|Year : 1965 | Volume
| Issue : 3 | Page : 109-113
Iatrogenic disorders in ophthalmology
|Date of Web Publication||22-Feb-2008|
T M Kumaraswami
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kumaraswami T M. Iatrogenic disorders in ophthalmology. Indian J Ophthalmol 1965;13:109-13
The continued advance in medicine has sometimes produced more problems than it has solved. Multitudinous drugs are hurled on the market, many of them therapeutic failures, some with undesirable side-effects, not infrequently, developing into long-term catastrophies. A drug used for a certain action produces deleterious action elsewhere in the body and this has given birth, recently to a group of diseases going by the name of Iatrogenic or doctor-cum-drug induced diseases. latrogenic is a combination of two words "latro", from the Greek "latros" which means "physician" or "medicine" and "genic" that is produced by. The craze for new drugs is an appalling modern phenomenon. Polypharmacy, polyantibiotics, antibiotics-steroid combinations poly- vitamins are sometimes used as shot gun therapy and as substitutes for proper diagnosis without being aware of their unpredictable hazards. We have many iatrogenic diseases induced by drug medication and I shall refer only to the iatronenic disorders in ophthalmology.
Eyelids and conjunctiva: Contact allergy of the eyelids and conjunctiva constitutes the most common form of allergic reaction encountered in ophthalmic practice. It is generally caused by the local use of drugs. The clinical picture is one of eczematous dermato-conjunctivitis beginning in the conjunctiva, and then trickling over the adjacent canthi on to the skin. Severe itching, papillitis, conjunctivitis and eczema of the skin of the eyelids and conjunctival eosinophiles are noted. Allergy to ointment often first shows along the lid margin, which becomes swollen and inflamed. Many ophthalmic drugs are true sensitisers. Such reaction to local anesthetics, anti-biotics, sulphonamides, mercurial and ophthalmic alkaloids are the most frequently encountered. On a patient with an allergic history, one should never use an untried drug in both the eyes. The conjunctival test for penicillin sensitivity carried out by some practitioners is not desirable, the intradermal test being more preferable.
The nonrecognition of polycythemic conjunctivitis allows for this condition to be incorrectly treated by Adrenalin instillations daily until pigmentation of the conjunctiva results. Tearing and burning of the eyes associated with folicular conjunctivitis in the lower palpebral conjunctiva and associated with preauricular glandular enlargements may be due to epinephrine bitartrate used in the treatment of glaucoma. Brownish discolouration of the conjunctiva may follow prolonged use. Instances of auto-inoculation from a vaccination pustule resulting in multiple vaccina of the eyelids with oedema, cervical adenitis and rise of temperature are not uncommon and this warrants elementary precautions after vaccination. It is almost rare today to see cases of argyrosis from excessive use of silver nitrate or argyrol, due to the advent of the antibiotics and the more specific treatment of external infections.
Cornea: One cannot too strongly emphasise the contraindication to the use of steroids, particularly locally in fungus infections and in infection with Herpes simplex virus. Progression to ulceration and perforation of the cornea may ensue. Corticosteroids exert their harmful effect by interfering with normal reparative processes and with the structural integrity of the cornea.
Corneal changes have been reported following the use of anti-malarial drugs such as atabrin, that produced corneal oedema with blurred vision and halos around lights. Camoquin has produced opacification of the subepithelial layers and Bowman's membrane. Chloroquine, used for a prolonged period, produced deposits in the corneal epithelium. Changes occured just under the Bowman's membrane and a yellowish pigmentation occured just below the pupil. A very interesting case of filiform karatitis brought on by the use of plaquenil has been reported. The patient was treated for rheumatoid arthritis with this hydroxychloroquine. When he was first seen eight months after taking the medication, both corneas were affected by this pathological change and vision was very much reduced. Assuming a probable relation, the medication was stopped and the patient put on premarin. In two weeks the cornea was perfectly clear and the vision returned to normalcy in both eyes. The drug was then started again and the filiform karatitis began to recur. Discontinuance again returned the eyes to normality. Patients taking chloroquine should have eye examination at intervals, as drug changes can be reversed to normal if detected early and if the medication is discontinued.
