By James A. Garrity MD
Whitney and Betty MacMillan Professor of Ophthalmology
Mayo Clinic, Rochester, MN
One of the functions of the Vasculitis Foundation has been to provide information to patients regarding the various types of vasculitis and its treatment. We have never considered organ-specific effects of treatment on the eye.
The following information is intended to educate patients about the use and side effects of various drops, pills and injectable medications often used in the treatment of vasculitis. This is not intended to be a comprehensive list but rather some practical aspects. A very complete list of potential side effects and interactions are listed with each product package insert.
While patients have a ready appreciation of what effect their disease can have on their various organ systems, what may not be apparent is what effect the treatment can have on the various organs. If the eye itself is involved by the disease there may be a need to use local therapy, usually in the form of various drops, which can treat inflammation, elevated intraocular pressures, or dry eye symptoms but may cause unwanted side effects.
Inflammation inside the eye or affecting the eye structures itself may be treated with a steroid containing eye drop. There are three practical concerns with steroid eye drops:
• Infections: Infectious concerns are primarily related to viral infections, notably herpes simplex which can “spread” with inappropriate use of steroid drops. However, there are certain instances where steroid eye drops are used with herpes simplex eye infections but this requires close supervision by your ophthalmologist.
• Glaucoma: Prolonged use of steroid-containing eye drops can lead to elevated intraocular pressures that can progress to glaucoma. It is not known how long one has to use the drops before the pressure in the eye rises, but anyone using steroid-containing eye drops for longer than a month should be followed closely by their eye doctor.
• Cataracts: Cataracts are also possible after extended use of steroid-containing eye drops. It can be difficult to tell if the drops caused the cataract or underlying ocular inflammation.
Elevated intraocular pressures are sometimes treated with one or more “glaucoma drops”. Most drops are well tolerated although timolol (a beta-blocker) can be associated with asthma and its use should be avoided in susceptible individuals. Another glaucoma drop, brimonidine (an alpha adrenergic agonist), can be associated with red, irritated eyelids and globe in some users. Stopping the drop is curative.
Artificial tears provide supplemental lubrication to individuals with dry eye symptoms. There are many different types and brands available. In general, there are two categories of drops, those with preservatives and those without. Drops with preservatives are cheaper and more convenient to use. Very frequent use of artificial tear drops with preservatives can cause irritation instead of the intended relief because of sensitivity to the preservative. This condition is called “medicamentosa”. Switching to non-preserved tears is curative. It is physically impossible to overuse non-preserved artificial tears.
Another drop for dry eye conditions is called Restasis®, which is a cyclosporine drop. It affects the lacrimal gland itself and works well for autoimmune-related dry eye conditions. The cost and stinging after application are drawbacks. In theory, Restasis does not work well for “mechanical” causes of dry eye such as eyelids that don’t close or a protruding eye since there is not autoimmune component to this. The medication should not be used in the presence of a herpes simplex infection.
Perhaps the most commonly used “pill” with potential ocular side effects is prednisone, a powerful anti-inflammatory drug with significant potential side effects. From the eye standpoint, there are two primary concerns, cataract and glaucoma. It has been estimated that daily use of at least 15 mg prednisoneday for a year will lead to cataract formation. The chance of glaucoma from oral steroids is probably less with pills than with steroid-containing eye drops but patients should still be monitored periodically for elevated intraocular pressures.
Anti-Tumor Necrosis Factor (TNF) drugs — like infliximab, adalimumab, golimumab, etanercept, certolizumab pegol — may rarely be associated with ocular issues. There are three primary considerations:
• Malignant tumors, such as non-melanoma skin cancer and lymphoma have been reported.
• Infections including herpes zoster (shingles) have also been reported. Herpes zoster can affect the eyeball itself which can lead to serious ocular consequences.
• Demyelinating neurologic conditions including optic neuritis. There have been rare reports of vision loss in the form of an optic neuritis in patients taking these drugs.
For more information about how medications may impact your eyes, ask your treating physician.