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Toxic Cataract
P.G.Swann* and J.F. Elliott?
Department of Optometry, Queensland Institute of Technology
ABSTRACT A host of ocular adverse reactions may adverse drug reactions, the mechanisms of toxicity and
result from the use of systemic medications. Included the variables concerned in the productions of such side
in these reactions is that of the crystalline lens effects.
known as toxic cataract. This paper will consider A n early classification recognised overdose,
this response with special reference to lens changes intolerance, side effects, secondary effects, idio-
resulting from the use of steroids and certain tran- syncrasy and hypersensitivity.75When the mechanism
quillizers. of toxicity is known, these reactions can be divided
Keywords: ocular adverse reactions, toxic cataract, into:78
steroid cataract, chlorpromazine cataract. 1. Dose related: -
(a) side effects - unavoidable pharmacological
Introduction effect.
In 1973, Davidsonlstated that of the 28,000 cases of (b) secondary - indirect consequence of drug
drug adverse reactions reported to the Committee on action. Predictable - dilution may reduce or
Safety of Drugs since its establishment in 1963, 1,000 abolish reaction.
reports were made in reference to the eye. Of these, 2. Unrelated to dose:-
about 5O/n concerned the crystalline lens and the onset (a) allergy
of toxic cataract or lens deposits. Davidson also noted (b) idiosyncrasy - genetic predisposition
that only a very small proportion of adverse events 3. Unknown
would be reported using such. a voluntary system - 4. Teratogenic
5 . Interactions.
perhaps as few as lo/n.
The cataractogenic nature of certain substances, Furthermore, the variables involved in the produc-
whether medicinal or otherwise has been known for tion of a side effect should be defined. They
many years.2" Good examples are the slimming agent include"?-
dinitrophenol, the insecticide paradichlorobenzene 1. The nature of the drug
and the salts of certain metals such as thallium. Many 2. The amount consumed
such preparations have now been discontinued. 3. The route of administration
However, a considerable number of potentially 4. The patient's general health, the condition being
cataract-producing systemic drugs are available and treated
some such as the cortico-steriods and the 5 . Individual idiosyncrasy
phenothiazines are regularly prescribed. 6. Other substances which may potentiate side effects
Table 1 lists drugs where evidence for catarac- 7. Previous exposure to the drug.
togenity is strong; and Table 2, those drugs where Rawlins and Thompson7shave simplified matters by
reports have been more isolated and less compelling. dividing adverse drug reactions into those that arise
In addition, a few preparations have been listed as hav- from the normal pharmacological action of a drug, and
ing a teratogenic effect on the lens, either before term those that represent a totally abnormal and novel
or via lactation. Table 3 lists these drugs. response; that is, type A and type B reactions.
A n adverse reaction to a drug can be defined as a
response that is noxious and unintended, and occurs at Type A Reactions
dosages used in man for prophylaxis, diagnosis or Resulting from an exaggerated, but otherwise nor-
therapy, excluding failure to accomplish the desired mal pharmacological action of a drug given in the usual
purpose. Many attempts have been made to classify therapeutic doses, Type A reactions are frequently pre-
* Senior Lecturer- dictable on the basis of a drug's known pharmacology.
t Optometrist, Brisbane They are usually dose dependent.
3
Generic Name Brand Name
CORTICO
-STEROIDS16-25
Aldosterone
Betamethasone
Cortisone
Aldocorten
Celestone
Austracort
hti-Inflammatory Posterior
Subcapsular
Cataracts
' Increased
LOP.:
Myopic shift :
Desoxycorticosterone Cortiron Exophthalmos:
Dexamethasone Dexasone Extraocular
Fludrocortisone Florinef muscle paresis:
Fluorometholone F.M.L. Liquifitm Field defects:
Fluprednisolone Alphadrol Retinal oedema
Hydrocortisone Hycor and
Medrysone H.M.S. Liquifii haemorrhages:
Methylprednisolone Medrol conjunctival
Paramethasone Metilar oedema and
Prednisolone Prelone hemorrhages.
Prednisone Presone
Triamcinolone Aristocort
PHENOTHIMINES
Chlorpromazine26-38 Largactil Antipsychotic, Stellate anterior Granules in cornea:
Trifluoperazine34-35 Stelazine (tranquillizer) capsular and Field defects:
subcapsulargranules. Ocular melanosis:
moridazine36-37 Mellaril Polar cataract Pigmentary retinopathy :
Prochlorperazine73 Stemetil following high dosages. Optic atrophy:
Fluphenazine34 Modecate Oculomotor palsies:
Methotrimeprazine34 Veractil
I I
PIPERAZINE
DERIVATIVE
1+Bis - Diphenazine; Antipsychotic
1
@henylisopropyl)- Quietidin (trallquillizer) and anterior radial of hair and eyebrows.
piperazine9.39
~ o p ~ i n o1340,82983
Ill Zyloprim
capsular changes. reactions.