In the treatment of recurrent pterygium with stramonium 90 photophobia, itching, burning and punctate karatitis may be produced by trauma due to radiant therapy. To protect the lens, surface doses of 2000 to 2500 rep should not be exceeded and the patients should be under observation for a prolonged period.
Corneal strangulation can result from wearing contact lenses with too sharp a posterior curvature. The lens curve creates a suction cup effect that can prevent the metabolic exchange of gases, hypertonic tears and heat. Punctate karatitis, confluent superficial erosion of the corneal epithelium, central epithelial abrasions and conjunctival infection were found. Patients must be warned not to wear the lens too long or while sleeping. They should also be warned never to use the lenses if they have conjunctivitis, blepharitis or an upper respiratory infection. Saliva should never be used for cleaning the lens.
Transference by tonometers is a means of spreading infection. No tension should be taken when the eye is infected and the tonometer should be sterilized before and after use by flame or by other means.
Sometimes corneal ulcers are produced by ophthalmic ointments contaminated with bacteria and moulds. The habit of anesthetists touching the cornea while giving anaesthesia should be denounced as the cornea may get infected with dire consequences.
Lens: Bilateral lens opacitis were reported following the use of DFP. DFP also caused retinal detachment and has induced myopia and congestive iritis. Dinitrophenol prescribed for weight reduction also produced cataracts. New drugs for weight reduction should be well investigated before being released for general use. Posterior subcapsular opacities appeared in patients who received prolonged corticosteroid therapy for rheumatoid arthritis. The importance of low maintenance dosage of corticosteroids is therefore emphasised. Increased intraocular pressure is induced by prolonged local or systemic corticosteroid therapy, the pressure becoming normal when the therapy is discontinued.
Retina: Today Dicumoral is being advocated more freely than in the past. Choroidal haemorrage which has destroyed vision has been reported. Chlorathiazide, in a small percentage of cases, has produced haemorrages. The drug should be withdrawn with the hope that nature can reverse the pathological changes which have occured. In the literature there have been cases of retinal detachment directly related to the use of DFP. Because of this danger, any substitute which is not dangerous may be prescribed. Retinal hemorrhages have been reported by and large and continued use of vitamin A in the treatment of acne. Other changes associated with overdosage of vitamin A are exophthalmos, choked disc, increased intracranial pressure, loss of hair and enlarged spleen and liver. Interestingly enough, I have not encountered a case of hypervitaminosis A. Toxic retinopathy with vascular proliferation and haemorrages into the vitreous has been reported in patients treated for asthma with arsenic. Arsenic is a capillry poison and it is found in the body some years after the therapy was stopped. Chlorpromazine when used for a prolonged period with an aggregate dose of 25-9 often damaged the retina permanently. This is truly iatrogenic as the treatment is not absolutely indicated. Thiodiazine or mellaril also belong to this category. Chloroquine used for rheumatoid arthritis has induced retinal complications in some and also rarely mepacrine. The National Institute of Health in U.S.A., reported cases of grave retinopathy following chloroquine therapy.
Optic Nerve: Digitalis produced various forms of visual disturbances; central scotoma and xanthopsia are the most common complications. There is no specific therapy except reducing the dosage of the drug. Tridione also causes a dazzling whiteness and poor vision in bright light. In susceptible individuals, quinine can cause permanent amblyopia even after the administration of comparatively small doses. Results may vary from haziness of the disc margins to optic atrophy with marked constriction of the retinal arterioles. One should be cautious in prescribing this medication and safer substitutes can be used.
Injections of arsenic used for the treatment of bronchial asthma and eosinophelia produced sudden blindness and fundus examination showed pallor of the optic discs. Though, fortunately, the era of arsenic has ended yet it is not uncommon to encounter patients treated with arsenicals.
