5. Gastrointestinal agents

Generic Name: Naproxen.

Fincham JE. Exacerbation of glaucoma in an elderly female taking naproxen sodium: a case report. J Geriatr Drug Ther. 1989;3:139–143.

Fraunfelder FT. Interim report: National Registry of Possible Drug-Induced Ocular Side Effects. Ophthalmol. 1979;86:126–130.

Fraunfelder FT, Samples JR, Fraunfelder FW. Possible optic nerve side effects associated with nonsteroidal anti-inflammatory drugs. J Toxicol Cut Ocular Toxicol. 1994;13(4):311–316.

Harry DJ, Hicks H. Naproxen hypersensitivity. Hosp Form. 1983;18:648.

McEvoy GK. American Hospital Formulary Service Drug Information 87. American Society of Hospital Pharmacists: Bethesda; 1987 [pp 942–946] .

Mordes JP, Johnson MW, Soter NA. Possible naproxen associated vasculitis. Arch Intern Med. 1980;140:985.

Shelley WB, Elpern DJ, Shelley ED. Naproxen photosensitization demonstrated by challenge. Cutis. 1986;38:169–170.

Svihovec J. Anti-inflammatory analgesics and drugs used in gout. Excerpta Medica: Amsterdam; 1980:152. Dukes MNG. Meyler’s Side Effects of Drugs. vol 9.

Szmyd L Jr, Perry HD. Keratopathy associated with the use of naproxen. Am J Ophthalmol. 1985;99:598.

Generic Name: Piroxicam.

Duró JC, Herrero C, Bordas X. Piroxicam-induced erythema multiforme. J Rheumatol. 1984;11:554–555.

Fraunfelder FT, Samples JR, Fraunfelder FW. Possible optic nerve side effects associated with nonsteroidal anti-inflammatory drugs. J Toxicol Cut Ocular Toxicol. 1994;13(4):311–316.

Halasz CL. Photosensitivity to the nonsteroidal anti-inflammatory drug piroxicam. Cutis. 1987;39:37–39.

Roujeau JC, Phlippoteau C, Koso M, et al. Sjögren-like syndrome after drug-induced toxic epidermal necrolysis. Lancet. 1985;1:609–611.

Stern RS, Bigby M. An expanded profile of cutaneous reactions to nonsteroidal anti-inflammatory drugs. Reports to a specialty-based system for spontaneous reporting of adverse reactions to drugs. JAMA. 1984;252:1433–1437.

Varela P, Amorim I, Sanches M, et al. Photosensitivity induced by piroxicam. Acta Med Portuguesa. 1998;11(11):997–1001.

Vasconcelos C, Magina S, Quirino P, et al. Cutaneous drug reactions to piroxicam. Contact Dermatitis. 1998;39(3):145.

Generic Names: Aspirin (acetylsalicylic acid).

Assia EI, Raskin T, Kaiserman I, et al. Effect of aspirin intake on bleeding during cataract surgery. J Cataract Refract Surg. 1998;24:1243–1246.

Banerjee S, Denniston AK, Gibson JM, et al. Does cardiovascular therapy affect the onset and recurrence of preretinal and vitreous haemorrhage in diabetic eye disease? Eye. 2004;18:821–825.

Basu PK, Matuk Y, Kapur BM, et al. Should corneas from donors receiving a high dose of salicylate be used as grafts: an animal experimentation. Exp Eye Res. 1984;39:393–400.

Benawra R, Mangurten HH, Duffell DR. Cyclopia and other anomalies following maternal ingestion of salicylates. Pediatrics. 1980;96:1069–1071.

Birch J, Chisholm IA, Kinnear P, et al. Acquired color vision defects. Pokorny J, Smith VC, Verriest G, et al. Congenital and Acquired Color Vision Defects. Grune & Stratton: New York; 1979:243–350.

Black RA, Bensinger RE. Bilateral subconjunctival hemorrhage after acetylsalicylic acid overdose. Ann Ophthalmol. 1982;14:1024–1025.

Chak M, Williamson TH. Spontaneous suprachoroidal haemorrhage associated with high myopia and aspirin. Eye. 2003;17:525–527.

