Yong Meng Hsien Lecturer & Ophthalmologist, UKM & HCTM, Malaysia yongmenghsien@ppukm.ukm.edu.my Last edited: Feb 202

1. Drugs & Eyes
Dr Yong Meng Hsien
Lecturer & Ophthalmologist, UKM & HCTM
yongmenghsien@ppukm.ukm.edu.my
Last edited: Feb 2022

2. Drug  Eye
• Therapeutic for eye dz
• Diagnostic for eye dz
– FFA/ICGA
• Ocular S.E
– Topical drugs
– Systemic drugs
• Systemic S.E with eye involvement
– SJS/TEN

3. Systemic Drug with Ocular SE
• Anatomical Approach
• Drug Group

4. Cornea
• Vortex K
– ABCDEFGH
– arthritis (diclofenac), breast Ca (Tamoxifen), cardiac
(Amiodarone), depression (chlorpromazine),
Enzyme+Fabry+Galactosidase A, HCQ
• EndoT/deep deposit
– Chlorpromazine (yellow brown/within palpebral fissure
– Silver (argyrosis + conj)/gold (chrysiasis, +lens +marginaK)
• Epitheliopathy
– Amantadine (+reverse)

5. CB & Iris
• AACG with choroidal effusion
– Topiramate (for migraine/fits + wt loss)
• @starting of drug
– Sulfonamide/Diamox
• Floppy iris with small pupil
– Alpha agonist (tamsulosin) for BPH: life time risk
despite stop

6. Lens
• Cataract
– Steroid >PSCC
– Chlorpromazine >ASCC
– Amiodarone >ASCC
– Gold >ASCC
– Allopurinol (+SJS)

7. Uveitis
• Rifabutin
• Cidofovir
• Biphosphamate (+ orbital inflam/scleritis)
• Sulphonamide/Diamox (+ ciliary
effusion/AACG)
• Fluroquinolones (+iris transillumination)
• TNF (infliximab/adalimumab) (+ induce
sarcoidosis)

8. Retina
• Maculopathy
– HCQ
• Pigmentary retinopathy
– Chlopromazine (psy)- salt & pepper
– Desferroxamine (chelating)- diffuse punctate
• Crystalline maculopathy
– Tamoxifen
– Nitrofurantoin (UTI)
– Canthaxanthine (sun tan), Methoxyflurare,
– Didanosine, clofazimine (+Bull M)
• CMO
– IF alpha/beta (MS): +ischemic retinopathy/RVO/AION
– fingolimob (MS): incidence 0.5%, dose dependent (0.5mg), occur within
months, reversible (take up to 6mth)
• Retina ischemia
– Gentamycin
– IF alpha

9. Optic Neuropathy
• Amiodarone (NAION/non dose dependent)
• AntiTB: ethambutol >
isoniazid/streptomycin
• Vigabatrin (>nasal or generalised VF defect)
• MTX (if no folinic acid supplement)
• Sildenafil (ischemic ON)
• Tetracycline/minocycline  papilloedema
(raised ICP)
• Digoxin  yellow vision
(xanthopsia)/unexplained LOV ?ON
• CSA/tacrolimus  PRES with BE LOV + CNS
(reverse if early)

10. Others
• Drug avoid in MG
• Drug worsen glaucoma/AION: antiHPT
• Drug induced
– Myopia: pilocarpine, sulfonamide, MTX, HCTZ
– Accommodation loss: anticholinergic
– Hypermetropia

11. Drug Groups (Top 10)
• Steroid!
• Hydroxychloroquine
• Amiodarone
• Chlopormazine
• Tamoxifen
• Ethambutol
• Amantadine
• Allopurinol
• Topiramide
• Sildenafil

12. Hydroxychloroquine/Chloroquine
(antimalarial/biological agents)
Main RPE toxicity (melanotrophic)  RPE depigmentation/altered foveal
reflex  PRC damage  Bull’s eye maculopathy (irreversible)  RP-
like (pigmentary changes + attenuated vessels + optic atrophy)
- paracentral/entral scotoma
Others Vortex K (reversible/non dose-duration dependent)
ON (rare)
Monitoring AAO 2011: HVF 10-2 (subjective) + SD OCT/mfERG/FAF (objective)
Optional: CV, Amsler, fundus photo
Baseline within 1st yr  yearly aft 5yr  more if high risk
Remarks Risk: dose (>6.5mg/kg/day, or 400mg/day), duration (>5yr,
cumulative effect >1kg HCQ or >0.5kg CQ), renal/liver dz/age
>60/obese
*Further deterioration for years despite stop
* Use for RA/SLE- better side effect profile vs DMARDs, not need on-
going serological monitoring
Systemic SE Renal & hepatic dysfunction

