Drugs and the Eye

This page discusses interactions of drugs with the eyes and the vision. This is not intended to be a complete catalog of all possible ocular side effects from different medications. Instead, it lists common ocular side effects, or those which deserve special mention. Just because a drug is not listed here does not mean that it does not have any possible ocular side effects. Included are over-the-counter medications, prescription medications, and legal and illegal recreational drugs. Eye medications are not included here.

Read this important information before proceeding further: These sections are not intended to replace the professional examination and diagnosis by a physician, and they are presented here purely for informational purposes. All possible diagnoses and treatment options are not covered, and the information discussed should not be taken as a recommendation to self-diagnose and self-treat a condition. A misdiagnosed or improperly treated eye condition can result in a permanent loss of vision, or a permanent loss of function of the eye or visual system. In the case of any eye problem, seek medical attention promptly. This can include emergency room treatment, as well as treatment by a medical physician or eyecare provider.

Sections Include:

• Over-the-counter Drugs

• Pharmaceutical Drugs

• Legal Non-pharmaceutical Drugs

• Illegal Non-pharmaceutical Drugs (Recreational Drugs)

For eye anatomy explanations, go to ANATOMY

Antihistamines

Antihistamines are found as prescription and non-prescription pills, capsules, liquids, and effervescent tablets (like alka-seltzer). They may be sold as and individual medication or in combination with other medications such as decongestants, pain medications, etc. Often listed as a warning in package information sheets for antihistamines is that the drug should not be used if one has glaucoma. However, for most people with glaucoma, antihistamines can be used safely. The most common type of glaucoma is termed "open angle glaucoma". Antihistamines generally should have no effect with this type of glaucoma.

With a more rare type of glaucoma termed "angle closure glaucoma" or "narrow angle glaucoma", the use of antihistamines may trigger an attack of angle closure glaucoma. Basically, the part of the eye that drains fluid becomes blocked and the pressure within the eye will skyrocket. This is usually accompanied by pain, blurred vision, eye redness, seeing rainbows around lights, and even nausea or vomiting. Angle closure glaucoma is an emergency, and vision can be permanently lost. Many people may be at risk for angle closure glaucoma unknowingly. A recent study found that people of Vietnamese descent may have increased risk for this type of glaucoma. If in doubt, consult with an ophthalmologist who can determine if it is safe to use antihistamines. For more information on glaucoma, go to Glaucoma.

Aspirin

Aspirin has been found to have many beneficial side effects involving the cardiovascular system as an "anticoagulant", or blood thinner. Similarly, certain vascular diseases of the eye may possibly be helped by aspirin. However, this anticoagulant effect can exaggerate bleeding of the eye, such as with subconjunctival hemorrhages or eyelid bruising after trauma. Most eye surgeons recommend that aspirin be discontinued for at least a week before undergoing eyelid surgery.

Vitamin A

Vitamin A has a reputation for being beneficial to the eye. The retina does need a normal amount of vitamin A to properly function, and this amount can be obtained with a well balanced diet without supplements. Large dosages of vitamin A have NOT been shown to help to preserve vision in conditions which cause retinal degeneration (such as retinitis pigmentosa). Large vitamin A intake can be harmful, as it is stored by the body. One condition that can be caused by a large intake of vitamin A (or of foods containing a large amount of vitamin A such as liver) is "pseudotumor cerebri", which is an increase in the pressure of the fluid around the brain (increased intracranial pressure). This can cause visible swelling of the optic nerve within the eye, as well as headache and visual disturbances.

Accutane

Accutane is commonly used to treat acne, and is known to cause dryness of mucous membranes, and the eye is included. Symptoms of dry eye include the sensation that something is in the eye, redness, burning, and even blurred vision. Artificial tears and ointments may help. Accutane may also lead to temporary visual disturbances and trouble with night vision.

Amitriptyline (Tri-cyclic antidepressants)

This class of medication including amitriptyline can have several ocular side effects. They can cause a decrease in tearing, which can lead to dry eye problems. They also can lead to a decrease in focusing ability (accommodation). This temporary effect may cause difficulty with reading or even distance vision. Finally, these medications may have a risk for causing acute angle closure glaucoma, in those persons at risk for this type of glaucoma. Most people with glaucoma have "open angle" glaucoma, and would have no problem with taking these medication. Consult with your ophthalmologist is you are unsure. For more information on this risk of glaucoma, see the section above under Antihistamines.