Cheng H. Aspirin and cataract (Editorial). Br J Ophthalmol. 1992;76:257–258.

Chew EY, Klein ML, Murphy RP, et al. Effects of aspirin on vitreous/preretinal hemorrhage in patients with diabetes mellitus. Arch Ophthalmol. 1995;113:52–55.

Christen WG, Ajani UA, Schaumberg DA, et al. Aspirin use and risk of cataract in posttrial follow-up of physicians’ health study I. Arch Ophthalmol. 2001;119:405–412.

Cumming RG, Mitchell P. Medications and cataract. The Blue Mountains Eye Study. Ophthalmol. 1999;105:1751–1757.

De Jong PT, Chakravarthy U, Rahu M, et al. Associations between aspirin use and aging macula disorder: the European eye study. Ophthalmol. 2012;11:112–118.

Early Treatment Diabetic Retinopathy Study Research Group. Effects of aspirin treatment on diabetic retinopathy. Ophthalmology. 1991;98:757–765.

Foong AW, Saw SM, Loo JL, et al. Rationale and methodology for a population-based study of eye diseases in Malay people: the Singapore Malay eye study (SiMES). Ophthalmic Epidemiol. 2007;14:25–35.

Fraunfelder FT, Sciubba JJ, Mathers WD. The role of medications in causing dry eye. J Ophthalmol. 2012 [Epub Aug 27] .

Ganley JP, Geiger JM, Clement JR, et al. Aspirin and recurrent hyphema after blunt ocular trauma. Am J Ophthalmol. 1983;96:797–801.

Kageler WV, Moake JL, Garcia CA. Spontaneous hyphema associated with ingestion of aspirin and alcohol. Am J Ophthalmol. 1976;82:631–634.

Klein BE, Howard KP, Gangnon RE, et al. Long-term use of aspirin and age-related macular degeneration. JAMA. 2012;308(23):2469–2478.

Klein R, Klein BE, Jensen SC, et al. The five-year incidence and progression of age-related maculopathy: the Beaver Dam Eye Study. Ophthalmol. 1997;104(1):7–21.

Klein R, Klein BE, Linton KL. Prevalence of age-related maculopathy: the Beaver Dam Eye Study. Ophthalmol. 1992;99(6):933–943.

Kokolakis S, Zafirakis P, Livir-Rallatos G, et al. Aspirin intake and bleeding during cataract surgery. J Cataract Refract Surg. 1999;25:301–302.

Lumme P, Laatikainen LT. Risk factors for intraoperative and early postoperative complications in extracapsular cataract surgery. Eur J Ophthalmol. 1994;4:151–158.

Makeia A-L, Lang H, Korpela P. Toxic encephalopathy with hyperammonaemia during high-dose salicylate therapy. Acta Neurol Scand. 1980;61:146–156.

Moss SE, Klein R, Klein BE. Prevalence of and risk factors for dry eye syndrome. Arch Ophthalmol. 2000;118(9):1264–1268.

Moss SE, Klein R, Klein BE. Long-term incidence of dry eye in an older population. Optom Vis Sci. 2008;85(8):668–674.

Ong-Tone L, Paluck EC, Hart-Mitchell RD. Perioperative use of warfarin and aspirin in cataract surgery by Canadian Society of Cataract and Refractive Surgery members: survey. J Cataract Refract Surg. 2005;31:991–996.

Paris GL, Waltuch GF. Salicylate-induced bleeding problem in ophthalmic plastic surgery. Ophthalmic Surg. 1982;13:627–629.

Parkin B, Manners R. Aspirin and warfarin therapy in oculoplastic surgery. Br J Ophthalmol. 2000;84:1426–1427.

Price KS, Thompson DM. Localized unilateral periorbital edema induced by aspirin. Comment in Ann Allergy Asthma Immunol. 1997;79:420–422.

Ranchod TM, Guercio JR, Ying G-S, et al. Effect of aspirin therapy on photodynamic therapy with verteporfin for choroidal neovascularization. Retina. 2008;28:711–716.

Ruocco V, Pisani M. Induced pemphigus. Arch Dermatol Res. 1982;274:123–140.

