6. Cardiac, vascular and renal agents

Possible aggravated keratoconjunctivitis sicca

Clinical significance

Ocular side effects due to these anticholinergic agents vary depending on the drug. Adverse ocular reactions are seldom significant and are reversible. None of the preceding drugs has more than 10–15% of the anticholinergic activity of atropine. The most frequent ocular side effects are decreased vision, mydriasis, decreased accommodation and photophobia. While these effects are not uncommon with some of these agents, rarely are they severe enough to modify the use of the drug. The weak anticholinergic effect of these agents seldom aggravates open-angle glaucoma; however, it has the potential to precipitate narrow-angle glaucoma attacks. Varssano et al (1996) showed that topical ocular glycopyrronium may be faster and stronger and have a more persistent mydriatic effect than atropine. Some of these agents, especially tolterodine, may increase tear film breakup time and aggravate or cause keratitis sicca. All of these agents can cause dry mouth and therefore are suspect in causing or aggravating dry eye. There are over 400 reports of dry eye associated with tolterodine in the National Registry. Two cases of unilateral pupillary dilatation were seen in patients who inadvertently got antiperspirants containing propantheline on their fingers and transferred it to their eyes.

Glycopyrrolate cream is applied to the axilla for hair removal. The thinness of the skin in this area may allow for systemic absorption causing mydriasis and accommodative failure in susceptible patients (Izadi et al 2006; Panting et al 2007; Williams et al 2004, 2008).

Class: Gastrointestinal and Urinary Tract Stimulants

Generic Name:

Bethanechol chloride.

Proprietary Names:

Duvoid; Urecholine.

Primary use

This quaternary ammonium parasympathomimetic agent is effective in the management of postoperative abdominal distention and nonobstructive urinary retention.

Clinical significance

Adverse ocular reactions due to bethanechol are unusual, but they may continue long after use of the drug is discontinued. Some advocate use of this agent in the treatment of Riley Day syndrome and ocular pemphigoid because the drug is associated with an increase in lacrimal secretion.

Generic Name:


Proprietary Names:

Carbostat; Miostat.

Clinical significance

Probably the most frequent ocular side effect due to carbachol is a decrease in vision secondary to miosis or accommodative spasms. In the younger age groups, transient drug-induced myopia also may occur. Follicular conjunctivitis often occurs after long-term therapy, but this in general is of limited clinical significance. Some of the topical ocular side effects may be aggravated or caused by the benzalkonium chloride preservative. Enhancement of cataract formation is probably common to all miotics after many years of exposure. Miotics can induce retinal detachments but probably only in eyes with preexisting retinal pathology (Beasley et al 1979). This topical ocular medication may be one of the more toxic agents on the corneal epithelium. Roberts (1993) showed increased cells and flare post–cataract surgery due to carbachol by delaying the reestablishment of the blood aqueous barrier after surgery, causing a more prolonged inflammatory process. Phillips et al (1997) suggested that intraocular carbachol post surgery did not play a role in increasing postcapsular opacification.

If there are abrasions of the conjunctiva or corneal epithelium, care must be taken not to apply topical ocular carbachol since this enhances absorption and increases the incidences of systemic side effects. In general, systemic reactions to carbachol are rare, usually occurring only after excessive use of the medication.

Section 6.

Cardiac, vascular and renal agents

Class: Agents Used to Treat Migraine

Generic Names:

1. Ergometrine maleate (ergonovine); 2. ergotamine tartrate; 3. methylergometrine maleate (methylergonovine).

Proprietary Names:

1. Ergotrate; 2. Ergomar; 3. Methergine.

Primary use

These ergot alkaloids and derivatives are effective in the management of orthostatic hypertension migraine or other vascular types of headaches and as oxytocic agents.

Clinical significance

Ocular side effects due to these ergot alkaloids are rare, but patients on standard therapeutic dosages can develop significant adverse ocular effects. This is probably due to an unusual susceptibility, sensitivity or pre-existing disease that is exacerbated by the ergot preparations. Increased ocular vascular complications have been seen in patients with a preexisting occlusive peripheral vascular disease, especially in dosages higher than normal. Crews (1963) reported a healthy 19 year old in whom a standard therapeutic injection of ergotamine apparently precipitated a central retinal artery occlusion. Borooah et al (2008) reported a prolonged cilioretinal artery spasm leading to a permanent retinal disturbance in a 31-year-old postpartum patient after receiving ergometrine during delivery. Gupta et al (1972) reported a bilateral ischemic optic neuritis that may have been due to ergotamine. Merhoff et al (1974) reported a case with possible drug-induced central scotoma, retinal vasospasms and retinal pallor. Heider et al (1986) reported the case of a long-term ergot user who developed reversible decreased vision with decreased sensitivity in the central 30 ° in his visual field. Sommer et al (1998) described a 31-year-old male who developed bilateral ischemic optic neuropathy after administration of ergotamine tartrate and macrolides. Mieler (1997) reported a 19-year-old female who received ergot alkaloids to control postpartum hemorrhage and had a toxic retinal reaction, including bilateral cystoid macular edema, central retinal vein occlusion papillitis and optic disc pallor. Ahmad (1991) described a case of ergometrine given intravenously that unmasked a previously “cured” myasthenia gravis. According to Creze et al (1976) methylergometrine-induced cerebral vasospasm may have caused transitory cortical blindness. There are sporadic reports of cataracts in the literature, but these are rare and it is difficult to prove a cause-and-effect relationship.

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Nov 21, 2017 | Posted by in OPHTHALMOLOGY | Comments Off on 6. Cardiac, vascular and renal agents

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