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Hey, what's up everyone, Doctor 
Zeeshan here. 

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Before we get into the top ten 
drugs that the boards love for 

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vision changes as a side effect,
I want you to look into our 

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comments section. 
There is a link that is a 

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downloadable PDF of all these 10
drugs. 

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It's a one sheet, a nice little 
pretty print out. 

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Make sure you download it, make 
sure you print it out so you 

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have it as a reference. 
The other thing is, is with 

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these drugs, I'm going to focus 
just on the vision changes 

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because these drugs have a lot 
of other uses, a lot of other 

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side effects. 
They have a lot of other 

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contraindications. 
So make sure you know these 

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drugs beyond what I'm teaching 
you just about the vision. 

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But know that these drugs are 
going to pop up on your boards 

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for eye exams, vision changes, 
neuropathies, things of that 

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nature. 
So make sure you know these 

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inside out and enjoy the 
download. 

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OK, so let's talk about the top 
ten drugs that the boards are 

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going to ask when it comes to 
vision changes. 

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Remember when I talk about 
pharmacology, typically it's 

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going to be a freebie question 
and ones that we're going to 

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check our vision on is a 
teaching point education. 

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One of the six ways we ask 
pharmacological questions, And I

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say this on day one of our 
program, I say, look, if you see

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a drug that affects your 
hearing, if you see a drug that 

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affects your vision, make sure 
you know these drugs. 

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In this situation, we're going 
to look at the top ten drugs and

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identify them, which is one of 
the six ways that we actually do

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pharmacological questions is 
identifying the drug. 

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And then we're going to take it 
a step further and we're going 

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to go through 10 drugs that the 
boards absolutely love. 

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And not only do they affect 
vision, but how are they going 

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to affect vision and what are 
these drugs used for? 

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So not only is this section 
going to be about the top ten 

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drugs that affect vision, but 
we're also going to go into 

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identifying them and knowing 
what they're used for. 

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Because again, memorization is 
not something that I am OK with.

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I want us to understand and know
where they apply as well to. 

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And I'll throw in exactly how 
the boards would ask these 

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questions because ultimately 
this is how I would ask these 

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questions. 
So the first one is 

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hydroxychloroquine. 
Where do we see this drug? 

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We see hydroxychloroquine in a 
couple of different situations. 

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We'll see it as an anti 
malarial. 

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We'll also see it with systemic 
lupus erythematosus. 

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Systemic lupus erythematosus. 
So SLE, this drug can cause 

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retinopathy. 
So pathology of the retina. 

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And what can happen is we can 
develop permanent vision loss. 

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So what are we going to do? 
We're going to educate our 

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patients to get eye exams, how 
frequently, well, we're going to

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say anywhere in between six 
months to a year, six months to 

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a year. 
But ultimately before we start 

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this drug because especially in 
a situation where we're dealing 

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with SLE, this may be a drug 
that we're taking for an 

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extended period of time. 
In that situation, we want to 

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make sure that we're doing a 
baseline test as well to so make

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sure you do a retinal scan. 
And once we do a retinal scan, 

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we get a baseline, then we're 
going to continue to do the 

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annual and or, or semi annual 
exams. 

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So hydroxychloroquine, 
hydroxychloroquine being the 

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first drug on our list of drugs 
that affect vision. 

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The next drug is ethambutol. 
Ethambutol is part of our ripe 

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regimen that rifampin, 
isoniazid, parazinamide, and the

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last one in RIPE is ethambutol. 
This is the regimen that we use 

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for tuberculosis. 
And the way that I used to 

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remember this one is the E in 
ethambutol reminded me the EN 

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the spelling of I. 
So ethambutol I and this can 

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cause an optic neuritis. 
Again, knowing what they cause 

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like that retinopathy or this 
optic neuritis, that's not 

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really what's important. 
I'm just kind of telling you 

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what is happening here. 
But ultimately just know in 

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general that they do affect 
vision in this situation. 

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We're going to, again, it will 
not in just this situation, but 

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in general, we're always going 
to do what and I teach you this 

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repetitively stop the offending 
agent, right? 

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Always stop the offending agent.
In this situation, we're going 

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to stop the drug immediately and
we are going to see that this 

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patient is complaining of this 
red, green color blindness. 