Sacca SC, Cerqueti PM, et al. Topical use of aspirin in allergic conjunctivitis. Bull Ocul. 1988;67(Suppl 4):193–196 [(Italian)] .

Schachat AP. Can aspirin be used safely for patients with proliferative diabetic retinopathy? Arch Ophthalmol. 1992;110:180.

Smidt D, Torpet LA, Nauntofte B, et al. Associations between oral and ocular dryness, labial and whole salivary flow rates, systemic diseases and medications in a sample of older people. Community Dent Oral Epidemiol. 2011;39:276–288.

Spaeth GL, Nelson LB, Beaudoin AR. Ocular teratology. Jakobiec FA. Ocular Anatomy, Embryology and Teratology. JB Lippincott: Philadelphia; 1982:955–975.

Tilanus MA, Vaandrager W, Cuyper MH, et al. Relationship between anticoagulant medication and massive intraocular hemorrhage in age-related macular degeneration. Graefes Arch Clin Exp Ophthalmol. 2000;238:482–485.

Tong L, Wong TY. Aspirin and dry eye? Ophthalmol. 2009;116(1):167–168.

Valentic JP, Leopold IH, Dea FJ. Excretion of salicylic acid into tears following oral administration of aspirin. Ophthalmol. 1980;87:815–820.

Wilson HL, Schwartz DM, Bhatt HR, et al. Statin and aspirin therapy are associated with decreased rates of choroidal neovascularization among patients with age-related macular degeneration. Am J Ophthalmol. 2004;137:615–624.

Generic Names: 1. Codeine; 2. dextropropoxyphene.

Bergmanson JP, Rios R. Adverse reaction to painkiller in Hydrogel lens wearer. Am Optom Assoc. 1981;52:257–258.

El-Mallakh RS. Internuclear ophthalmoplegia with narcotic overdosage. Ann Neurol. 1986;20:107.

Leslie PJ, Dyson EH, Proudfoot AT. Opiate toxicity after self poisoning with aspirin and codeine. BMJ. 1986;292:96.

Ostler HB, Conant MA, Groundwater J. Lyell’s disease, the Stevens-Johnson syndrome, and exfoliative dermatitis. Trans Am Ophthalmol Otolaryngol. 1970;74:1254–1265.

Ponte CD. A suspected case of codeine-induced erythema multiforme. Drug Intell Clin Pharm. 1983;17:128–130.

Rizzo M, Corbett J. Bilateral internuclear ophthalmoplegia reversed by naloxone. Arch Neurol. 1983;40:242–243.

Wall R, Linford SM, Akhter MI. Addiction to Distalgesic (dextropropoxyphene). BMJ. 1980;280:1213–1214.

Weiss IS. Optic atrophy after propoxyphene overdose. Report of a case. Ann Ophthalmol. 1982;14:586–587.

Generic Name: Paracetamol (acetaminophen).

Gérard A, Roche G, Presles O, et al. Drug-induced Lyell’s syndrome. Nine cases. Therapie. 1982;37:475–480.

Johnson DA. Drug-induced psychiatric disorders. Drugs. 1981;22:57–69.

Kashihara M, Danno K, Miyachi Y, et al. Bullous pemphigoid-like lesions induced by Phenacetin. Report of a case and an immunopathologic study. Arch Dermatol. 1984;120:1196–1199.

Kneezel LD, Kitchens CS. Phenacetin-induced sulfhemoglobinemia: report of a case and review of the literature. Johns Hopkins Med J. 1976;139:175–177.

Krenzelok EP, Best L, Manoguerra AS. Acetaminophen toxicity. Am Hosp Pharm. 1977;34:391–394.

Malek-Ahmadi P, Ramsey M. Acute psychosis associated with codeine and acetaminophen: a case report. Neurobehav Toxicol Teratol. 1985;7:193–194.

McEvoy GK. American Hospital Formulary Service Drug Information 87. American Society of Hospital Pharmacists: Bethesda; 1987:998–1002.

Neetans A, Martin J, Rubbens MC, et al. Possible iatrogenic action of phenacetin at the levels of the visual pathway. Bull Soc Belge Ophthalmol. 1977;178:65–76.

Generic Names: 1. Naloxone hydrochloride; 2. naltrexone.

