References and Further Reading

Bergamini MVW. Pharmacology of flurbiprofen, a nonsteroidal antiinflammatory drug. Int Ophthalmol Rep 6: 2, 1981.

Feinstein NC. Toxicity of flurbiprofen sodium. Arch Ophthalmol 106: 311, 1988.

Flurbiprofen – an ophthalmic NSAID. Med Lett Drugs Ther 29: 58, 1987.

Gimbel HV. The effect of treatment with topical nonsteroidal anti-inflam- matory drugs with and without intraoperative epinephrine on the maintenance of mydriasis during cataract surgery. Ophthalmology 96(5): 585–588, 1989.

Miller D, et al. Topical flurbiprofen or prednisolone. Effect on corneal wound healing in rabbits. Arch Ophthalmol 99: 681, 1981.

Romano A, Pietrantonio F. Delayed hypersensitivity to flurbiprofen. J Int Med 241(1): 81–83, 1997.

Samples JR. Sodium flurbiprofen for surgically induced miosis and the control of inflammation. J Toxico Cut Ocular Toxico 8(2): 163–166, 1989.

Trousdale MD, Dunkel EC, Nesburn AB. Effect of flurbiprofen on

herpes simplex keratitis in rabbits. Invest Ophthalmol Vis Sci 19: 267, 1980.

Possible

1. Optic or retrobulbar neuritis

2. Myopia

3. Papilledema secondary to intracranial hypertension

4. Visual fields

a.Scotomas – centrocecal or paracentral

b.Constriction

c.Hemianopsia

d.Enlarged blind spot

5. Toxic amblyopia

6. Macular edema

7. Subconjunctival or retinal hemorrhages secondary to drug-induced anemia

8. Eyelids or conjunctiva

a.Lupoid syndrome

b.Erythema multiforme

c.Stevens-Johnson syndrome

d.Lyell’s syndome

e.Lupus erythematosus

Generic name: Ibuprofen.

Proprietary names: Advil, Ibu, Ibu-tab, Genpril, Motrin, Nuprin.

Primary use

This antipyretic analgesic is used in the treatment of rheumatoid arthritis and osteoarthritis.

Ocular side effects

Systemic administration

Certain

1.Decreased vision

2.Diplopia

3.Problems with color vision

a.Color vision defect, red-green defect

b.Colors appear faded

4.Abnormal visual sensations

a.Moving mosaic of colored lights

b.Shooting streaks

5.Abnormal ERG or VEP

6.Keratoconjunctivitis sicca

7.Photophobia

8.Visual hallucinations

9.Eyelids or conjunctiva

a.Erythema

b.Conjunctivitis – non-specific

c.Edema

d.Photosensitivity

e.Angioneurotic edema

f.Urticaria

g.Purpura

10. Cornea – vortex keratopathy

Probable

1. Periorbital edema

Clinical significance

Ibuprofen is one of the largest selling antiarthritic agents in the world. The adverse ocular event most commonly associated with this drug is transient blurred vision. In those patients who have experienced a drug rechallenge, refractive error changes, diplopia, photophobia, dry eyes and decrease in color vision appear to be well documented. A typical vortex keratopathy with deposition limited to the corneal epthelium has been described. Once the drug was stopped, this resolved within 3 weeks. Other nonsteroidal inflammatories such as indometacin and naproxen can also cause corneal epithelial deposition. While sicca has been ­attributed to this drug, one suspects that this in part is secondary to the drug being in the tears and aggravating an already dry eye. Palungwachira et al (2005) described a case of periorbital edema due to ibuprofen and there is one case of this in the ­ational Registry as well. Nicastro (1989) described three young females who were long-term ibuprofen users who possibly developed macular edema with vision in the 20/30 to 20/50 range. Once the drug was stopped, vision returned to 20/20. Reversible toxic ambyopia has been reported (Ravi et al 1986; ­Clements et al 1990).

This drug can cause other CNS changes, including aseptic meningitis with secondary effects on the visual system. If ibuprofen is not discontinued, permanent visual loss may result. For a drug so commonly used in combination with other agents, it is not possible to implicate specifically this agent. However, many of the cases are outside the usual multiple sclerosis age group and occur shortly after starting this medication. Patients on this drug should therefore be told to stop this medication if a sudden decrease in vision occurs. If there is an unexplained decrease­ in vision that occurs while on ibuprofen, tests to rule out optic nerve abnormalities should be considered. There may be a rare idiosyncratic optic nerve response associated with the use of this drug. The typical sequence is that after a few months of therapy, a unilateral or bilateral marked decrease in visual acuity occurs, with vision receding to the 20/80 to 20/200 range. Visual fields may show various types of scotomas. If the medication is stopped, visual acuity usually returns to normal in 1–3 months, but it may take up to 8 months for color vision to return to normal.

Ibuprofen, as well as other non-steroidal anti-inflammatories, may possibly cause intracranial hypertension. This is more common if used in combination with other antiarthritic agents, which can also induce this side effect.