Ocular Side Effects of Systemic Drugs and Nutraceuticals

A SUMMARY OF THE MOST OFTEN USED MEDICATIONS

Written by Larry J Alexander OD FAAO Monday, 03 December 2012

Ocular Side Effects of Systemic Drugs and Nutraceuticals

Health care providers should be cognizant of the potential side effects of the various medications prescribed to their patients by other providers.  Those concerns must include self-prescribed over the counter agents.  The pharmacist is the coordinator of the team regarding prescriptive medications.  Included in the list of potential offenders should be some of the over-the-counter medications and nutraceuticals with some attention to the interaction of the various combinations in the management of the patients.  For example, patients often do not consider the interactions of supplemental vitamin E or Gingko Biloba with often used anti-coagulants.  Questioning of patients regarding all supplements that they may use is critical and must be recorded in the chart.

While routine spectral domain OCT (SDOCT) evaluation of all patients on systemic medications is unrealistic, the practitioner and pharmacist must consider pre-treatment SDOCT on patients placed on medications that may create pupillary mydriasis, which could potentiate angle-closure glaucoma.  Likewise, patients placed on some retinotoxic medications such as plaquenil should have both pre-treatment fundus photography and SDOCT.  The pre-existence of structural changes in the eye could facilitate the toxic effects and necessary precautions should be undertaken.  Those recommendations are outlined in this discussion.  A more in-depth discussion of plaquenil toxicity is also on the website eyelessons.com.

Specific agents create specific side effects.   A listing of these side effects is the basis of this discussion with the emphasis placed on using Spectral Domain OCT (SDOCT) to assist in the detection.  SDOCT offers an early warning system, as ophthalmoscopic signs and patient symptoms often occur well after structural changes.  Narrow angles may only be revealed effectively with SDOCT.  As new drugs are added in the categories, the list will be updated.

BASIC PHARMACEUTICAL CATEGORIES WITH ADVISED PRECAUTIONS

CATEGORIES OF DRUGS WITH SOME MORE COMMON EXAMPLES HAVING THE POTENTIAL TO CREATE PUPILLARY DILATION AND THUS ANGLE CLOSURE

PRE-TREATMENT ANTERIOR CHAMBER SDOCT MEASUREMENT ADVISED TO MINIMIZE THE RISK OF ANGLE CLOSURE GLAUCOMA

AN EXAMPLE OF AN ANGLE THAT WOULD NOT BE AFFECTED BY ANY OF THE FOLLOWING MEDICATIONS 

open angle

AN EXAMPLE OF AN ANGLE THAT COULD BE AFFECTED (POTENTIALLY OCCLUDABLE CREATING ANGLE CLOSURE GLAUCOMA) BY ANY OF THE FOLLOWING MEDICATIONS

closed angle

ANTI-ANXIETY MEDICATIONS

  • *Clonazepam (KLONOPIN), Midazolam (VERSED), Alprazolam (XANAX)

ANTI-CONVULSANT MEDICATIONS

  • *Gabapentin (NEURONTIN), Topiramate (TOPAMAX), Lamotrigine (LAMICTAL)
  • NOTE: Topiramate (TOPAMAX) IS ALSO BEING USED FOR MIGRAINE AND VERY OFTEN FOR WEIGHT CONTROL…IT EXERTS MANY POTENTIAL ACTIONS ON THE OCULAR SYSTEM THAT CAN BE DEVASTATING

ANTI-DEPRESSANT MEDICATIONS

  • *Heterocyclics and Tricyclics (EFFEXOR, ELAVIL, SINEQUAN)
  • *Selective Serotonin Re-Uptake Inhibitor (SSRI)-(Citaloparm-CELEXA, Escitalopram-LEXAPRO, Fluoxetine-PROZAC, Paroxetine-PAXIL, Sertraline-ZOLOFT)

ADHD MEDICATIONS

  • *Dexmethylphenidate HCL (FOCALIN XR)

