 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
 With OD licensure expanding in Oregon and Washington to include oral and injectable drugs, the side effects of pharmaceutical agents need to be on our minds. We should be on the alert for ocular ill-effects of medications that we and others prescribe. This article reviews the side effects of several commonly prescribed oral medications.Enjoy!
Ben Stoebner, OD
PCLI - Vancouver |
||
|
||
|
Hydroxychloroquine (Plaquenil)
Hydroxychloroquine is an anti-inflammatory drug that has been used in the treatment of rheumatoid arthritis and systemic lupus erythematosus since the 1950s. It suppresses the responsiveness of T lymphocytes to mitogens, interferes with the replication of viruses, decreases leukocyte chemotaxis, stabilizes lysosomal membranes, and traps free radicals.
Symptoms of Toxicity include:
Signs of Toxicity include:
Follow-up
Exams are recommended every 6 months. Specific testing should include:
Prednisone
 Prednisone is a corticosteroid used in treating autoimmune disorders, inflammatory bowel disease, lupus erythematosus, allergic reactions, asthma, COPD, and giant cell arteritis—among others. In general it is used to inhibit inflammation and to induce immunosupression.Toxicity
Prednisone is quite cytotoxic to certain subsets of T cells but can suppress both cellular immunity and antibody as well as prostaglandin and leukotriene synthesis. Prednisone use may lead to cataract formation, pseudotumor cerebri, and elevated IOP. In most cases elevated IOP may occur during the first 4-6 weeks of use. Oral steroid use can lead to posterior subcapsular cataract and nuclear sclerosis after months to years of use.
Follow-up
IOP should be measured 2 months after initiation of treatment. Exams are recommended every 6-12 months thereafter. Specific testing should include:
Amiodarone (Cordarone)
Amiodarone is used to treat cardiac arrhythmias by delaying repolarization of the myocardium. It slows the sinus rate and atrioventricular conduction, prolongs the QT interval and QRS duration. It is a weak calcium channel blocker as well as a non-competitive beta-blocker. It also has anti-anginal effects.
Toxicity
Amiodarone is deposited in tissue and can be found in nearly every organ. Most readily it can be seen in the anterior subcapsular lens and cornea as yellowish-brown microcrystals. Such deposits usually occur after 1-3 months of use. Visual symptoms are rare with halos and reduction in acuity from the deposits occurring infrequently. Adverse neurologic effects however are common. Pseudotumor cerebri and optic neuropathy have been reported.
Follow-up
Exams are recommended every 6 to 12 months. Specific testing should include:
|
Thioridazine (Mellaril)
Thioridazine is a phenothiazine derivative used for the management of schizophrenia. Phenothiozines have an affinity for binding to pigmented ocular surfaces like the retinal pigment epithelium.
Symptoms of Toxicity include:
Signs of Toxicity include:
Such changes appear to be dose dependent so thioridazine should be limited to 800mg per day to reduce the possibility of complications. It has been reported that phenothiazines also induce cataracts. It is suspected that the high lipophilicity of these drugs cause calcium to accumulate in the lens.
Follow-up
Exams are recommended every 6 months. Specific testing should include:
Isoniazid (INH)
 Isoniazid is an antitubercular drug which inhibits a variety of enzymes that are necessary for the survival of mycobacterium tuberculosis. By interfering with mycolic acid synthesis it disrupts the formation of the bacteria cell wall.Toxicity
Symptoms of toxicity include blurred vision associated with its anticholinergic effects on the pupil and accommodation. At high dosing levels signs of RPE disruption may result in the macula. An uncommon but potentially serious side effect of isoniazid is optic neuropathy. It can occur in days to months from starting the drug. Isoniazid toxicity is variable in permanence. Discontinuation of the drug can allow for toxicity reversal if caught soon enough.
Follow-up
Exams are recommended every 3-6 months. Specific testing should include:
Tamoxifen (Nolvadex)
 Tamoxifen is a competitive inhibitor of estradiol at the receptor and is used in the treatment of breast cancer, and to reduce the risk of breast cancer in high risk women. It is used in doses of 10-20 mg twice daily. It has an initial half life of 7-14 hours and is predominantly excreted by the liver. Standard-term and long-term users of tamoxifen more frequently develop cataracts than non-users. One study shows that five or more years of tamoxifen use increases the risk of cataract.Follow-up
Exams are recommended every 6-12 months, depending on duration of treatment. Specific testing should include:
References:
Basic and Clinical Pharmacology, Fifth Edition. Katzung BG. Appleton and langue 1992.