Bellini C, Bacaini M, D’Egidio P, et al. Naloxone anisocoria: a noninvasive inexpensive test for opiate addiction. Int J Clin Pharm Res. 1982;11:55.

Drago F, Aguglia E, Dal Bello A, et al. Ocular instillation of naloxone increases intraocular pressure in morphine-addicted patients: a possible test for detecting misuse of morphine. Experimentia. 1985;41:266–267.

Fanciullacci M, Boccuni M, Pietrini U, et al. The naloxone conjunctival test in morphine addiction. Eur J Pharmacol. 1980;61:319–320.

Jasinski DR, Martin WR, Haertzen C. The human pharmacology and abuse potential of N-Allylnoroxymorphone (naloxone). I Pharmacol Exp Ther. 1967;157:420–426.

Martin WR. Opioid antagonists. Pharmacol Rev. 1967;19:463–521.

Nomof N, Elliott HW, Parker KD. The local effect of morphine, nalorphine, and codeine on the diameter of the pupil of the eye. Clin Pharmacol Ther. 1968;9:358–364.

Generic Name: Diacetylmorphine (diamorphine, heroin).

Alinlari A, Hashem B. Effect of opium addiction on intraocular pressure. Glaucoma. 1985;7:69.

Caradoc-Davies TH. Opiate toxicity in elderly patients. BMJ. 1981;283:905–906.

Cosgriff TM. Anisocoria in heroin withdrawal. Arch Neurol. 1973;29:200–201.

Crandall DC, Leopold IH. The influence of systemic drugs on tear constituents. Ophthalmol. 1979;86:115–125.

Dally S, Thomas G, Mellinger M. Loss of hair, blindness and skin rash in heroin addicts. Vet Human Toxicol. 1982;24(Suppl):62.

Firth AY. Heroin and diplopia. Addiction. 2005;100:46–50.

Gill AC, Oei J, Lewis NL, et al. Strabismus in infants of opiate-dependent mothers. Acta Paediatr. 2003;92:379–385.

Gómez Manzano C, Fueyo J, Garcés JM, et al. Internuclear ophthalmopathy associated with opiate overdose. Med Clin (Barc). 1990;94:637.

Hawkins KA, Bruckstein AH, Guthrie TC. Percutaneous heroin injection causing heroin syndrome. JAMA. 1977;237:1963–1964.

Hogeweg M, De Jong PT. Candida endophthalmitis in heroin addicts. Doc Ophthalmol. 1983;55:63–71.

Kowal L, Mee JJ, Nadkarni S, et al. Acute esotropia in heroin withdrawal: a case series. Binocul Vis Strabismus. 2003;Q18:163–166.

Rathod NH, De Alarcon R, Thomson IG. Signs of heroin usage detected by drug users and their parents. Lancet. 1967;2:1411–1414.

Salmon JF, Partridge BM, Spalton DJ. Candida endophthalmitis in a heroin addict: a case report. Br J Ophthalmol. 1983;67:306–309.

Siepser SB, Magargal LE, Augsburger JJ. Acute bilateral retinal microembolization in a heroin addict. Ann Ophthalmol. 1981;13:699–702.

Sutter FK, Landau K. Heroin and strabismus. Swiss Med Wkly. 2003;133:293–294.

Tarr KH. Candida endophthalmitis and drug abuse. Aust J Ophthalmol. 1980;8:303–305.

Vastine DW, Horsley W, Guth SB, et al. Endogenous candida endophthalmitis associated with heroin use. Arch Ophthalmol. 1976;94:1805.

Generic Names: 1. Hydromorphone hydrochloride (dihydromorphinone); 2. oxymorphone hydrochloride.

1985. Acute drug abuse reactions. Med Lett Drugs Ther. 1985;27:77.

De Cuyper C, Goeteyn M. Systemic contact dermatitis from subcutaneous hydromorphone. Contact Dermatitis. 1992;27(4):220–223.

1986. Drug Evaluations. ed 6. American Medical Association: Chicago; 1986 [p 59] .

Gilman AG, Goodman LS, Gilman A. The Pharmacological Basis of Therapeutics. ed 6. Macmillan: New York; 1980:495–511.

