Medications topical and Systemic of Toxicity• 16Retinalchapter
A B
Figure 16.23 (A) Color photograph of right eye, and (B) left eye of a patient with acute methanol toxicity. There is prominent disc congestion and retinal edema, which gradually gave way to optic disc pallor. The patient did not recover useful vision in spite of prompt recognition of the condition.
CMV retinitis is less common since the advent of highly active antiret- |
sildenafil appears to cause no apparent long-term retinal damage, |
roviral therapy (HAART). Additionally, CMV retinitis often responds |
although individuals with preexisting retinal disease may be at |
favorably to intravitreal ganciclovir and foscarnet injections, which are |
increased risk.191,192 |
not known to cause uveitis. |
|
LATANOPROST
See the section on cystoid macular edema (above).
MISCELLANEOUS (SUBJECTIVE
OCULAR EFFECTS)
CARDIAC GLYCOSIDES
Cardiac glycosides such as digoxin are used in the treatment of chronic heart failure and as antiarrhythmic agents. Although these drugs do not cause a characteristic retinal abnormality, ocular symptoms, including blurred vision, scintillating scotomas, and xanthopsia (yellowing of vision), are common.181,182 These changes probably are caused by direct toxicity to the photoreceptors. The visual symptoms are reversible with discontinuation of the drug.
SILDENAFIL
The widely used erectile dysfunction agent sildenafil is an inhibitor of phosphodiesterase 5 (PDE-5) in the penile corpora cavernosa, but demonstrates cross-activity with the PDE-6 in the photoreceptors as well.183 A single dose may cause transient and reversible dyschromatopsia,184,185 though symptoms are generally dose-related. Typically, the fundoscopic examination and FA are normal, but rare reported complications include retinal hemorrhages, retinal vascular occlusion,186 nonarteritic anterior ischemic optic neuropathy,187 acceleration of proliferative diabetic retinopathy,188 and central serous chorioretinopathy.45,189 Changes commensurate with the above-noted diagnoses may be seen on FA. More reproducible abnormalities, even in asymptomatic subjects, include transient depressions in ERG and mfERG.190 In most cases,
METHANOL
Methanol is occasionally accidently ingested by alcoholics. Visual blurring and field deficits are seen within 12–18 hours. Early retinal findings include optic nerve hyperemia and retinal edema (Figure 16.23), while late findings include optic disc atrophy. Nerve toxicity is mediated by formic acid, a breakdown product of methanol, which directly affects the inner retina and optic nerve.193 The degree of systemic acidosis correlates well with the extent of visual dysfunction. Early hemodialysis is effective in removing methanol from the body, but if visual recovery is not evident by 6 days, it often remains permanently decreased.
VIGABATRIN
Vigabatrin is used for treatment of epilepsy, and has been associated with optic atrophy and visual field defecits.194,195
SUMMARY AND KEY POINTS
Although there are thousands of systemic medications, only a small number of these agents produce retinal changes. Retinal toxicity can occur when agents are used at standard therapeutic dosages, or when utilized for nonapproved indications. The mechanism by which toxicity develops is unknown in many cases. With multiple new drugs reaching the market annually, ophthalmologists need to maintain a high index of suspicion that patients’ symptoms and clinical findings may be related to one or more of their systemic medications.
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