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So all they're going to see is 
red and green and their visual 

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acuity, the ability to see sharp
objects is also going to 

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decrease as well too. 
So again, ethambutol being part 

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of that ripe regimen causing 
that optic neuritis. 

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The next one is a drug that I 
really don't talk about. 

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It's vision changes because it 
has so many other nasty side 

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effects. 
But the third drug on our list 

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is actually amiodarone. 
And if we think about 

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amiodarone, we talk about it 
extensively in our EKG lecture. 

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The thing about amiodarone is it
has very, very nasty side 

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effects. 
Remember that pneumonic PFTS, 

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LFTS, TFTS, so the pulmonary 
function, the liver function, or

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the thyroid function, all are 
affected by this one drug 

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significantly more important 
than the vision changes. 

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But again, because the boards 
love vision changes, amiodarone 

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can cause these corneal micro 
deposits, kind of like that Halo

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vision, which we'll see here in 
other drugs as well too. 

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Ultimately what we're going to 
see is that if we have these 

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visual Halos, educate your 
patient to notify the healthcare

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provider because what we're 
going to do is we're going to 

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stop the offending agent. 
So again, educate, educate, 

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educate. 
One of the six ways that we do 

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in fact talk about these farm 
drugs, The 4th drug is our 

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corticosteroids, things like 
Prednisone or dexamethasone in 

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short term use. 
Remember with Prednisone, 

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dexamethasone or the steroids, 
corticosteroids in general, 

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educate them about tapering off.
But what about a situation where

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we're taking these drugs 
chronically? 

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Well, Doctor Z, when do we take 
these drugs chronically? 

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We take these drugs chronically 
when we're talking about things 

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like chronic bronchitis, when 
we're dealing with chronic 

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inflammation of the airway of 
the bronchios, then we have to 

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be on a steroid long term. 
Now, do we want to be on a 

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steroid long term? 
No, we don't. 

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We don't want to be on a steroid
long term. 

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Why? 
Because of that pneumonic, a big

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fib, that excess cortisol. 
Remember that from endocrine 

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lecture when we talk about a big
fib, appetite, blood pressure, 

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insulin resistance, 
gluconeogenesis, right, the 

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fibroblasts, immune system, 
we're talking about bone 

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formation, all these things with
a big fib with excess cortisol 

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that we're getting from this 
corticosteroid long term use. 

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Now in short term use, we're 
typically not going to be too, 

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too concerned about these side 
effects, but in long term side 

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effects we are. 
And why? 

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Because with the long term side 
effects that a big fib is huge. 

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But visual changes can come in 
the form of cataracts and 

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glaucoma, cataracts and 
glaucoma. 

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So the way that we're going to 
see this is with the cataracts, 

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when they start to drive at 
night time, that's going to be 

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your clue. 
They're going to start to see 

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sort of a fuzzy appearance 
around lights. 

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So a signal light or street 
lights. 

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They're not going to be crisp. 
They're going to have this 

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extended beam or beams around 
it, almost a Halo, but not a 

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Halo that you're seeing out of 
your eyes, but almost a Halo 

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around the light that you're 
looking at. 

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But look at them talking about 
for cataracts especially, you're

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going to see this in night time 
visual changes. 

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Night time visual changes. 
The 5th drug on our list is our 

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erectile dysfunction drugs, 
specifically sildenafil and 

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tadalafil. 
Sildenafil and tadalafil, these 

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erectile dysfunction drugs can 
also 'cause that visual change, 

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but it's going to come in the 
form of a blue tinged visual 

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change, a blue tinged visual 
change. 

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So the way that I would remember
it is that if you looked at a 

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pill of Viagra, it is in fact a 
little blue pill. 

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And when it's a blue pill, I 
think about blue visual changes.

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So that's kind of the a quick 
little silly way of remembering 

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it. 
Blue tinged visual changes in 

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this situation. 
Again, stop the offending agent.

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This is used for erectile 
dysfunction. 

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So it is an optional treatment. 
It's an optional medication. 

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The 6th drug on our list of 10 
is our anticholinergics. 

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And again, these drugs make us 
less leaky, meaning that it will

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increase our intraocular 
pressure. 