Katcher J, Walsh D. Opioid-induced itching: morphine sulfate and hydromorphone hydrochloride. J Pain Symptom Manage. 1999;17(1):70–72.

Sweetman SC. Martindale: The Complete Drug Reference. ed 34. Pharmaceutical Press: London; 2004:45–76.

Generic Name: Methadone hydrochloride.

Gill AC, Oei J, Lewis NL, et al. Strabismus in infants of opiate-dependent mothers. Acta Paediatr. 2003;92:379–385.

Gupta M, Mulvihill AO, Lascaratos G, et al. Nystagmus and reduced visual acuity secondary to drug exposure in utero: long-term follow up. J Ped Ophthalmol Strab. 2012;49(1):58–63.

Hamilton R, McGlone L, MacKinnon JR, et al. Ophthalmic, clinical and visual electrophysiological findings in children born to mothers prescribed substitute methadone in pregnancy. Br J Ophthalmol. 2010;94:696–700.

Linzmayer L, Fischer G, Grunberger J. Pupillary diameter and papillary reactions in heroin dependent patients and in patients participating in a methadone and morphine replacement program. Weiner Medizinische Wochenschrift. 1997;147(3):67–69.

Murphy SB, Jackson WB, Pare JA. Talc retinopathy. Can J Ophthalmol. 1978;13:152–156.

Nelson LB, Ehrlich S, Calhoun JH, et al. Occurrence of strabismus in infants born to drug-dependent women. Am J Dis Child. 1987;141:175–178.

Ratcliffe SC. Methadone poisoning in a child. BMJ. 1963;1:1056–1070.

Rothenberg S, Peck EA, Schottenfeld S, et al. Methadone depression of visual signal detection performance. Pharmacol Biochem Behav. 1979;11:521–527.

Rothenberg S, Schottenfeld S, Gross K, et al. Specific oculomotor deficit after acute methadone. I. Saccadic eye movements. Psychopharmacology (Berl). 1980;67:221–227.

Rothenberg S, Schottenfeld S, Selkoe D, et al. Specific oculomotor deficit after acute methadone. II. Smooth pursuit eye movements. Psychopharmacology (Berl). 1980;67:229–234.

Sweetmand SC. Martindale: The Complete Drug Reference. ed 34. Pharmaceutical Press: London; 2004:57–59.

Generic Names: 1. Morphine; 2. opium.

Aminlari A, Hashem B. Effect of opium addiction on intraocular pressure. Glaucoma. 1965;7:69.

Andersen PT. Alopecia areata after epidural morphine. Anesth Analg. 1984;63:1142.

Castano G, Lyons CJ. Eyelid pruritus with intravenous morphine. J Am Assoc Pediatr Ophthalmol Strabismus. 1999;3(1):60.

Crandall DC, Leopold IH. The influence of systemic drugs on tear constituents. Ophthalmol. 1979;86:115–125.

Fish DJ, Rosen SM. Epidural opioids as a cause of vertical nystagmus. Anesthesiology. 1990;73:785–786.

Gill AC, Oei J, Lewis NL, et al. Strabismus in infants of opiate-dependent mothers. Acta Paediatr. 2003;92:379–385.

Henderson RD, Wijdicks EF. Downbeat nystagmus associated with intravenous patient-controlled administration of morphine. Anesth Analg. 2000;91:691–692.

Murphy DF. Anesthesia and intraocular pressure. Anesth Analg. 1985;64:520–530.

Shelly MP, Park GR. Morphine toxicity with dilated pupils. BMJ. 1984;289:1071–1072.

Stevens RA, Sharrock NE. Nystagmus following epidural morphine. Anesthesiology. 1991;74:390–391.

Ueyama H, Nishimura M, Tashiro C. Naloxone reversal of nystagmus associated with intrathecal morphine [letter]. Anesthesiology. 1992;76:153.

Generic Name: Pentazocine.

Belleville JP, Dorey F, Bellville JW. Effects of nefopam on visual tracking. Clin Pharmacol Ther. 1979;26:457–463.

Burstein AH, Fullerton T. Oculogyric crisis possibly related to pentazocine. Ann Pharm. 1993;27(7–8):874–876.

