Hey, what's up everyone, Doctor Zeeshan here.
Before we get into the top ten drugs that the boards love for
vision changes as a side effect, I want you to look into our
comments section. There is a link that is a
downloadable PDF of all these 10 drugs.
It's a one sheet, a nice little pretty print out.
Make sure you download it, make sure you print it out so you
have it as a reference. The other thing is, is with
these drugs, I'm going to focus just on the vision changes
because these drugs have a lot of other uses, a lot of other
side effects. They have a lot of other
contraindications. So make sure you know these
drugs beyond what I'm teaching you just about the vision.
But know that these drugs are going to pop up on your boards
for eye exams, vision changes, neuropathies, things of that
nature. So make sure you know these
inside out and enjoy the download.
OK, so let's talk about the top ten drugs that the boards are
going to ask when it comes to vision changes.
Remember when I talk about pharmacology, typically it's
going to be a freebie question and ones that we're going to
check our vision on is a teaching point education.
One of the six ways we ask pharmacological questions, And I
say this on day one of our program, I say, look, if you see
a drug that affects your hearing, if you see a drug that
affects your vision, make sure you know these drugs.
In this situation, we're going to look at the top ten drugs and
identify them, which is one of the six ways that we actually do
pharmacological questions is identifying the drug.
And then we're going to take it a step further and we're going
to go through 10 drugs that the boards absolutely love.
And not only do they affect vision, but how are they going
to affect vision and what are these drugs used for?
So not only is this section going to be about the top ten
drugs that affect vision, but we're also going to go into
identifying them and knowing what they're used for.
Because again, memorization is not something that I am OK with.
I want us to understand and know where they apply as well to.
And I'll throw in exactly how the boards would ask these
questions because ultimately this is how I would ask these
questions. So the first one is
hydroxychloroquine. Where do we see this drug?
We see hydroxychloroquine in a couple of different situations.
We'll see it as an anti malarial.
We'll also see it with systemic lupus erythematosus.
Systemic lupus erythematosus. So SLE, this drug can cause
retinopathy. So pathology of the retina.
And what can happen is we can develop permanent vision loss.
So what are we going to do? We're going to educate our
patients to get eye exams, how frequently, well, we're going to
say anywhere in between six months to a year, six months to
a year. But ultimately before we start
this drug because especially in a situation where we're dealing
with SLE, this may be a drug that we're taking for an
extended period of time. In that situation, we want to
make sure that we're doing a baseline test as well to so make
sure you do a retinal scan. And once we do a retinal scan,
we get a baseline, then we're going to continue to do the
annual and or, or semi annual exams.
So hydroxychloroquine, hydroxychloroquine being the
first drug on our list of drugs that affect vision.
The next drug is ethambutol. Ethambutol is part of our ripe
regimen that rifampin, isoniazid, parazinamide, and the
last one in RIPE is ethambutol. This is the regimen that we use
for tuberculosis. And the way that I used to
remember this one is the E in ethambutol reminded me the EN
the spelling of I. So ethambutol I and this can
cause an optic neuritis. Again, knowing what they cause
like that retinopathy or this optic neuritis, that's not
really what's important. I'm just kind of telling you
what is happening here. But ultimately just know in
general that they do affect vision in this situation.
We're going to, again, it will not in just this situation, but
in general, we're always going to do what and I teach you this
repetitively stop the offending agent, right?
Always stop the offending agent. In this situation, we're going
to stop the drug immediately and we are going to see that this
patient is complaining of this red, green color blindness.
So all they're going to see is red and green and their visual
acuity, the ability to see sharp objects is also going to
decrease as well too. So again, ethambutol being part
of that ripe regimen causing that optic neuritis.
The next one is a drug that I really don't talk about.
It's vision changes because it has so many other nasty side
effects. But the third drug on our list
is actually amiodarone. And if we think about
amiodarone, we talk about it extensively in our EKG lecture.
The thing about amiodarone is it has very, very nasty side
effects. Remember that pneumonic PFTS,
LFTS, TFTS, so the pulmonary function, the liver function, or
the thyroid function, all are affected by this one drug
significantly more important than the vision changes.
But again, because the boards love vision changes, amiodarone
can cause these corneal micro deposits, kind of like that Halo
vision, which we'll see here in other drugs as well too.
Ultimately what we're going to see is that if we have these
visual Halos, educate your patient to notify the healthcare
provider because what we're going to do is we're going to
stop the offending agent. So again, educate, educate,
educate. One of the six ways that we do
in fact talk about these farm drugs, The 4th drug is our
corticosteroids, things like Prednisone or dexamethasone in
short term use. Remember with Prednisone,
dexamethasone or the steroids, corticosteroids in general,
educate them about tapering off. But what about a situation where
we're taking these drugs chronically?
Well, Doctor Z, when do we take these drugs chronically?
We take these drugs chronically when we're talking about things
like chronic bronchitis, when we're dealing with chronic
inflammation of the airway of the bronchios, then we have to
be on a steroid long term. Now, do we want to be on a
steroid long term? No, we don't.
We don't want to be on a steroid long term.