Antipsychotic medications

Many of these psychiatric medications can have risk for angle closure glaucoma in those persons at risk for this type of glaucoma. Most people with glaucoma have "open angle" glaucoma, and would not be at risk with taking these medication. Consult with your ophthalmologist if you are unsure. For more information on this risk of glaucoma, see the section above under Antihistamines.

Amiodarone

Amiodarone is a potent cardiac medication with a common ocular side effect which rarely gives any symptoms. A person taking this medication will develop a whorl-like pattern on the surface of the cornea over a period of time. Rarely this may interfere with vision or cause glare symptoms. The condition is reversible.

Recently, an association between amiodarone and optic neuritis or optic neuropathy has been made. This has prompted the manufacturer of Cordarone (amiodarone) to revise the Warnings section of this medication's prescribing information. It now states that cases of optic neuritis and/or optic neuropathy have been reported in patients receiving this drug, and that the problem could develop at any time during the use of the drug. It has NOT been clearly established that the drug causes the optic nerve problem, but if there are any changes in vision or peripheral vision then an prompt ophthalmic examination should be performed. Regular ophthalmic examination is recommended for patients receiving amiodarone.

Chloroquine

This is an anti-malarial drug also rarely now used in arthritic conditions. Currently, Plaquenil (hydroxychloroquine) is more commonly used in arthritis, with fewer side effects. Chloroquine can cause degeneration of the optic nerve. It can also cause a retinal degeneration which can lead to blind spots in the vision, reduced color vision, and blurred central vision. The risk of retinal problems may be related to the total cumulative amount of chloroquine taken over time. See the section on Plaquenil below for more information on this potential retinal problem.

Cimetidine

This anti-ulcer medication can rarely lead to angle closure glaucoma in people susceptible to this type of glaucoma. Most people with glaucoma have "open angle" glaucoma, and would not be at risk with taking these medication. Consult with your ophthalmologist if you are unsure. For more information on this risk of glaucoma, see the section above under Antihistamines.

Chlorpromazine (Thorazine)

Thorazine, a psychiatric medication, taken in large dosages can lead to pigmentation of the conjunctiva, cornea, and eyelids. A pigmentary retinal degeneration can also occur. Cataract is also possible. This drug is in the class of drugs known as "phenothiazines", and Mellaril (thioridazine) can have similar side effects.

Chlorpropamide

This diabetic medication can rarely cause a degeneration of the optic nerve.

Digitalis

This cardiac drug can cause a few ocular symptoms, such as glare symptoms and seeing halos around light. In cases of over dosage of digoxin, the vision may become yellowish. This is important since the blood level of digoxin needs to be monitored and may fluctuate for different reasons.

Ephedrine

This stimulant can lead to pupillary dilation and may give risk for angle closure glaucoma in people susceptible to this type of glaucoma.

Estrogen

Estrogens are commonly used in post-menopausal women for symptoms related to estrogen deficiency, and their use has also been associated with a decreased risk for heart disease and hip fracture. A recent study suggests that estrogen use in post-menopausal women may give a protective effect against the formation of cataract (the nuclear sclerotic type of cataract).

5-Fluoro-Uracil (5-FU)

This cancer chemotherapeutic agent can lead to scarring and closure of the tear drainage system (nasolacrimal obstruction). This commonly leads to spontaneous tearing.

Ethambutal

This agent used in the treatment of tuberculosis can rarely lead to a degeneration of the optic nerve.

Haldol

This psychiatric sedative medication can lead to decreased tear production, decreased focusing ability, pupillary dilation, and may give risk for angle closure glaucoma in people susceptible to this type of glaucoma. See the section discussing Tricyclic Antidepressants for more information on these side effects.

Indomethacin

This anti-inflammatory medication can rarely lead to whorl-like changes on the surface of the eye (cornea). This rarely causes any visual symptoms.

Isoniazide

This agent used in the treatment of tuberculosis can rarely lead to a degeneration of the optic nerve.

Minocycline

Minocycline, which is a drug similar to tetracycline, is commonly used orally in the treatment of acne and rosacea. Recently reported is a pigmentation of the white of the eye (sclera) which can occur with the use of this drug. It is typically a blue-gray discoloration, but may also be black or brownish. It may be worse in areas exposed to sunlight. This is also true with the similar skin pigmentation which can occur with the drug, as well as fingernail and tooth discoloration. If the abnormal pigmentation is recognized quickly, discontinuation of the drug may allow the skin, eye, etc. to return to their normal appearance.