ANTI-DIARRHEAL MEDICATIONS

  • Diphenoxylate (LOMOTIL)

ANTI PSYCHOTIC OR PSYCHOTROPIC MEDICATIONS

  • *Phenothiazines (Chlorpromazine-THORAZINE, Thioridazine-MELLARIL, Prochlorperazine-COMPAZINE)

ANTI-TREMOR MEDICATIONS

  • *Bentropine (COGENTIN)

ANTI-VERTIGO MEDICATIONS

  • *Scopolomine (TRANSDERM V)

UROLOGICAL MEDICATIONS

  • *Oxybutynin Chloride (DITROPAN)

CATEGORIES OF DRUGS AND EXAMPLES WITH THE POTENTIAL TO CREATE RETINAL TOXICITY 

PRE-TREATMENT BASELINE FUNDUS PHOTOGRAPHY, RETINAL MAP SDOCT AND GANGLION CELL COMPLEX ASSESSMENT IS RECOMMENDED TO MINIMIZE THE POTENTIAL LOSS OF VISION.  NOTE THAT HISTORICALLY FINDINGS REGARDING A SIGNIFICANT PROPORTION OF THESE MEDICATIONS ARE BEING MODIFIED BASED ON NEW TECHNOLOGY THAT UNCOVERS TOXICITY ISSUES SOONER. 

AN EXAMPLE OF EARLY DETECTION OF PLAQUENIL TOXICITY BY SDOCT THAT PREVIOUSLY WOULD HAVE BEEN MISSED.  THIS REPRESENTS A ZONE OF RETINAL THINNING 1 TO 1.5 MM FROM THE FOVEA CHARACTERISTIC OF EARLY PLAQUENIL TOXICITY

se oct

  

AIDS-RELATED MEDICATION

ANTI-HIV

  • Ritonavir-Macular Edema/Optic Neuritis

ANTI-CYTOMEGALOVIRUS

  • Cidofovir (VISTIDE)-Retinal Vascular Changes

ANTI-BACTERIAL

  • Rifabutin (MYCOBUTIN)-Posterior Uveitis

ANTI-CANCER MEDICATION

  • *Tamoxifen (NOLVADEX)-Macular Edema/Pigmentary Changes
  • Imatinib Mesylate (GLEEVAC)-Edema and Vascular Changes
  • Paclitaxel (TAXOL)-Cystic Macula
  • Gembitabine-Vascular Changes

ANTI-CHOLESTEROL MEDICATION

  • LIPITOR/ZOCOR-Macular Edema
  • Nicotinic Acid (Niacin)-Macular Edema
  • Fludarabine-Vascular Changes/Optic Neuropathy

ANTI-CONVULSANT MEDICATION

  • Gabapentin (NEURONTIN), Topiramate (TOPAMAX), Lamotrigine (LAMICTAL)-Macular Edema

ANTI-DIABETIC MEDICATION

  • *Thiazolidinediones (AVANDIA/ACTOS)-Macular Edema

ANTI-HYPERTENSIVE MEDICATION

  • Angiotensin-Converting Enzyme Inhibitors (LISINOPRIL, ZESTRIL)-Vascular Changes
  • Calcium Channel Blockers (NORVASC, PROCARDIA, CALAN)-Vascular Changes
  • ANTI-INFLAMMATORY MEDICATION

    • Indomethacin-Macular Changes
  • Ibuprofen-Macular Changes
  • ANTI-IRON MEDICATION

    • *DEFEROXAMINE-Multifocal Pattern Dystrophy and Optic Neuropathy

    ANTI-MALARIAL/RHEUMATOLOGIC MEDICATION

    • *Chloroquine (ARALEN) and Hydroxychloroquine (PLAQUENIL)