Anterior subcapsular
Generic Name Brand Name Drug Action cataract Type Other Ocular Changes
BUTYROPHENONES
Haloperid0113e43 Serenace Antipsychotic. Capsular cataracts. Pupil and accommodation
Trifluperidol Triperidol (tranquillizer) Rapid progression. anomalies: Eyelid and
conjunctival reactions:
Visual hallucinations.
THIOXANTHENES
ChlorprothixenegJ3 Taractan Lens deposits beneath Retinal pigmentary
anterior capsule: changes: Pupil and
Thiothixene Navane Fine lenticular accommodation anomaliis:
pigmentation. Keratitis.
Chloroquin Anti-malatial Posterior axial Retinopathy: Corneal
subcapsular flakes. opacities; Optic atrophy;
Hydr oxychloroquine Plaquenil Brown anterior surface Field defects.
flakes.
Anorex Anorexiant Posterior subcapsular Pupil, accommodation and
Duromine opacities convergence anomalies.
Clomid Ovulatory Agent Posterior subcapsular Loss of central vision;
cataracts scintillatinn scotoma.
Hyperstat Antihypertensive Information unavailable Lacrimation; Lid and
conjunctival reactions;
Decreased vision.
Table 2: Possibly cataractogenic systemic drugs. * Continued Overleaf
4 Aust. J. Optom,, 66.1: January 1983
* Continued
Generic Name Brand Name Drug Action Cataract Type Other ocular ChulgeIl
I Radiomimetic
tetracycline^^^-^
Sulphonamides64-67 I
No. of
Datients
693
Percentage exhibiting lens changes
6. A type of hue diabetic cataract manifesting as a therapys, it is widely believed that children are more
posterior subcapsular opacity and frequently show- susceptible than adults to cataract formation following
ing fine granular radial striae extending from the corticosteroid administration.
equatorial regions into the main opacity.80 The role of individual susceptibility has been
Careful investigation of the patient’s ocular and explored by Skalka & Prchal.2OTheir study confirmed a
general health as well as occupational factors should correlation between the incidence of posterior subcap-
make the diagnosis certain. sular catpact and the administration of corticosteroids,
Dosage and Susceptibility but failed to find a statistically significant relationship
The relevant literature discloses disagreement on between lens opacities and total dose, weekly dose,
the relationship between corticosteroid lenticular duration of dose or the age of the patient. They suggest
changes and total dose, dosage intensity and the dura- that the most important factor may be an individual
tion of administration of the medication. susceptibility to the side-effect of corticosteroids, and
Early reports have suggested that 75% of patients propose abandonment of the concept of a ‘safe dose’.
receiving Prednisone in excess of 15 mg/day would Cataracis h a v e been reported following t h e
develop posterior subcapsular lens opacitiess, whereas administration of corticosteroids via an aerosol spray21,
dosages of less than 10 mg/day of Prednisone o r its and the association between topically applied cor-
equivalent were unlikely to excite the formation of ticosteroids to the eye and cataracts is well known. 17.19.23
cataract.’* Similarly, patients treated for less than one Posterior subcapsular cataracts were n o t e d by
year, or who were receiving intermittent therapy, were Donshik, et aP3, in 28 out of 86 eyes subjected to topi-
held to be less at risk. However Loredo, ef UP,have cal corticosteroids following keratoplasty for
reported cataracts occurring in children who received keratoconus. The development of opacities was signifi-
corticosteroids for periods ranging from 3 to 10 cantly related to total cumulative dose and the total
months. The concept of a ‘safe dose’ or ‘boundary period over which steroids were administered. Cases
figure’ has been suggesteds, and a systemically where unilateral topical steroids have produced
administered Prednisone equivalent of 3.5 gm in one cataract in the treated eye only, have also been
year has been considered to approximate such a figure. reported. 5
The underlying disease may have a bearing on the Corticosteroid induced glaucoma and cataracts have
incidence of lens changes. For example, some authors been reported in patients for whom the drug was
believe that arthritics are m o r e a t risk than prescribed to reduce irritation produced by contact lens
asthmatics.79 Whilst i t can be contended that wear.17 Individuals with a high degree of myopia and a
asthmatics are younger and receive a less concentrated family history of glaucoma have an increased suscep-
Prednisone up to 40 mg/day
1.9182
r3D
+ 2D
ilD
Plam
-ID
-20
- 3D
1974 1978 : May : May : Aug : Aug : Sept : Feb : March : June : July
1380 1981 1981 i 1981 I 1981 i 1982 1982 i 1982 i 1982 i
*
%2
Figure 10: The same changes as figure 9 observed with the fundus Figure 11: Anterior polar cataract following long term, high dosage
camera. chlorpromazineand trifluoperazine medication.
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