Why? Because of that pneumonic, a big
fib, that excess cortisol. Remember that from endocrine
lecture when we talk about a big fib, appetite, blood pressure,
insulin resistance, gluconeogenesis, right, the
fibroblasts, immune system, we're talking about bone
formation, all these things with a big fib with excess cortisol
that we're getting from this corticosteroid long term use.
Now in short term use, we're typically not going to be too,
too concerned about these side effects, but in long term side
effects we are. And why?
Because with the long term side effects that a big fib is huge.
But visual changes can come in the form of cataracts and
glaucoma, cataracts and glaucoma.
So the way that we're going to see this is with the cataracts,
when they start to drive at night time, that's going to be
your clue. They're going to start to see
sort of a fuzzy appearance around lights.
So a signal light or street lights.
They're not going to be crisp. They're going to have this
extended beam or beams around it, almost a Halo, but not a
Halo that you're seeing out of your eyes, but almost a Halo
around the light that you're looking at.
But look at them talking about for cataracts especially, you're
going to see this in night time visual changes.
Night time visual changes. The 5th drug on our list is our
erectile dysfunction drugs, specifically sildenafil and
tadalafil. Sildenafil and tadalafil, these
erectile dysfunction drugs can also 'cause that visual change,
but it's going to come in the form of a blue tinged visual
change, a blue tinged visual change.
So the way that I would remember it is that if you looked at a
pill of Viagra, it is in fact a little blue pill.
And when it's a blue pill, I think about blue visual changes.
So that's kind of the a quick little silly way of remembering
it. Blue tinged visual changes in
this situation. Again, stop the offending agent.
This is used for erectile dysfunction.
So it is an optional treatment. It's an optional medication.
The 6th drug on our list of 10 is our anticholinergics.
And again, these drugs make us less leaky, meaning that it will
increase our intraocular pressure.
But with anticholinergic drugs such as atropine, scopalamine,
maybe even some antihistamines that have these anticholinergic
properties, the number one complaint you're going to get is
blurred vision. And the one that you're going to
see the most on the boards is probably scopalamine.
And what is scopalamine used for?
It's a patch that you're going to use for motion sickness.
So if you think about a patient that's going on a cruise that
may develop motion sickness, the drug of choice that you're going
to give them is going to be scopalamine patches.
So remember, go back to our lecture, we talk about patch
education. Again, a great way for the
boards to ask it, can they ask patch education regarding
scopalamine? Absolutely they can.
So with scopalamine patch education, the fact that it is
an anticholinergic, it's use is going to be for things like
cruises or motion sickness. So again, what are we going to
educate them on? Avoid driving and because of
that medriasis, that pupil dilation which is causing blurry
vision. Wear sunglasses, watch out for
the sun affecting your vision. The 7th drug out of the 10 is
Digoxin and we talk about digoxin because it has so many
nasty, nasty side effects. We talk about it in EKG lecture
and cardio. The contractility of the heart,
we're talking about it dropping the heart rate, neurotoxicity,
cardio toxicity. But here we are talking about
visual changes. And the visual changes that come
with digoxin are that yellow vision, yellow vision.
So now this is not that their eyes look yellow.
That would be scleral icterus. We see that where we see scleral
icterus when we have jaundice. But in this situation, they're
going to yellow vision. So if they look out, everything
looks yellow. Imagine wearing a pair of yellow
sunglasses and everything has this yellow tinge to it.
So if they complain of that yellow vision changes.
This is a classic sign of toxicity.
A classic sign of toxicity. And remember, digoxin is one of
those drugs that has a very narrow therapeutic index.
Remember that digoxin therapeutic range is going to be
0.5 to 2 point O nanograms per milliliter nanograms.
So it is one of those drugs that has a very narrow therapeutic
index. So warning these drugs are
pretty lethal. Warning these drugs, the drugs
being digoxin and that pneumonic warning these drugs are pretty
lethal. So again, if we're starting to
see visual changes, stop the offending agent as usual, but
this is indicative of toxicity. Our 8th drug is topiramate.
Topiramate, This drug is an anti seizure medication.
It's also used for migraine prevention.
In this situation, we're worried about blurred vision.
The 9th drug is isotretinoin, Isotretinoin.
Isotretinoin is accutane. It is used for acne and in this
situation we are going to get poor night vision and extremely,
extremely dry eyes. In this drug.
We are going to use artificial tears.
The dryness of the eye, it is going to get injured very easily
because that lubrication is not there.
So because it's so dried out, we want to give that artificial
tears. And when we give those
artificial tears, we want to educate them that this is in
fact something that they're going to be doing throughout the
duration of consumption of this medication.
And the last one is Lenosalid. Lenosalid is an antibiotic.
It's one of the big guns that we use.
Lenosalid is going to 'cause that optic neuropathy and with
that optic neuropathy, again, it's going to come over long
term use, decrease visual acuity and color changes for Lenosalid.
Again, with all these 10 drugs, we're going to look at stopping
the offending agent. But first and foremost, we want
to educate the patient to regularly keep track of their
visual changes. If there are any visual changes,
then you're going to notify your healthcare provider immediately
and stop the offending agent. So these are our top ten drugs.
Again, hydroxychloroquine, ethanbutal, amiodarone,
corticosteroids are Ed drugs like sildenafil to Datafil,
anticholinergics, digoxin, topiramate, isotretinoin, and
linozolid.