    ANTI-PSYCHOTIC OR PSYCHOTROPIC MEDICATION

    • Phenothiazines (Chlorpromazine-THORAZINE, Thioridazine-MELLARIL,-Pigmentary Changes
  • Prochlorperazine-COMPAZINE)-Pigmentary Changes
  • ANTI-SMOKING MEDICATION

    • Varenicline (CHANTIX)-Vascular Changes/Edema

    GRAFT VERSUS HOST DISEASE MEDICATION

    • Denileukin Diftitox (ONTAK)- Macular Edema/Pigmentary Changes

    IMMUNOMODULATOR MEDICATION

    • Interferon-Macular Changes and Vascular Changes

    ORAL CONTRACEPTIVE MEDICATION

    • Vascular Change

    UROLOGIC MEDICATION

    • VIAGRA/LEVITRA/CIALIS-Macular Edema

     

     

     

    CATEGORIES OF DRUGS WITH THE POTENTIAL TO CREATE OPTIC NERVE CHANGES 

    AN EXAMPLE OF THE EFFECT OF GROWTH HORMONES ON THE STATUS OF THE OPTIC NERVE HEAD.  BILATERAL PAPILLEDEMA.

    pap odpap os

     

    * PRE-TREATMENT BASELINE FUNDUS PHOTOGRAPHY WITH SDOCT RETINAL NERVE FIBER LAYER AND GANGLION CELL COMPLEX ASSESSMENT TO MINIMIZE THE RISK OF VISION LOSS


    Alcohol

    *Amiodarone (CORDARONE)

    Deferoxamine

    *Ethambutol

    *Growth Hormone

    Ibuprofen

    Fludarabine

    Ritovir

    Indomethacin

    Interferon

    *Isoniazid (INH)

    Isoretinoin (ACCUTANE)

    Leuprolide Acetate

    Lithium

    Oral Contraceptives/Estrogen

    *Tamoxifen (NOLVADEX)

    Tetracyclines

    VIAGRA/LEVITRA/CIALIS

     

    SPECIFIC PHARMACEUTICAL CATEGORIES THAT MAY CREATE OCULAR SIDE EFFECTS

    Following is a list of the more common pharmaceutical agent categories used in the treatment of chronic disorders that have the potential to create ocular side effects.  The agents have been categorized related to the intent for treatment with some of the pertinent ocular complications and recommendations for SDOCT imaging.  These are to serve as guidelines and will be modified as new agents are added to the armamentarium.  It is also recognized that other systemic agents and nutraceuticals may impact on the ocular system creating side effects.  The clinician should always be cognizant of that possibility when evaluating new patient symptoms.   Drug interactions may also contribute to ocular side effects and the pharmacist should be consulted regarding that potential.  For complete information regarding all potential complications the clinician should either consult the Physician’s Desk Reference or call the pharmacy that supplied the prescription.

    ANTI-ANGINAL

    Amiodarone (CORDARONE)

    Treats arrhythmia

    • Corneal Whorls
    • Ischemic Optic Neuropathy
    • Photophobia

    SDOCT Indications with Symptoms:

    • Evaluate Corneal Tear Film
    • Evaluate Corneal Cross Section
    • Pachymetry
    • *Baseline Evaluate ONH and GCC

    ANTI-ADHD

    Dexmethylphenidate HCL (FOCALIN XR)

    Neurologic/Psychogenic used to treat ADHD

    • Contraindicated in Glaucoma

    SDOCT Indications:

    • *Baseline Evaluate Anterior Chamber Angle and Measure
    • Pachymetry
    • Evaluate ONH and GCC

    ANTI-ANXIETY

    Clonazepam (KLONOPIN), Midazolam (VERSED), Alprazolam (XANAX)

    Neurologic/Psychogenic Epilepsy, Anxiety and Panic

    • Mydriasis

    SDOCT Indications

    • *Baseline Evaluate Measurement of Anterior Chamber Angle

    ANTI-CANCER

    Leuprolide Acetate

    Used in treatment of prostate cancer, endometriosis and precocious puberty.  Also for breast cancer and infertility

