucoma

5. Iris atrophy

6. Vertical nystagmus

Ocular teratogenic effects

Conditional/Unclassified

1. Optic nerve hypoplasia

Clinical significance

Quinine has been used for centuries and serious ocular side effects occur mainly in deliberate self-harm situations. It is also used as a diluent for many ‘street drugs’ and as a method of terminating a pregnancy. An excellent overview of almost 300 articles on this subject can be found in Grant’s Toxicology of the Eye. Quinine seldom causes ocular side effects except in overdose situations. Waddell (1996) reports two cases of blindness occurring on routine therapy. In rare instances, hypersensitivity reactions or long-term low dosages can cause significant ocular effects. In cases of massive exposure, visual loss may be sudden or progressive over a number of hours or days. In the worst cases, retinal arteriolar constriction, venous congestion, and retinal and papillary edema are pronounced. Complete, irreversible loss of vision may occur, but most ­patients have some return of vision. In severe cases there is often permanent loss of the peripheral visual field. Boland et al (1974) give an excellent overview of 165 patients hospitalized with quinine poisoning, of which 42% had significant visual