Nalidixic Acid

This medication is one of several that can be associated with the development of increased pressure of the fluid around the brain, or "pseudotumor cerebri". This can lead to headache, visual changes, and a visibly swollen optic nerve.

Nasal Steroids (spray)

Inhaled steroids for asthma have been recently implicated as causing glaucoma, in susceptible people (note, this is "open angle glaucoma".)

Niacin, Niacinamide

These drugs may lead to a cystic swelling of the retina known as "cystoid macular edema". Blurred and distorted vision are common with this.

Oral Contraceptives

Oral contraceptives, or birth control pills, can lead to numerous ocular problems. Migraine headaches may be caused by this. Also, increased pressure of the fluid around the brain (pseudotumor cerebri) can occur, leading to headache, visual changes, and a swollen optic nerve. Finally, certain retinal vascular problems may be caused or worsened by oral contraceptives.

Plaquenil

Plaquenil is a drug used as an anti-inflammatory medication which is helpful in certain rheumatological conditions such as rheumatoid arthritis or lupus. It is similar to chloroquine, an anti-malarial agent, which also has much more potential toxicity. Plaquenil can rarely cause a retinal problem involving the central visual area, or macula. In dosages usually used, there is usually no problem with the retina. Nevertheless, it is recommended to have an eye examination at least once a year to look for signs of toxicity. Visual changes may include blurred vision, decreased color vision, distorted vision, blind spots in the vision, and halos around lights. Monitoring the vision between examinations with an "Amsler grid" make help an individual to pick up a problem with the vision early. The retina may take on a specific appearance when it is being adversely affected by plaquenil. Discontinuing the drug at the earliest sign of toxicity may help to prevent visual loss. Generally, however, visual loss from this medication is almost unheard of, and it may have less potential ocular toxicity than other medications that may be used.

Quinine

Quinine can rarely cause difficulty with night vision, or seeing in the dark. If taken by pregnant women, it can lead to "optic nerve hypoplasia" in the fetus, which is a birth defect characterized by an under-developed optic nerve.

Rifabutin

This medication is used as a preventive treatment for "mycobacterium avium", which is an infection that can occur in HIV positive people. It has been shown to cause intra-ocular inflammation (iritis or uveitis) in some people.

Scopolamine Patch

This is a patch often placed behind the ear to help which motion sickness, or sea-sickness. Scopolamine is a potent dilating agent, with the pupillary dilation lasting 3 to 5 days. When used normally, this ocular side effect is not usually seen. However, if the patch is broken open or cut, and the contents are inadvertently rubbed into the eyes, this pupil dilation could occur. A loss of focusing ability also occurs with the dilation.

Steroids (Prednisone)

Oral or intravenous steroids are commonly used especially during attacks of asthma or emphysema, and as an anti-inflammatory agent with arthritis. It is also used after organ transplantation. Short term use of steroids normally does not cause eye problems, but long term chronic use may lead to two possible complications. One complication is glaucoma. Certain predisposed individuals exhibit a rise in eye pressure with the use of steroids, usually after 3 to 4 weeks. This includes oral and IV steroids as well as eyedrop steroids. The glaucoma is treatable using medication or rarely surgery, and the pressure usually returns to normal if steroids can be stopped.

Cataract is another complication. The typical steroid induced cataract develops on the back surface of the lens in the eye, and is called a "posterior subcapsular cataract". This can be a rapidly forming and very visually significant type of cataract, often causing much glare disability. Once cataract forms, it cannot be reversed, although surgery can remove the cataract and restore the vision.

Tamoxifen

This medication is often used after breast cancer treatments. It can lead to crystalline deposits in the retina and cornea in some cases.

Tetracycline

Tetracycline is a commonly used antibiotic. It has a property whereby the oil gland secretions become more thinned. Thus, it is commonly used in cases of acne. It also can thin the oil secretions of the "Meibomian glands" in the eyelids. This can help prevent stye formation and can help with inflammation of the eyelid (blepharitis).

Tetracycline has also been shown to rarely lead to increased intracranial pressure (pseudotumor cerebri), which can cause headache, blurred vision, and blind spots in the vision.