    • Idiopathic Intracranial Hypertension

    SDOCT Indications with Symptoms:

    • Evaluate ONH and GCC

    ANTI-CANCER

    Tamoxifen (NOLVADEX)

    Used in cancer treatment

    • Ocular irritation
    • Crystalline Retinopathy
    • Pigmentary Retinopathy
    • Optic Neuropathy

    SDOCT Indications:

    • Evaluate Corneal Tear Film
    • Evaluate Corneal Cross Section
    • Evaluate ONH and GCC
    • *Baseline Evaluate Perifoveal Retinal Thickness
    • Evaluate Retina Cross Line and EnFace

    ANTI-CANCER

    Cisplatin and Etoposide

    Chemotherapy

    • Retinopathy
    • Retinal Ischemia
    • Neovascularization

    SDOCT Indications:

    • Evaluate ONH and GCC
    • Evaluate Perifoveal Retinal Thickness and Follow Yearly
    • Evaluate Retina Cross Line and EnFace

    ANTI-CHOLESTEROL

    LIPITOR/ZOCOR

    Used in the treatment of hypercholesterolemia

    • Cystoid Macular Edema

    SDOCT Indications with Symptoms:

    • Evaluate ONH and GCC
    • Evaluate Perifoveal Retinal Thickness
    • Evaluate Retina Cross Line and EnFace

    ANTI-CHOLESTEROL

    Nicotinic Acid (Niacin)

    • Used for hypercholesterolemia
    • Cystoid Macular Edema

    SDOCT Indications with Symptoms:

    • Evaluate ONH and GCC
    • Evaluate Perifoveal Retinal Thickness
    • Evaluate Retina Cross Line and EnFace

    ANTI-CONVULSANTS

    Gabapentin (NEURONTIN), Topiramate (TOPAMAX), Lamotrigine (LAMICTAL)

    Neurologic/Psychogenic, also used in migraine control and off-label weight control

    • Optic Neuropathy
    • Macular Edema
    • Secondary Angle Closure Secondary to Acute Myopia
    • Mydriasis
    • Suprachoroidal Effusion
    • Increased Myopia
    • Bilateral Angle Closure

    SDOCT Indications:

    • *Baseline for Topamax Evaluate Anterior Chamber Angle and Measure Pre-Treat and Post-Treat
    • Pachymetry
    • Evaluate ONH and GCC

    ANTI-DEPRESSANTS

    Heterocyclics and Tricyclics (EFFEXOR, ELAVIL, SINEQUAN)

    • Dry Eye
    • Photophobia
    • Mydriasis

    SDOCT Indications with Symptoms:

    • *Baseline Evaluate Measurement of Anterior Chamber Angle
    • Evaluate Corneal Tear Film
    • Evaluate Corneal Cross Section
    • Pachymetry

    ANTI-DEPRESSANTS

    Selective Serotonin Re-Uptake Inhibitor (SSRI)-(Citaloparm-CELEXA, Escitalopram-LEXAPRO, Fluoxetine-PROZAC, Paroxetine-PAXIL, Sertraline-ZOLOFT)

    Neurologic/Psychogenic

    Obsessive Compulsive Disorders, Bulimia, Anxiety Disorders

    • Mydriasis
    • Severe Dry Eye

    SDOCT Indications with Symptoms:

    • Evaluate Corneal Tear Film
    • Evaluate Corneal Cross Section
    • Baseline Evaluate Anterior Chamber Angle and Measure
    • Pachymetry
    • Evaluate ONH and GCC

    ANTI-DIABETICS

    Thiazolidinediones (AVANDIA/ACTOS)

    Used to increase insulin sensitivity in diabetes

    • Macular Edema

    SDOCT Indications with Symptoms:

    • Evaluate Perifoveal Retinal Thickness
    • Evaluate Retina Cross Line and EnFace