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But with anticholinergic drugs 
such as atropine, scopalamine, 

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maybe even some antihistamines 
that have these anticholinergic 

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properties, the number one 
complaint you're going to get is

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blurred vision. 
And the one that you're going to

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see the most on the boards is 
probably scopalamine. 

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And what is scopalamine used 
for? 

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It's a patch that you're going 
to use for motion sickness. 

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So if you think about a patient 
that's going on a cruise that 

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may develop motion sickness, the
drug of choice that you're going

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to give them is going to be 
scopalamine patches. 

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So remember, go back to our 
lecture, we talk about patch 

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education. 
Again, a great way for the 

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boards to ask it, can they ask 
patch education regarding 

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scopalamine? 
Absolutely they can. 

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So with scopalamine patch 
education, the fact that it is 

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an anticholinergic, it's use is 
going to be for things like 

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cruises or motion sickness. 
So again, what are we going to 

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educate them on? 
Avoid driving and because of 

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that medriasis, that pupil 
dilation which is causing blurry

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vision. 
Wear sunglasses, watch out for 

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the sun affecting your vision. 
The 7th drug out of the 10 is 

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Digoxin and we talk about 
digoxin because it has so many 

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nasty, nasty side effects. 
We talk about it in EKG lecture 

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and cardio. 
The contractility of the heart, 

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we're talking about it dropping 
the heart rate, neurotoxicity, 

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cardio toxicity. 
But here we are talking about 

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visual changes. 
And the visual changes that come

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with digoxin are that yellow 
vision, yellow vision. 

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So now this is not that their 
eyes look yellow. 

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That would be scleral icterus. 
We see that where we see scleral

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icterus when we have jaundice. 
But in this situation, they're 

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going to yellow vision. 
So if they look out, everything 

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looks yellow. 
Imagine wearing a pair of yellow

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sunglasses and everything has 
this yellow tinge to it. 

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So if they complain of that 
yellow vision changes. 

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This is a classic sign of 
toxicity. 

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A classic sign of toxicity. 
And remember, digoxin is one of 

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those drugs that has a very 
narrow therapeutic index. 

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Remember that digoxin 
therapeutic range is going to be

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0.5 to 2 point O nanograms per 
milliliter nanograms. 

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So it is one of those drugs that
has a very narrow therapeutic 

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index. 
So warning these drugs are 

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pretty lethal. 
Warning these drugs, the drugs 

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being digoxin and that pneumonic
warning these drugs are pretty 

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lethal. 
So again, if we're starting to 

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see visual changes, stop the 
offending agent as usual, but 

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this is indicative of toxicity. 
Our 8th drug is topiramate. 

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Topiramate, This drug is an anti
seizure medication. 

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It's also used for migraine 
prevention. 

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In this situation, we're worried
about blurred vision. 

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The 9th drug is isotretinoin, 
Isotretinoin. 

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Isotretinoin is accutane. 
It is used for acne and in this 

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situation we are going to get 
poor night vision and extremely,

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extremely dry eyes. 
In this drug. 

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We are going to use artificial 
tears. 

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The dryness of the eye, it is 
going to get injured very easily

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because that lubrication is not 
there. 

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So because it's so dried out, we
want to give that artificial 

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tears. 
And when we give those 

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artificial tears, we want to 
educate them that this is in 

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fact something that they're 
going to be doing throughout the

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duration of consumption of this 
medication. 

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And the last one is Lenosalid. 
Lenosalid is an antibiotic. 

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It's one of the big guns that we
use. 

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Lenosalid is going to 'cause 
that optic neuropathy and with 

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that optic neuropathy, again, 
it's going to come over long 

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term use, decrease visual acuity
and color changes for Lenosalid.

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Again, with all these 10 drugs, 
we're going to look at stopping 

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the offending agent. 
But first and foremost, we want 

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to educate the patient to 
regularly keep track of their 

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visual changes. 
If there are any visual changes,

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then you're going to notify your
healthcare provider immediately 

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and stop the offending agent. 
So these are our top ten drugs. 

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Again, hydroxychloroquine, 
ethanbutal, amiodarone, 

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corticosteroids are Ed drugs 
like sildenafil to Datafil, 

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anticholinergics, digoxin, 
topiramate, isotretinoin, and 

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linozolid.