Mark W. Leitman - Manual for Eye Examination and Diagnosis

Source : Courtesy of Bonnie Henderson, MD, Harvard Medical School.

Prostaglandin analogues are the most commonly prescribed glaucoma medications. Side effects include rare, irreversible darkening of the iris ( Fig. 11) and reversible reduction in orbital fat ( Fig. 12) with frequent darkening and lengthening of the lashes ( Fig. 13). The lash changes are often considered desirable by patients and, consequently, lead to another prostaglandin medication called Latisse , which is specifically prescribed for cosmetic reasons to alter the lashes.

Fig 10 Stevens–Johnson syndrome with inflammation and adhesions of lid and bulbar conjunctiva.

Source : Reprinted with permission from Am. J. Ophthalmol ., Aug. 2008, Vol. 1146, p. 271. Surgical strategies for fornix reconstruction. Based on Symblepharon Severity , Ahmad Kheirhah, Gabriella Blanco, Victoria Casas, Yasutaka Hayashida, Vadrecu K. Radu, Scheffer C.G. Tseng. Copyright 2008, Elsevier.

Amiodarone (Cordarone, Pacerone), one of the most potent anti‐arrhythmia drugs, and sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra), used to treat erectile dysfunction, have all been suspected of causing nonarteritic anterior ischemic optic neuropathy. Amiodarone almost always causes deposits in the cornea that rarely reduce vision, but may cause glare ( Fig. 14).

Fig 11 Irreversible darkening of a blue iris after 3 months of latanoprost (Xalatan) therapy. This is the most common drug for treating glaucoma.

Source : Courtesy of N. Pfeiffer, MD, P. Appleton, MD, and Arch. Ophthalmol ., Feb. 2011, Vol. 119, p. 191. Copyright 2001, American Medical Association. All rights reserved.

Fig 12 (A) Prostaglandin‐analogue induced fat atrophy of the left orbit with sunken superior sulcus after 1 year (↑) and darkened skin ( ∧). Courtesy of University of Iowa, Eyerounds.org. (B) After discontinuing eye drops that had been used in the left eye for 1 year, orbital fat atrophy, darkened and lengthened lashes, and improved skin pigmentation are seen.

Source : Courtesy of N. Pfeiffer, MD, P. Appleton, MD, and Arch. Ophthalmol ., Feb. 2011, Vol. 119, p. 191. Copyright 2001, American Medical Association. All rights reserved.

Fig 13 After long‐term use of prostaglandin analogue in the left eye, the patient developed hyperpigmentation of periorbital skin, darkening and lengthening of lashes, and loss of orbital fat, causing a deepening of the upper eyelid sulcus.

Topiramate (Topamax), used to treat seizures and prevent migraine headaches, may cause angle‐closure glaucoma by causing edema of the ciliary body which pushes the iris toward the cornea closing the drainage system. Immediately discontinue the drug.

Fig 14 Epithelial deposits radiating from a central point in the inferior cornea. They occur in almost all patients with Fabry’s disease, which is an X‐linked systemic accumulation of a glycosphingolipid. Easily seen on a slit lamp exam, it can be the first clue in recognizing the presence of this disease, which is amenable to therapy. Indistinguishable deposits eventually appear in almost all patients using amiodarone and, less often, with hydroxychloroquine.

Source : Courtesy of Neal A. Sher, MD, and Arch. Ophthalmol ., Aug. 1979, Vol. 97, pp. 671–676. Copyright 1979. American Medical Association. All rights reserved.

Inquire about drug allergies before eye drops are placed or medications prescribed. Neomycin, a popular antibiotic eye drop, may cause conjunctivitis and reddened skin ( Fig. 15).

Cataracts, refractive errors, retinal degeneration, and strabismus—to name a few—may all be inherited. In glaucoma, family members have a 10% chance of acquiring the disease. Eighty‐five percent of people with migraine have an immediate relative with the disease.

Fig 15 Neomycin allergy occurs in 5–10% of the population.

A special question should be directed to a healthy lifestyle. It has been steadily worsening, causing a decrease in American lifespan to 78.6 years in 2017, compared with 82 years in Canada, Japan, and France. Fourteen percent of Americans still smoke cigarettes. It doubles the rate of cataracts, macular degeneration, and all types of uveitis. It also worsens exophthalmos due to thyroid disease, and was responsible for 480,000 deaths in America in 2018. Care must be taken in prescribing pain medications. In 2017, opioid use was the number one cause of death in America in those younger than age 50. At age 70, 80% of Americans have been diagnosed with high blood pressure. Over 50% of adults are diabetic or pre‐diabetic. One‐third of Americans are obese and another one‐third are overweight, contributing to cancer, hypertension, and diabetes. Patients should be reminded about minimizing the consumption of red and preserved meats, salt, sugar, and saturated fats. Recommend instead an antioxidant diet rich in fruits, vegetables, beans, nuts, fish, and whole‐grain cereals. Staying thin, minimizing stress, and following a routine daily exercise program should also be advocated, since even sitting at your job has been shown to shorten life span by 2 years. Mental disorders must be properly addressed since suicide, drug addiction, and alcoholism contribute significantly to morbidity. Remind patients that they must be proactive in taking responsibility for their health, and that they must become less dependent on pharmaceutical answers.

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