    ANTI-HYPERTENSIVES

    Angiotensin-Converting Enzyme Inhibitors (LISINOPRIL, ZESTRIL)

    Used to treat hypertension, diabetic nephropathy, heart failure

    • Photophobia
    • Subconjunctival and/or Retinal Hemorrhage
    • Lupoid syndrome

    SDOCT Indications with Symptoms:

    • Evaluate ONH and GCC
    • Evaluate Perifoveal Retinal Thickness and Follow Yearly
    • Evaluate Retina Cross Line and EnFace

    ANTI-HYPERTENSIVES

    ANTI-ANGINAL

    Calcium Channel Blockers (NORVASC, PROCARDIA, CALAN)

    Used to treat hypertension, angina, arrhythmia, heart failure

    • Retinal and subconjunctival hemorrhage secondary to anemia

    SDOCT Indications with Symptoms:

    • Evaluate Perifoveal Retinal Thickness
    • Evaluate Retina Cross Line and EnFace

    ANTI-INFLAMMATORY

    Ibuprofen

    Used to treat pain, aches and fevers

    • Photophobia
    • Corneal Whorl
    • Macular Edema
    • Idiopathic Intracranial Hypertension

    SDOCT Indications with Symptoms:

    • Evaluate Corneal Cross Section
    • Pachymetry
    • Evaluate ONH and GCC
    • Evaluate Perifoveal Retinal Thickness
    • Evaluate Retina Cross Line and EnFace

    ANTI-INFLAMMATORY

    Indomethacin

    Used to treat pain

    • Photophobia
    • Corneal Toxicity
    • Macular Changes
    • Idiopathic Intracranial Hypertension

    SDOCT Indications with Symptoms:

    • Evaluate Corneal Cross Section
    • Pachymetry
    • Evaluate ONH and GCC
    • Evaluate Perifoveal Retinal Thickness
    • Evaluate Retina Cross Line and EnFace

    ANTI-MALARIAL/RHEUMATOLOGIC

    Chloroquine (ARALEN) and Hydroxychloroquine (PLAQUENIL)

    Refer to: http://www.optometricretinasociety.org/ white paper on New Plaquenil Guidelines

    Antimalarial, also used to treat immune based disorders

    • Corneal Whorls
    • Retinal Toxicity

    SDOCT Indications:

    • Evaluate Corneal Tear Film
    • Evaluate Corneal Cross Section
    • Pachymetry
    • Evaluate ONH and GCC
    • Baseline Evaluate Perifoveal Retinal Thickness and Follow Yearly
    • Evaluate Retina Cross Line and EnFace

    ANTI-PSYCHOTICS OR PSYCHOTROPICS

    Phenothiazines (Chlorpromazine-THORAZINE, thioridazine-MELLARIL, Prochlorperazine-COMPAZINE)

    Neurologic/Psychogenic

    • Retinal Pigment Epithelial Changes
    • Nyctalopia
    • Mydriasis
    • Dry Eye

    SDOCT Indications with Symptoms:

    • Evaluate Corneal Tear Film
    • Evaluate Corneal Cross Section
    • Baseline Evaluate Anterior Chamber Angle and Measure
    • Pachymetry
    • Evaluate ONH and GCC
    • Evaluate Perifoveal Retinal Thickness
    • Evaluate Retina Cross Line and EnFace

    ANTI-SMOKING

    Varenicline (CHANTIX)

    • Dry Eye
    • Ocular Vascular Changes/Edema

    SDOCT Indications with Symptoms:

    • Evaluate Corneal Tear Film
    • Evaluate Corneal Cross Section
    • Evaluate Perifoveal Retinal Thickness
    • Evaluate Retina Cross Line and EnFace

    ANTI-TREMOR

    Bentropine (COGENTIN)

    Neurologic/Psychogenic for Muscle Spasms and Parkinsonian Pain

    • Mydriasis
    • Subconjunctival and Retinal Hemorrhages

    SDOCT Indications with Symptoms:

    • Baseline Evaluate Measurement of Anterior Chamber Angle

    ANTI-TUBERCULAR

    Isoniazid (INH), Ethambutol

    Used to treat tuberculosis

    • Optic Neuropathy

    SDOCT Indications:

    • Evaluate ONH and GCC Baseline then monthly at doses >15mg/kg/day

    CORTICOSTEROIDS

    Treatment for multiple conditions

    • Elevated IOP
    • Posterior Subcapsular Cataract

    SDOCT Indications with Symptoms:

    • Evaluate Anterior Chamber Angle and Measure
    • Pachymetry
    • Evaluate ONH and GCC

    DERMATOLOGIC

    Isoretinoin (ACCUTANE)

    Used to treat dermatological conditions

    • Severe Dry Eye
    • Optic Neuropathy
    • Nyctalopia

    SDOCT Indications with Symptoms:

    • Evaluate Corneal Tear Film
    • Evaluate ONH and GCC

    DERMATOLOGIC

    Tetracyclines

    Treatment for multiple conditions

    • Idiopathic Intracranial Hypertension

    SDOCT Indications with Symptoms:

    • Evaluate ONH and GCC

    GROWTH HORMONE

    Growth Hormone (HGH)

    • Idiopathic Intracranial Hypertension

    SDOCT Indications:

    • Baseline Evaluate ONH and GCC
    • Evaluate Retina Cross Line and EnFace

    IMMUNOMODULATOR

    Interferon

    Used in Bone Marrow Transplants

    • Severe Dry Eye
    • Cotton Wool Spots
    • Optic Neuropathy

    SDOCT Indications with Symptoms:

    • Evaluate Corneal Tear Film
    • Evaluate Corneal Cross Section
    • Evaluate ONH and GCC
    • Evaluate Retina Cross Line and EnFace

    ORAL CONTRACEPTIVES

    • Dry Eye
    • Optic Neuropathy
    • Retinal Vascular Disorders
    • Idiopathic Intracranial Hypertension

    SDOCT Indications with Symptoms:

    • Evaluate Corneal Tear Film
    • Evaluate Corneal Cross Section
    • Pachymetry
    • Evaluate ONH and GCC
    • Evaluate Perifoveal Retinal Thickness
    • Evaluate Retina Cross Line and EnFace

    UROLOGIC

    Oxybutynin Chloride (DITROPAN)

    Used to treat overactive bladder

    • Increases risk of angle closure

    SDOCT Indications with Symptoms:

    • Baseline Evaluate Anterior Chamber Angle and Measure

    UROLOGIC

    Tamsulosin Hydrochloride (FLOMAX)

    Used in benign prostatic hypertrophy

    • Iris laxity

    SDOCT Indications:

    • Baseline Evaluate Cornea/Anterior Chamber with Measurements and Real Time Dark/Light Evaluation Prior to Any Intraocular Surgery

    UROLOGIC

    VIAGRA/LEVITRA/CIALIS

    • Blue tinge to vision
    • Ischemic Optic Neuropathy
    • Macular Edema

    Clinical Note:  Erectile dysfunction usually has associated systemic vascular issues that should be monitored as well

    SDOCT Indications with Symptoms:

    • Evaluate ONH and GCC
    • Evaluate Perifoveal Retinal Thickness
    • Evaluate Retina Cross Line and EnFace

    CAUTIONS REGARDING POTENTIAL OVERDOSE TOXICITIES AND DRUG INTERACTIONS ASSOCIATED WITH VITAMIN SUPPLEMENTATION AS RELATED TO THE EYE

    While over-the-counter medications and supplements are perceived by most to be totally safe, there are several cautions that must be addressed.   The clinician must be wary of these effects when evaluating any patient with retinal or optic nerve disease.  A general rule has always been that water-soluble vitamins are not much of a threat because excesses are usually rapidly eliminated.  Likewise, fat-soluble vitamins offer some threat as they are stored.  In a 2007 report:

