Eyeworld

EW NEWS & OPINION 26 February 2017 by Vanessa Caceres EyeWorld Contributing Writer Although patients using hydroxy- chloroquine for 10 years have a 2% or less risk of retinopathy, that percentage increases to 20% after 20 years of treatment. The AAO released new guidelines last year on how hydroxychloroquine-associated retinopathy is diagnosed. 1 The AAO found that use of spectral domain optical coherence tomography can show retinopathy- related changes earlier than visual field testing. They also reported that concurrent use of tamoxifen in- creased the risk for retinopathy, and in the Asian population, the retinop- athy tends to be more extramacular. Many screening tools used by ophthalmologists in this area, such as fluorescein angiography, Amsler grid testing, and color testing, are not necessary, Dr. Wellik said. Ophthalmologists should test patients on hydroxychloroquine after they have used it for 5 years. Effects of ED medications Phosphodiesterase type 5 inhibi- tors—erectile dysfunction medica- tions—were prescribed 1.5 million times in 2016, Dr. Wellik said. The first drug, sildenafil (Viagra, Pfizer, New York), was approved in 1998, but others followed thereafter. Com- mon side effects include headaches, dyspepsia, and hearing loss, but in the eyes, color and light perception can occur. There's another possible side effect. "Dozens of case reports in the literature show an interaction with Stay vigilant about medication changes in patients S ixty-two percent of doc- tor visits are associated with a new or continued medication prescription, according to Sarah Wellik, MD, associate professor of clinical ophthalmology, Bascom Palmer Eye Institute, University of Miami. So it may not be surprising that medication use is the second most frequent reason for malpractice claims and the third most frequent reason for ophthalmologists—sec- ond only to cataract surgery and retinal detachment. Medication-related claims can be expensive to defend, Dr. Wellik said. Ophthalmologists and their staff members should regularly ask patients about any new medications to help stay alert for medication-re- lated ocular changes. In her presentation at the 2016 American Academy of Ophthalmolo- gy (AAO) annual meeting, Dr. Wellik reviewed some common systemic medications that can have ocular side effects. Toxicity from hydroxychloroquine One area of recent change is reti- nopathy caused by long-term use of hydroxychloroquine, a medication frequently prescribed for rheuma- tological disorders, Dr. Wellik said. Systemic medications can have ocular side effects A 70-year-old male with blurry vision for 3 weeks was later found to have ocular syphilis. Source: Raquel Goldhardt, MD Watch out for systemic infections seen in the eye A nother issue that ophthalmologists might be among the first to diagnose are signs of certain systemic infections, said Raquel Goldhardt, MD, FACS, associate professor of clinical ophthalmology, Bascom Palmer Eye Institute, University of Miami, and staff physician, Miami Veterans Affairs Medical Center. Dr. Goldhardt also presented at the 2016 AAO annual meeting. One infection on the rise in the U.S. and seen frequently in the eye is syphilis. There's a 40% increase of syphilis cases now compared with 2010 and a 15.1% increase compared with 2013, Dr. Goldhardt said. In 2014, a total of 20,000 new cases of primary and secondary syphilis were reported in the US. Syphilis can involve all ocular structures, but common signs and symptoms include pain, redness, conjunctivitis, episcleritis, scleritis, anterior or posterior uveitis with increased IOP, and syphilitic placoid chorioretinitis. In younger patients, be aware of interstitial keratitis, a manifestation of congenital syphilis that can present between 5 and 20 years of age. Dr. Goldhardt gave the example of a 70-year-old male patient who had blurry vision in his left eye for 3 weeks. He had no previous ocular history and had a positive purified protein derivative (tuberculosis) test in the past with a normal X-ray. The patient was receiving radiation treatment for prostate carcinoma. He also had a retinal lesion that did not look like metastasis. A workup confirmed the patient had syphilis. Bacterial endocarditis is another infection that can have subtle signs in the eye. One common sign associated with this is Roth's spots. "Don't miss this finding," Dr. Goldhardt said. "Roth's spots are famously related but not specific of bacterial endocarditis." If this infection is left untreated, it can be fatal. Even with treatment, the mortality rate is 15%, she said. Bacterial endocarditis is usually associated with dental extractions, transurethral resection of the prostate, endoscopy, colonoscopy, barium enema, and transesophageal echocardiography, Dr. Goldhardt said. Other symptoms beyond Roth's spots include a low-grade fever, anorexia, weight loss, and lethargy. Ophthalmologists also should remain vigilant for endogenous endophthalmitis, which makes up 2% to 8% of all endophthalmitis cases. Recent hospitalization, diabetes, urinary tract infections, drug abuse, and immunosuppression are more commonly associated with endogenous endophthalmitis. "This uncommon but potentially devastating eye infection needs to be diagnosed and managed promptly," Dr. Goldhardt said. EW continued on page 28 nonarteritic ischemic optic neuropa- thy [NAION]," Dr. Wellik said. "The problem is that the group using this drug is vasculopathic older men, which is the same group that tends to get NAION." However, two larger studies have shown there is not necessar- ily a larger risk for NAION in men using ED medications. "It may be appropriate to recommend against use if there was a previous NAION, but otherwise, it's not considered a major risk," Dr. Wellik said. Effects of topiramate Topiramate evolved from its initial use as an epileptic drug, then was used for weight loss, and is now prescribed for migraine headaches, Dr. Wellik said. There's even some research to indicate it could become a treatment for alcoholism and post-traumatic stress disorder. "I don't think this drug is going away anytime soon," Dr. Wellik said. Bilateral acute secondary angle closure can occur in some patients, Presentation spotlight

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