Davidson SI. Reports of ocular adverse reactions. Trans Ophthalmol Soc UK. 1973;93:495–510.

Gould WM. Central nervous disturbance with pentazocine. BMJ. 1972;1:313–314.

Jones KD. A novel side-effect of pentazocine. Br J Clin Pract. 1975;29:218.

Martin WR. Opioid antagonists. Pharmacol Rev. 1967;19:463–521.

Generic Name: Pethidine hydrochloride (meperidine).

Bron AJ. Vortex patterns of the corneal epithelium. Trans Ophthalmol Soc UK. 1973;93:455–472.

Carlson VR. Individual pupillary reactions to certain centrally acting drugs in man. J Pharmacol Exp Ther. 1957;121:501–506.

Goetting MG, Thirman MJ. Neurotoxicity of meperidine. Ann Emerg Med. 1985;14:1007–1009.

Hovland KR. Effects of drugs on aqueous humor dynamics. Int Ophthalmol Clin. 1971;11(2):99–119.

Johnson DA. Drug-induced psychiatric disorders. Drugs. 1981;22:57–69.

Lubeck MJ. Effects of drugs on ocular muscles. Int Ophthalmol Clin. 1971;11(2):35–62.

Waisbren BA, Smith MB. Hypersensitivity to meperidine. JAMA. 1978;239:1395.

Section 4.

Agents used in anesthesia

Class: Adjuncts to Anesthesia

Generic Name:


Proprietary Names:

Amphadase; Hydase; Hylenex; Vitrase.

Primary use

This enzyme is added to local anesthetic solutions to enhance the effect of infiltrative anesthesia. It has also been used in paraphimosis, lepromatous nerve reactions and the management of carpal tunnel syndrome.

Clinical significance

Adverse ocular reactions due to periocular injection of hyaluronidase are either quite rare or masked by postoperative surgical reactions. Subconjunctival injection of this drug causes myopia and astigmatism secondary to changes in the corneal curvature. This is a transitory phenomenon with recovery occurring within 2–6 weeks. Irritative or allergic reactions are often stated to be due to impurities in the preparation because pure hyaluronidase is felt to be nontoxic. Minning (1994) reported allergic reactions secondary to retrobulbar hyaluronidase. This occurred as an acute process simulating an expulsive choroidal or retrobulbar hemorrhage. Massive retrobulbar, peribulbar and intraorbital swelling may occur. Cases similar to this have been reported to the National Registry. Hyaluronidase decreases the duration of action of local anesthetic drugs by allowing them to diffuse out of the tissue more rapidly. Brown et al (1999) and Jehan et al (2001) pointed out that hyaluronidase may be important in decreasing or preventing damage from local anesthetics on adjacent extraocular muscles and nerves. This may occur, in part, by diffusion of the anesthetic, thereby decreasing the anesthetic concentration adjacent to muscle tissue. Miller (2000) has not found this to be true because he has not seen restrictive diplopia in over 7000 ocular procedures without using hyaluronidase. Ortiz-Perez et al (2011) describe two patients with orbital inflammation after hyaluronidase and zolendronic acid retrobulbar injection.

Some side effects of the local anesthetic are probably more frequent when it is used with hyaluronidase, because its absorption rate is increased. Infection or tumor cells may be allowed to spread as well, based on the same mechanism. A prospective double-blind study that suggests that cystoid macular edema is possibly caused by the use of hyaluronidase is of clinical importance. To date, these data are not completely accepted (Kraff et al 1983) and some of these cases may be secondary to inadvertent intraocular injection. If the patient is on heparin or if there is associated bleeding in the area of injection, the effect of hyaluronidase may be decreased because both human serum and heparin inhibit this agent.