To T-QH and Townsend JC, Ocular toxicity of systemic medications: A Case Series. Optometry 2000;71:29-39.
Kamei A, Mizumoto Y, Takehana M. The relationship between properties of antipsychotic drugs and cataract formation. Biol Pharm Bull 1994 Feb;17(2):237-42.
Paganini-Hill a, Clark LJ. Eye Problems in breast cancer patients treated with tamoxifen. Breast Cancer Res Treat 2000 Mar;60(2):167-72.
|
|
|
||
 |
||
LASIK Financing—a Paradigm Shift
When people become interested in LASIK, a major concern is usually how they will pay for the procedure. For this reason, ODs who refer patients for LASIK and perform pre and post-operative care are faced with more objections to pricing than we are at PCLI. Because we only accept patients for surgery on the referral of their family eye doctor, patients generally have already overcome the financial hurdle and worked out their payment strategies before we see them.
Considering this, you may want to make financing options available—in your practice.
Money Talk
Most doctors feel awkward talking to patients about fees. And that’s OK when insurance plans are picking up most of the tab. When third-party payers are footing the bill, financial discussions can largely be avoided. But LASIK plays by a different set of rules and ignoring them has been costly. With the invasion of LASIK discounters, many surgeons lowered their fees to match the competition. But all across the nation, lower prices led to lower surgery volumes.
Fear—Not Price
The fact is that fear—not price—is the major deterrent to LASIK surgery. I believe discounted fees have caused a large number of consumers to be even more reluctant. Patients who seek quality medical care are uncomfortable when surgeons promote discount prices. Already fearful of the risks involved, their trust in surgeons is further rattled by commercialization of the procedure.
Only after people get over their fear of the procedure will price become important. Therefore, we are shifting our emphasis from the overall cost of the procedure to the affordability of LASIK care. Most patients can’t afford to pay out-of-pocket for LASIK. National statistics show that only 25% of Americans have enough cash on hand to buy items costing $500 or more. People seldom save for major purchases anymore. For better or worse, credit cards and monthly payment plans are how consumers make purchases today.
Discomfort
A doctor’s discomfort with price discussion directly impacts how the staff presents LASIK fees. Any talk of fees is often put off until the end of the conversation and then presented in an apologetic tone. Usually, financing options are either not available or not discussed until it is learned that the patient really needs it.
We often act as if monthly payment plans are for the downtrodden and promote them as a last resort to those who have “bad credit.” But the truth is that most patients can’t afford to pay cash for LASIK—or any big ticket item.
Making it Affordable
Although we do not wish to encourage personal debt, we realize that monthly payments are a fact of life for the majority of consumers. Once patients have overcome their fear of treatment, doctors can make LASIK affordable by offering a payment plan to suit their budget.
At PCLI, we offer the option of flexible monthly payments to every LASIK patient and are in the process of including 0% financing. We have carefully researched numerous payment plans and are happy to recommend the following program for use in your office.
|
|
Vision Fee Plan
Practice Booster
Data from finance companies shows that well-run payment plans can boost patient volume 10 to 30%. By providing financing, you are not stuck trying to sell a $3000 to $4000 elective procedure. Instead, you can offer the option to improve vision for under $100 a month. And patients who have the funds, but simply want to spread their payments out over a few months, will be happy to learn about our new 0% interest option.
New in-office Promotion
Today, LASIK patients are attracted to practices that understand how an increasing number of products and services are being purchased—by monthly payments. To help you get the word out, we have designed a new office display with tear-off cards to guide patients through the LASIK decision making process. The goal of this new design is three-fold:
We’d like your input. Please click to view an enlarged image.
 Would this display, with its tear-off decision guideline cards, be valuable in your practice?
Several points were taken from “The Buck Stops Here,” an article in Cataract and Refractive Surgery Today written by Shareef Mahdavi, LASIK industry expert and former head of marketing for VISX.
Click to read his other articles:
|
 |
||
|
PCLI’s Web Services
Visit the “For Doctors” section of our website for free services that can benefit your practice.
See the top of this page for shortcuts to these services.
|
|
|
Corporate Office
2517 NE Kresky Avenue
Chehalis, WA 98532
 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
||||||
Copyright © 2010 Pacific Cataract and Laser Institute. All rights reserved.