Thioridazine (Mellaril)

This is a psychiatric medication in the same class as chlorpromazine (thorazine). In cases of high chronic dosages, it can lead to reduced night vision and blind spots in the vision. Retinal pigmentary changes and "brownish" vision can also occur.

Viagra (sildenafil citrate)

This medication is used for erectile dysfunction in men. Ocular side effects include pupillary dilation, redness, dryness, blurred vision, and a temporary bluish discoloration to the vision. The Academy of Ophthalmology cautions the use of this drug in individuals with retinitis pigmentosa, macular degeneration, and diabetic retinopathy. Some cases of vision loss secondary to an ischemic optic neuropathy have also been reported.

Alcohol (Ethanol)

In spite of the numerous medical complications of chronic alcohol abuse, the eyes are relatively spared from complications. Acute intoxication with alcohol can lead to temporary blurred vision, pupil dilation, eye redness, double vision, and difficulty focusing. Chronic alcohol abuse can lead to what is thought to be a nutritional degeneration of the optic nerve. This could result in permanently reduced vision, blind spots in the vision, and reduced color vision. Short term consumption of alcoholic beverages may be a trigger for migraine headache. In some cases, people may experience the visual aura (flashing jagged shimmering lights) of migraine without developing the headache. Other chemicals found in wine or beer may also trigger migraine.

Tobacco

While tobacco itself is not a drug, nicotine is a drug found in tobacco and is quite addictive. Nicotine itself probably does not cause ocular damage. However, other chemicals found in smoked tobacco materials have been shown to lead to ocular complications:

1. Cataract. Studies have proven that smoking tobacco increases the risk of cataract formation in men, and increases the risk of cataract surgery in women.

2. Macular degeneration. Studies have shown that smoking tobacco increases the risk for macular degeneration in men and women. This can lead to a rapid irreversible loss of vision.

3. Vascular disease. Smoking tobacco is known to contribute to arteriosclerosis, or hardening of the arteries, along with high cholesterol and hypertension (along with other factors as well). This arteriosclerosis may contribute to vascular problems of the eye such as vein occlusions, artery occlusions, and optic nerve damage. These are serious eye problems which often lead to substantial loss of vision.

4. Nutritional optic nerve degeneration. Tobacco is often implicated along with alcohol (in combination) as to causing a nutritional degeneration of the optic nerve.

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Amphetamines

Amphetamines use can lead to a reduced focusing ability and dilation of the pupil. With this dilation comes a risk for acute angle-closure glaucoma. In this glaucoma, the eye pressure becomes suddenly extremely elevated, leading to eye pain, redness, blurred vision, loss of vision, seeing rainbows around lights, nausea, and vomiting. Angle closure glaucoma is a serious eye emergency. Amphetamines otherwise can lead to hallucinations during usage.

Cocaine

Cocaine has been reported to potentially lead to corneal ulceration. These ulcers are sometimes sterile, and sometimes infected with bacteria. It is not fully understood why this occurs, except that cocaine is a potent eye anesthetic. Thus, with the eye numb, damage can occur unknowingly leading to the ulceration. Once the anesthetic effect wears off, the eye can become very painful with blurred vision. This problem can lead to scarring that can cause permanent vision loss.

Cocaine has also been shown to lead to an occlusion of the arteries in the retina. This leads to rapid and often irreversible loss of vision.

Intravenously injected drugs

The injection of drugs directly into the veins can lead to deposits of talc or other "cutting agents" forming in the retina. This can lead to loss of vision, and larger particles can potentially block the retinal circulation altogether, with a rapid and severe loss of vision.

Marijuana

The use of marijuana can lead to eye redness and dilated pupils. It can also cause visual hallucinations. More controversial is the use of marijuana as a helpful drug in the lowering of eye pressure in glaucoma. There is a scarcity of good studies demonstrating this pressure lowering effect, but apparently it does exist. However, marijuana is a poor choice as a drug for glaucoma for several reasons: It has a short duration of action, and must be taken (smoked) every 2 to 4 hours to maintain the effect. Many glaucoma drugs (eyedrops) are more effective at lowering pressure in the eye and only have to be taken ONCE at day. Furthermore, smoking is a poor drug delivery system. Depending on how deeply one inhales and on the potency of a given marijuana cigarette, the dosage of actual pressure lowering medication is variable. Finally, marijuana has numerous side effects, including impairment of thought processes and lung disease. The May 1997 issue of Consumer Reports has a good article on the medical use of marijuana (page 62 - 63).

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