Medications

Systemic and ocular medications and their side effects

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Eye Drops by Bottle Cap Color

Patients will often know the eye drops they use by the color of the bottle. We provide a quick guide on identifying the drug class by bottle cap color along with brief indications and side effects

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Eye Drops with Systemic Side Effects

Although most eye medications are topically used, some can be systemically absorbed and have side effects. We review some of the most common side effects of systemic drugs

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Systemic Medications with Ocular Side Effects

Some systemic medications can also have side effects on the eye. We briefly review some of the most common drugs that are important to know

 

 Eye Drops by Bottle Cap Cover

 
Courtesy of OptomEyesLife.com. Also see AAO guideline. Note that generic/over the counter eye drops may not follow these guidelines

Courtesy of OptomEyesLife.com. Also see AAO guideline. Note that generic/over the counter eye drops may not follow these guidelines

 

Purple/Light Green - Alpha Agonist/Alpha Agonist Combos

Drug names: Alphagan (brimonidine), Iopidine (apraclonidine)

  • Used in the treatment of glaucoma - prevent aqueous humor formation and increase uveoscleral outflow

  • Side effects: Follicular conjunctivitis, dermatitis, allergy and tachyphylaxis to drug, Systemic side effects (see below)

Gray - NSAIDs

Drug names: Prolensa (bromfenac), Acular/Acuvail (ketorolac), Nevanac (nepafenac), Voltaren (diclofenac)

  • Used for corneal abrasions, foreign bodies, and after cataract surgery

  • Side effects: Burning with application, concerns of corneal toxicity

  • Dark Green - Miotics/Parasympathomimetics

Drug names: Isoptocarpine (pilocarpine), Crabastat (carbachol)

  • Used to treat acute angle closure glaucoma

  • Side effects: Tearing, headache, blurry vision

  • Turquoise - Prostaglandin Analogues

Drug names: Xalatan (latanoprost), Travatan (travoprost), Lumigan (bimatoprost)

  • Used in the treatment of glaucoma - increase uveoscleral outflow

  • Side effects: Change in iris color, growth of eyelashes

Pink - Steroids

Drug names: Pred Forte/Pred Mild (prednisolone), Durezol (difluprednate)

  • Used to treat various inflammatory conditions such as uveitis, post eye-surgery, corneal ulcers, ocular trauma, chalazion

  • Side effects: Cataract formation, increased intraocular pressure, infection

Red - Mydriatics and Cycloplegics

Drug names: Cyclogyl (cyclopentolate), Prefrin (phenylephrine), Mydral (tropicamide), Atropine

  • Most often used in the ophthalmology office to dilate the eye to perform a fundus exam

  • Cycloplegics are used to paralyze the ciliary muscle and can be used in treatment of eye pain, uveitis or trauma.

  • Side effects: Blurriness of near vision, light sensitivity, Systemic side effects (see below)

Orange - Carbonic Anhydrase Inhibitors

Drug names: Trusopt (dorzolamide), Azopt (brinzolamide)

  • Used in the treatment of glaucoma - prevents aqueous humor production

  • Side effects: Burning/stinging on instillation, eye redness, discharge

Yellow/Light Blue/Dark Blue - Beta Blockers/Beta Blocker Combos

Drug names: Timoptic/Betimol/Istalol (timolol), Optipranalol (Metipranolol), Betagan (Levobunolol), Betoptic (Betaxolol), Cosopt (dorzolamide - timolol), Combigan (brimonidine - timolol)

  • Used in the treatment of glaucoma - prevent aqueous humor formation

  • Side effects: Eye redness, Systemic side effects (see below)

Tan - Anti infectives

Drug names: Vigamox (moxifloxacin), Ciloxan (ciprofloxacin)

  • Used in the treatment of infectious diseases, such as bacterial corneal ulcers, infection prophylaxis after surgery or bacterial conjunctivitis

  • Cycloplegics are used to paralyze the ciliary muscle and can be used in treatment of eye pain, uveitis or trauma