Optic neuritis associated with visual loss has been reported following treatment with trivalent antimony salts.
Tobacco amblyopia and alcoholism. ethyl to some extent and methyl to a greater extent, leading to optic atrophy are neither drug induced nor doctor induced but patient induced or politician induced.
Following chloramphenicol therapy, bilateral optic neuritis has been reported. Severe aplastic anemia, cutaneous eruptions, mucous membrane irritation and pschiatric disorders can also occur. Organic compounds that have benzene ring with an attached amino or nitro group and that are readily oxidisable can depress the bone marrow function. Chloramphenicol contains such a group. The skin lesions and anaemia improved on cessation of the chloramphenicol but the vision remained poor. Streptomycin, a common cause of nerve deafness, may also damage the optic nerve.
Today, with chloroquine being used in conditions other than malaria, namely, acute disseminated lupus erythematosus, rheumatoid arthritis, actinic dermatitis, lepra reaction and as a desludging agent in vascular disease processes, attention should be paid to possible retinal complications, such as field changes with visual loss, pale discs, narrowing of the retinal vessels, peripheral pigmentation and aggregation of fine pigment in the macula.
Bilateral central scotoma resulting in sudden decrease of vision occur as an unusual toxic reaction related to the use of chlorpropamide, (Diabenese) an oral hypoglycemic agent. Discontinuance of medication resulted in the return of normal vision. Oculogyric crisis occured following the use of perphenazine, prochlorperazine and trifluoperazine. Several proprietary preparations of these are used as anti- emetics and tranquillisers. Forced conjugate or askew movements of the eye (oculogyric crisis) indicate extrapyramidal involvement and are seen in persons with Parkinsonism and chronic encephalitis. Phenothiazines produce extrapyramidal reactions.
The needle, especially the long 2-inch needle, used for retrobulbar injection, may, rarely, injure the optic nerve and cause optic atrophy. This may be avoided by using the 1.5-inch needle in adults and the 1-inch needle in children. The needle is to be gently inserted towards the apex of the orbit and not rapidly thrust backward. Procaine and xylocaine injected into the orbit may produce a complete or partial loss of vision temporarily, due to a conduction block which involves all the sensory nerves including the optic nerve and motor nerves of the orbit.
Optic neuritis has been reported as an allergic response to some diets like fish, turkey or pork etc., as well as after injection of tetanus antitoxin, intracutaneous tuberculin and antirabic vaccine. Spinal anesthesia has caused a few cases of sixth nerve paralysis and retrobular neuritis.
| Conclusion|| |
Physicians who resort to drugs, oblivious to their damaging proclivities, are guilty of inducing iatrogenic blindness. This presentation is intended to make us all aware of the importance of including a history of medication at the time of examination in order to correctly understand the findings that we observe and to better correlate the disease with the cause, particularly in ophthalmo-iatrogenic disorders, Though modern therapy is contributing significantly to human good, it is also vastly increasing iatrogenic morbidities. The mind of the modern practitioner is often so brain washed by the fanfare and publicity that accompany the new drugs that he is not fully aware of the snare of the welter of these new drugs whose risks outweigh their usefulness. It is therefore, necessary that if we should use these modern double-edged potent drugs, we should be aware of the toxic effects they may produce and whether these are commensurate with the benefit. If they should be used, the risks must be accepted as a challenge and a cautious approach to the problem be made. This is particularly important in ophthalmology, as we use the most potent drugs to effect cure in the shortest possible time in order to save as much vision as possible. In our craze for new (Lugs and in our zeal to use them, let us refrain from placing knowledge before wisdom, science before art, cleverness before common sense and in making the remedy worse than the malady.
| Summary|| |
A list of possible iatrogenic disorders affecting the eye caused by drugs and therapeutic measures is given. Such disorders have increased with the advent of a host of new drugs on the market. Their indiscriminate use without good reason in actual practice is deprecated.
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