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Medications which can affect the eye

1. Prednisolone

Prednisolone is a type of steroid.  It is closely related to cortisone, and controls eye disease by dampening inflammation in the eye.  It decreases redness and swelling and decreases the number and activity of white blood cells inside the eye and also at any other sites in the body where inflammation might be occurring (joints, chest or skin).  It also decreases the ability of the body to fight infections.

What are the side effects?

Prednisolone is a powerful drug and side effects are common.  In the short term, fluid retention and weight gain are frequent, as are stomach upsets and indigestion and some mood disorders, including a feeling of agitation and restlessness.  In the long term, prednisolone may cause high blood pressure, weakening of the bones (in women and men!) and a long term tendency to diabetes. This tendency to weakening of the bones (osteoporosis) is much higher in elderly patients and especially in post-menopausal women.  It is possible to lessen the side effects on the bones by making sure that the diet is adequate in calcium, by getting adequate weight-bearing exercise (eg, walking), and by ceasing smoking.  Some women may benefit from hormone replacement therapy.

In addition, there are side effects if prednisolone is stopped suddenly; this may cause a feeling of weakness and even very low blood pressure.  Prednisolone increases one’s risk of infections.  It is important to minimise exposure to people who may have an infectious disease and especially to little children, who may have chicken pox or to adults who have shingles.  If you think you may have been exposed to an infection, especially to chicken pox, while on prednisolone you should let your local doctor or your eye doctor know promptly.  Prednisolone is only prescribed after careful consideration of the possible side effects and the benefits that may be gained by the treatment.

What are the alternatives?

Some people with inflammation in their eyes do not require any treatment at all.  If the inflammation is mild, then treatment may be with steroid drops or a steroid injection under the eye rather than with prednisolone tablets.  In general, prednisolone tablets are reserved for those patients with severe vision-threatening disease.  If the prednisolone helps but the side effects are too severe, there are alternatives which may be used in the long term.  If at any stage you feel the side effects of the prednisolone are worse than the visual loss from the uveitis, then it may be that you would be better off stopping the treatment and putting up with your poor vision.

Should I tell my doctor?

Yes, you should always let your doctor or dentist know that you are on prednisolone if you have other illness or are requiring an operation or are being started on any tablets.  In fact you should let your doctor know that you have been on prednisolone even if it is six months since you stopped it.

What should I do if I have problems?

If you have any problems or serious illness whilst on the prednisolone you should take them seriously.  If you develop a temperature or any signs of infection you should contact your eye doctor or your local doctor promptly.  If you have any questions at all do not hesitate to ask your eye doctor.

 

2. Plaquenil

Plaquenil (Hydroxychloroquine) is used to dampen inflammation in some forms of arthritis, especially rheumatoid arthritis and lupus.  Plaquenil is usually used for long term disease control, rather than in the short term to control active bursts of inflammation.  Plaquenil has important but uncommon side effects that may affect your eye.

How does Plaquenil affect your eyes?

The most important affect of Plaquenil on your eye is to damage the retina at the back of your eye.  Fortunately, this is very uncommon and generally only occurs in patients on high doses or patients with bad kidney function.  This sort of retinal damage may result in patchy loss of central vision or patchy loss of vision just close to the centre of your vision.  There are a number of other much less important side-effects of Plaquenil, including changes in the cornea and changes in the eyelids.  To be at risk of eye problems from Plaquenil you need to be on quite a high dose.  The dose that you can safely tolerate depends on your size.  If you weigh less than 30kg, then you may run in to problems on just one tablet a day.  If you weigh less than 60kg (around 9 ½ stone) then you may be at risk of eye problems on two tablets daily.What can I do to ensure my eyes are not affected?It is important to promptly report any changes in vision, especially any changes in your central vision whilst you are on Plaquenil. It is also useful to check your central and near central vision regularly.  It is recommended that you check you vision on an Amsler chart weekly (see below) . You do this by looking at the black dot in the centre with one eye at a time and noticing if there are any gaps or irregularities in the straight lines around the black dot. If there are any changes then you should tell your rheumatologist or your eye doctor promptly. The vast majority of patients on Plaquenil get absolutely no eye problems and you should not be unduly worried or concerned. If you have a good response in your arthritis to the Plaquenil then the benefits of a Plaquenil almost certainly outweigh the small risks to your eyes. So long as you are careful with your eyes, then there are no reasons that you should develop any problems in the long term.Using the Amsler Chart to test your vision:

Image of Amsler Grid to test macular degeneration

  1. Sit in an area with good lighting, wearing your reading glasses and look at the grid from a comfortable distance (30-40cm).
  2. Cover one eye.
  3. Look directly at the centre dot.  While looking directly at the dot, note whether all lines of the grid are straight or if any areas are distorted, blurred or dark.
  4. Repeat the test with the other eye.

If you experience…

  • distortion or curvy lines;
  • blurring;
  • holes or spots in some areas of the grid;

…see your ophthalmologist immediately.

3. Cyclosporin

Cyclosporin is a new drug used to dampen inflammation and the immune system throughout the body.  It is used in patients who have organ transplants to prevent the immune system damaging the new organ, and it is used in patients who have over-activity of the immune system, such as in uveitis, to dampen the inflammation in the affected organ.  It usually used in combination with other anti-inflammatory treatment, especially prednisolone (steroid).

What are the side effects?

Cyclosporin has some important common side effects and some equally important but very uncommon side effects.  The important common side effects are: a tendency to increased hair growth over the body, headaches and abdominal pain, some kidney impairment, a tendency to high blood pressure and tremors.  The important uncommon side effects are: a tendency to liver damage, some impairment of the salt (especially potassium) balance in your body, and a tendency to anaemia.  The most important uncommon side effect is that in some patients there is an increased risk of cancer.  This has only been seen in patients who are taking cyclosporin for long periods to prevent organ transplant rejection.  It has not been seen in patients using cyclosporin to treat uveitis.  It is possible that cyclosporin has a detrimental effect on growing babies and you should not take cyclosporin whilst pregnant or breast-feeding.  If there is any possibility that you may be pregnant or may become pregnant, it is important that you advise your doctor.

What can I do to prevent the side effects?

It is important that the drug be taken conscientiously twice daily.  You will have regular blood tests to monitor the level of cyclosporin in your blood and to monitor for any side effects, especially on the kidney and liver.  There are many drugs that interfere with cyclosporin absorption and metabolism.  You should not take any other medications while you are on cyclosporin without consulting your doctor.  Any problems you have while you are on cyclosporin, especially any suggestion of infection with fever or sore throat, should be taken seriously and treated promptly.

What will happen in the long term?

The benefits of cyclosporin and the side effects are largely temporary and reversible.  In general, patients having cyclosporin for uveitis will have a course of cyclosporin lasting just a few months and then the cyclosporin will be stopped.  Some patients do require repeated or prolonged courses of cyclosporin.  If you have any questions please write them down and feel free to ask at the time of your next consultation, or earlier.