14. Amiodarone
(CVS/anti-arrhythmics)
Main Vortex K (dose & duration dependent)
Others Neuropathy- NAION (due to dz or drugs, non dose dependent)
Cataract ASCC
Monitoring Cornea (VA/photo)
ON (CV/Bjerrum)
Special
Remarks
>insidious onset, BL
+systemic SE of thyroid disorder

15. Tamoxifen
(anti-neoplastic)
Main Crystalline retinopathy
- fine white retractile deposits in the inner retina centered
around the fovea
Others Vortex K
Cataract
macular edema
bird shot choroidopathy
optic neuritis
Monitoring Cornea/lens/fundus/ON
Remarks <40 mg/day =safe

16. Phenothiazine (Chlorpromazine/Thioridazine)
(antipsychotic)
Main - Pigmentary retinopathy @posterior pole  GA
 asymptomatic, scotomas (paracentral or ring), reduce VA,
nyctalopia
Others - corneal endothelial deposits (yellow brown/within
palpebral fissure)
- vortex K
- cataract >ASCC
- accommodative dysfunction, pupillary miosis/mydriasis,
Monitoring Fundus/lens/corneal
FAF
Remarks Maintenance dose <300 mg/day) =safe

17. Ethambutol
(antiTB)
Main Toxic optic neuropathy
Others Cecocentral/bitemporal VH defect
Blue-yellow CV defect
Monitoring ON (CV/HVF)
Remarks BL/slow/progress/irreversible
Risk: dose (15mg/kg/day=1%, 25mg-5%, 35mg-18%) , CKD,
>2mth use
>Sensitive tests: contrast sensitivity, mfERG

18. Sildenafil (Viagra) & Tadalafil (Cialis)
(PDE5 inhibitor/for ED)
Main Blue vision (interfere with neurotransmission within retina)-
reversible
Others Ischemic ON (due to dz or drugs)
CSCR
Subconjunctival hemorrhage
Monitoring
Remarks

20. Part 1 Master of Ophthalmology-
Pharmacology Syllabus in brief
● Local Anaesthesia (Amides & Esther)
● Muscarinic Drugs (Agonist & Antagonist)
● Nicotinic Drugs ( Agonist & Antagonist)
● Botulinum Toxin (Botox)
● Antifibronitic Agent (eg: MMC & 5FU)
● Antihistamine
● Mast Cell Stabilizer
● Adrenergic Agent (Alpha Adrenergic & Beta Adrenergic – Agonist & Antagonist)
● Carbonic anhydrase inhibitor
● Prostaglandin Analogue
● Osmotic Agent (glycerol, mannitol)
● Antibiotic
● Antifungal
● Antiviral (eg; acyclovir, ganciclovir & HAART)
● Antiprotozoa (eg; for Toxoplasma, Acanthameaba)
● Steroids
● Steroid Sparing Agent (antimetabolite, alkylating agents, T cell inhibitors, biologic)
● NSAIDs
● Anti vascular endothelial growth factor (ranibizumab, bevacizumab, aflibercept)

21. ● Focus on ophthalmic related medicatioens only, either
topical, intraocular or systemic use.
● If topical form is available, then question will usually be
targeted on topical forms e.g. topical NSAIDs instead of
systemic NSAIDs, topical anti-muscarinic instead of systemic.
● General guideline for students in answering pharmacology
question (drug-based question): Introduction, Classification,
MOA in details, ADME in brief (Absorption, Distribution,
Metabolism, Excretion), Route of Administration & Available
Preparation, Indication, Contraindication, Sides Effect
● Other types of pharmacology questions (beside drug based
questions): e.g factors affecting topical drugs absorption,
different routes of drug administration for eye diseases.
Part 1 Master of Ophthalmology-
Pharmacology Questions- some principle

23. Steroid & Eyes

24. Topical steroid
● Prednisolone acetate 1% achieves high
aqueous levels within 120 min and maintains a
significant level over 24 h, whereas
dexamethasone 0.1% attains peak aqueous
levels (20 times lower than prednisolone)
within 90 min, and detectable levels are seen at
12 h [16]. Table 1 details the potencies of the
currently available topical steroids