Ocular Side Effects of Systemic Drugs (ADRs): Modern and Classic
Last updated: October 2026
Ocular side effects of systemic drugs: first the associations seen most often in clinic and exams today, then the classic textbook list by drug group.
Screening for drug toxicity: hydroxychloroquine and other screening schedules.
High-yield modern associations
| Drug | Ocular effect | What to do |
|---|---|---|
| Hydroxychloroquine | Bull's-eye maculopathy (pericentral in Asian patients) | Dose ≤5 mg/kg real body weight per day; baseline, then yearly after 5 years (sooner with risk factors) with 10-2 fields and SD-OCT; 24-2 in Asian patients |
| Ethambutol | Toxic optic neuropathy: central scotoma, red-green defect | Baseline and regular acuity and colour checks; stop early |
| Topiramate (and sulfa drugs) | Bilateral angle closure with myopic shift (ciliochoroidal effusion), usually in the first weeks | Stop the drug, cycloplegics, aqueous suppressants; iridotomy does not help |
| Tamsulosin and α1-blockers | Intraoperative floppy iris syndrome | Ask before cataract surgery; intracameral adrenaline, pupil devices, low flow |
| Amiodarone | Vortex keratopathy (common, harmless); optic neuropathy (rare, bilateral, slow) | Differentiate from NAION; liaise with the cardiologist |
| Corticosteroids (any route) | Posterior subcapsular cataract, raised IOP, CSCR | Monitor IOP; ask about creams, inhalers and injections in CSCR |
| Bisphosphonates | Anterior uveitis, scleritis | Usually settles with topical steroid and stopping the drug |
| Vigabatrin | Irreversible concentric field loss | Baseline and regular perimetry |
| Pentosan polysulfate | Pigmentary maculopathy | Ask about long-term use for interstitial cystitis |
| MEK and immune checkpoint inhibitors | Serous retinal detachments (MEK); uveitis, VKH-like disease, myasthenia (checkpoint inhibitors) | Coordinate with oncology; often managed without stopping treatment |
| PDE5 inhibitors; semaglutide | Associated with NAION; cyanopsia with sildenafil | See semaglutide and NAION |
| Isotretinoin | Dry eye, meibomian dysfunction, reduced night vision, IIH (especially with tetracyclines) | Ask about headache and check the discs |
| Fingolimod | Macular oedema in the first 3–4 months | OCT at baseline and 3–4 months |
| Quinine | Acute retinal toxicity with blindness, dilated pupils, attenuated vessels | Supportive; history of overdose |
| Digoxin | Xanthopsia (yellow vision), flickering, colour disturbance | Check digoxin levels |
The classic textbook list
| Group | Drug | Ocular effect |
|---|---|---|
| Cardiovascular | Digitalis | Colour vision disturbance, scotomas |
| Thiazides | Xanthopsia, transient myopia | |
| Carbonic anhydrase inhibitors | Transient myopia, hypotony | |
| Quinidine | Optic neuritis (rare) | |
| Practolol / oxprenolol | Oculomucocutaneous syndrome (practolol), dry eye | |
| Nervous system | Phenothiazines (chlorpromazine, thioridazine) | Pigment in conjunctiva, cornea and lens; pigmentary retinopathy (thioridazine); oculogyric crisis |
| Tricyclics, anticholinergics | Mydriasis and cycloplegia; angle-closure risk | |
| Phenytoin, barbiturates, benzodiazepines | Nystagmus, diplopia | |
| Opioids | Miosis | |
| Lithium | Downbeat nystagmus, exophthalmos | |
| Amphetamines | Mydriasis, lid retraction | |
| Hormones | Oral contraceptives | Retinal vascular occlusion, IIH, contact lens intolerance |
| Corticosteroids | Cataract, glaucoma, infection, CSCR | |
| Anti-infectives | Chloramphenicol | Optic neuritis and atrophy |
| Ethambutol, isoniazid, linezolid | Optic neuropathy | |
| Tetracyclines | Idiopathic intracranial hypertension | |
| Sulfonamides | Stevens–Johnson syndrome, myopic shift | |
| Chloroquine | Vortex keratopathy, bull's-eye maculopathy | |
| Clioquinol / iodoquinol | Subacute myelo-optic neuropathy (SMON) | |
| Metals and chelators | Gold salts | Chrysiasis (corneal and conjunctival deposits) |
| Lead | Optic atrophy, papilloedema, ocular palsies | |
| Penicillamine | Ocular pemphigoid, optic neuritis, myasthenia | |
| Others | Chlorpropamide | Refractive change, diplopia, SJS |
| Vitamin A excess | Papilloedema (IIH), loss of lashes | |
| Vitamin D excess | Band keratopathy | |
| Salicylates | Nystagmus, retinal haemorrhages | |
| Indomethacin | Corneal deposits, retinal pigment change |
Related: Ocular pharmacology, Intravitreal drug doses, Eye drugs in pregnancy.
Revise with flip cards
📘 Want the exam-ready deep dive? This topic, and much more is covered in Ophthalmology Explorer (A High-Yield Clinical Reference for Ophthalmology Residents, Fellows & Board Exams) — available on Kindle. See all my books.
Experiencing symptoms like these? Learn about our Eye Department or book a consultation with Dr. Dhaval Patel.