Generic Names:

1. Hyoscine (scopolamine); 2. hyoscine methobromide (methscopolamine).

Proprietary Names:

1. Transderm Scop; 2. Pamine.

Clinical significance

Although ocular side effects from systemic administration of these drugs are common, they are reversible and seldom serious. Occasionally, patients on scopolamine have aggravated keratoconjunctivitis sicca problems due to decreased tear production. This is the only autonomic drug that has been reported to cause decreased tear lysozymes. Mydriasis and paralysis of accommodation are intended ocular effects resulting from topical ophthalmic application of hyoscine but may also occur from oral administration. This drug may elevate the intraocular pressure in open-angle glaucoma and can precipitate angle-closure glaucoma. Allergic reactions are not uncommon after topical ocular application. Transient impairment of ocular accommodation, including blurred vision and mydriasis, has also been reported following the application of transdermal hyoscine patches. Several case reports of unilateral dilated pupils with associated blurred vision and angle-closure glaucoma have been published, and inadvertent finger-to-eye contamination has been shown to be the cause.

Systemic side effects from topical ophthalmic use of hyoscine have been reported infrequently and are similar to those seen secondary to topical ophthalmic atropine. Toxic psychosis, however, especially in the elderly or visually impaired, has been reported in the literature and to the National Registry.

Generic Name:

Suxamethonium chloride (succinylcholine).

Proprietary Names:

Anectine; Quelicin.

Primary use

This neuromuscular blocking agent is used as an adjunct to general anesthesia to obtain relaxation of skeletal muscles.

Clinical significance

All ocular side effects due to suxamethonium chloride are transitory. The importance of the possible side effects of this drug effect on the “open” eye is an ongoing debate. Some feel a transient contraction of extraocular muscles may cause 5–15 mmHg of intraocular pressure elevations within 20–30 seconds or increased choroidal blood flow (Robinson et al 1991) after suxamethonium is given, lasting from 1–4 minutes. While this short-term elevation of intraocular pressure has little or no effect in the normal or glaucomatous eye, it has the potential to cause expulsion of the intraocular contents in a surgically opened or perforated globe. McGoldrick (1993) considers the drug safe in human “open” eyes with the benefits far outweighing the “unproven” risks. There are at least 20 publications taking either side of this argument, with most recommending avoiding this agent in an “open” eye. This may require anesthesiologists to use an agent they are not as familiar with, and the overall risk of this may be greater than that of using suxamethonium. Chidiac (2004) has suggested an algorithm that asks two questions with a total of three answers to help with the decision on whether or not to use this drug (see recommendations). Brinkley et al (2004) concur with this methodology. Eldor et al (1989) report two cases of this agent, inducing acute glaucoma.

Extraocular muscle contraction induced by suxamethonium may cause lid retraction or an enophthalmos. This may cause the surgeon to misjudge the amount of resection needed in ptosis procedures. Eyelid retraction may be due to a direct action on Müller’s muscle. Both eyelid retraction and enophthalmos seldom last for over five minutes after drug administration. Suxamethonium may cause abnormal forced duction tests up to 20 minutes after the drug is administered.

Prolonged respiratory paralysis may follow administration of suxamethonium during general anesthesia in patients with recent exposure to topical ocular echothiophate, anticholinesterase insecticides or in those with cholinesterase deficiency. Oral clonidine (Polarz et al 1992), thiopentone (Polarz et al 1993) and mivacurium (Chiu et al 1998) have been suggested to minimize suxamethonium ocular pressure effects on the eye.

Class: General Anesthesia

Generic Name:

Ether (anesthetic ether).

Proprietary Name:

Generic only.

Primary use

This potent inhalation anesthetic, analgesic and muscle relaxant is used during induction of general anesthesia.

Clinical significance

Adverse ocular reactions due to ether are common, reversible and seldom of clinical importance other than in the determination of the plane of anesthesia. Ether decreases intraocular pressure, probably on the basis of increasing outflow facility. Ether vapor is an irritant to all mucous membranes, including the conjunctiva. In addition, ether vapor has a vasodilator property. Permanent corneal opacities have been reported due to direct contact of liquid ether with the cornea. Blindness after induction of general anesthesia is probably due to asphyxic cerebral cortical damage.

Generic Name:

Ketamine hydrochloride.

Proprietary Name:


Primary use

This intravenous nonbarbiturate anesthetic is used for short-term diagnostic or surgical procedures. It may also be used as an adjunct to anesthesia. Orally it is taken for refractory major depression.

Nov 21, 2017 | Posted by in OPHTHALMOLOGY | Comments Off on 5. Gastrointestinal agents

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