    Overall, 60,719 exposures to different types of vitamins were reported to the poison control centers across the United States in 2008, accounting for 8 major adverse outcomes and 0 deaths. Of the total exposures, 46,550 incidents occurred in children younger than 6 years old and 8,255 involved individuals aged 6-19 years.  Morbidity and mortality from pure vitamins are rare. According to the American Association of Poison Control Centers' National Poison Data System, in 2008, more than 60,000 acute or chronic vitamin overdoses were documented, with 8 major adverse outcomes and 0 deaths.

    Bronstein AC, Spyker DA, Cantilena LR Jr, et al. 2009 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 27th Annual Report. Clin Toxicol (Phila). Dec 2010;48(10):979-1178. [Medline]http://emedicine.medscape.com/article/819426-clinical

    Gingko Biloba

    Certainly logic dictates that patients on blood thinners must exercise caution with aspirin, but a number of supplements will also create both a negation or potentiation of the effects of blood thinners.  For example, Vitamin E and Gingko Biloba, which have blood-thinning capacities, should only be recommended with caution for patients taking blood thinners.

    Iron

    Excesses in iron result in increased oxidants creating damage.  This could have a negative impact on the macular area and in retinal vasculature.  Iron containing vitamins are the most toxic, especially in pediatric acute ingestion.

    Niacin

    In excess in susceptible individuals, Niacin can create macular edema.

    Omega 3 Fish Oil

    Contrary to some reports of increased bleedability associated with Omega 3 supplementation, a significant review of the literature has debunked that myth. “However, an objective assessment of the evidence for clinically significant bleeding reveals that such concerns are unfounded. As such, the benefits of triglyceride lowering with omega-3 fatty acids more than outweigh any theoretical risks for increased bleeding.”

    Harris. (Am J Cardiol 2007;99[suppl]:44C–46C)

    Vitamin A Palmitate

    Vitamin A Palmitate in excess increases the risk of idiopathic intracranial hypertension, which is associated with optic neuropathy. The beta carotene form of vitamin A is contraindicated in smokers because of a reported increase of lung cancer.

    Vitamin E

    Not only does Vitamin E consumption increase bleedability risks, but has recently been shown to increase the risk of prostate cancer among healthy men.

    Vitamin K

    Spinach, which is an excellent source for lutein should be avoided in patients on blood thinners because the coincident presence of Vitamin K enhances coagulation.  Likewise there may be an increased risk for the development of kidney stones associated with oxalic acid.

    Zinc

    It is known that excess consumption of zinc recommended by many for ARMD may actually precipitate the formation of early ocular signs of ARMD and is associated with an increase in genitourinary tract infections as well as in increase in serum lipids.  This interaction must be considered when evaluating macular changes.

     

    About the Author(s)

    Larry J Alexander OD FAAO

    Larry J Alexander OD FAAO

    Dr. Alexander (1948-2016) was a 1971 graduate of Indiana University School of Optometry. He served in the US Navy then served as a Professor at the University of Alabama Birmingham School of Optometry. Larry contributed to a number of chapters in textbooks and has published three editions of Primary Care of the Posterior Segment, as well as contributed to the professional literature. He also lectured extensively in the area of ocular and systemic disease. His areas of special interest included dysfunctional tear syndrome, glaucoma and macular degeneration.  His lessons are the basis for this site and he will be dearly missed. 

    Comments (2)

    • Caryn West

      19 February 2013 at 17:34 | #

      Thank you for the terrific and extensive information on ocular side effects of systemic medications. I probably missed it, but didn't see Gilenya on your list. It's a med for MS relapses that can cause ME.

      reply

    • Larry Alexander

      19 February 2013 at 19:02 | #

      Thanks Caryn will add Gilenya. there are soo many I can't keep up. it is interesting that there is not a universal source for this information.

      Larry

      reply

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