Eye Drops with Systemic Side Effects

Numerous eye drops can be systemically absorbed. There are 3 classes of common medications that you should be familiar with in particular. To avoid systemic absorption of these drugs, patients are advised to squeeze their nasal punctum while administering drops

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Topical alpha-2 adrenergic agonists

Purple/light green tops: Alphagan (brimonidine), Iopidine (apraclonidine)

  • Headaches

  • Dry Mouth

  • Fatigue

  • Bradycardia

  • Hypotension

  • Contraindicated in infants and children due to increased risk of somnolence, hypotension, seizures and apnea due to increased CNS penetration

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Topical Beta Blockers

Yellow/Light Blue/Dark Blue tops: Timoptic/Betimol/Istalol (timolol), Optipranalol (Metipranolol), Betagan (Levobunolol), Betoptic (Betaxolol), Cosopt (dorzolamide - timolol), Combigan (brimonidine - timolol)

  • Bradycardia

  • Arrhythmia

  • Heart Failure

  • Heart Block

  • Syncope

  • Bronchospasm

  • CNS (depression, weakness, fatigue, hallucinations)

  • Impotence

  • Elevation of blood cholesterol levels

  • In patients with diabetes: Reduced glucose tolerance, hypoglycemic signs can be masked

  • May aggravate myasthenia gravis

  • Abrupt withdrawal can exacerbate symptoms of hyperthyroidism

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Topical Anticholinergics

Red top: Atropine, Tropicamide, Cyclogyl (cyclopentolate), Homatropine

  • Mouth and eye dryness

  • Delirium and restlessness

  • Tachycardia

  • Flushed skin and face

Systemic Medications with Ocular Side Effects

A Brief Review of Autonomic Physiology and Ocular Effects of Autonomic Medications

  • This 6 minute video reviews autonomic physiology as it relates to the eye

  • It provides an overview of common ocular effects that can be seen with the administration of systemic adrenergic or cholinergic agonists/antagonists

  • It then provides cases applying these principles

 

Corticosteroids and the Eye

  • This 7 minute video provides an overview of corticosteroid usage in ophthalmology

  • It describes key ophthalmic indications for steroid use:

    • Post-operative anti-inflammatory (in corneal transplants and cataract surgery)

    • Autoimmune (uveitis, vasculitis)

    • Infection (rarely used)

    • Allergies (allergic conjunctivitis)

    • Trauma (prevents scarring)

  • It assesses the side effects of topical and systemic steroids on parts of the eye:

    • Worsening eye infection (will see discharge and corneal opacity)

    • Increased ocular pressure (can worsen glaucoma)

    • Cataract formation (associated with long term steroid use)

    • Mild hypertension and hyperglycemia with topical steroids

  • It identifies the following red flag symptoms and signs associated with corticosteroid use:

    • Infection (red eye, purulent discharge)

    • High intraocular pressure (mid-dilated fixed pupil, hazy cornea, eye pain)

    • Cataract (depressed red reflex, whitened lens opacity visible through pupil, blurry vision, increased glare)

 

Ocular Side Effects of Hydroxychloroquine

  • This 5 minute video reviews how to recognize common ocular side effects associated with hydroxychloroquine (HCQ)

  • HCQ is toxic to the retina (specifically to the RPE) and damage is irreversible and continues after cessation due to drug’s long half life

  • HCQ can also cause a transient difficulty in accomodation, which can be alleviated with time or dose reduction

  • Dose greater than 5mg/kg/day is toxic to the retina and risk increases with longer use

  • Other risk factors for toxicity include renal disease, pre-existing retinal disease and age older than 60

  • Signs include scotomas (areas of partial vision loss)

  • Special ophthalmic imaging is needed to detect early damage, hence early examination (baseline exam within 1 year of initiation of therapy) is recommended

  • For patients on chronic HCQ, annual screening is recommended after 5 years of exposure (sooner if risk factors present)