Amiodarone Induced Ocular Toxicity

J Rational Pharmacother Res An Official Publication of ISRPT

CASE REPORT

Amiodarone Induced Ocular Toxicity Surbhi Gupta*, Vishal R Tandon,Vijay Khajuria, Vivek Mahajan, Neelam Rani, Roshi Abstract Many systemic drugs like bisphosphonates, topiramate, vigabatrin, isotretinoin and other retinoids, ethambutol, chloroquine and hydroxychloroquine, tamoxifen, quetiapine, cyclo-oxygenase (COX)-2 inhibitors are known to produce ocular toxicity.We herby report ocular toxicity with amiodarone showing presence of bilateral arborising horizontal lines in the corneal epithelium in a pattern resembling cat's whiskers in a 36 years old male patients prescribed for WPW Syndrome. Key Words Amiodarone, Ocular Toxicity, Adverse Drug Reaction Received- 14.12.13

Revised -01.1.14

Accepted-15.1.14

From the *RD Sood Eye Care & Research Centre and Department of Pharmacology, Govt. Medical College Jammu Correspondence to : Dr. Vishal R Tandon, Incharge ADRM Centre, Deartment of Pharmacology. E-mail: [email protected]

Introduction Amiodarone is an iodine-rich benzofuran derivative with well known ocular, dermatologic, gastrointestinal, neurologic, cardiovascular, thyroid and pulmonary toxicity. Therefore reserved for use in patients with refractory and/or life-threatening supraventricular and ventricular tachyarrhythmias. [1] Many systemic drugs beside amiodarone like bisphosphonates, topiramate, vigabatrin, isotretinoin and other retinoids, ethambutol, chloroquine and hydroxychloroquine, tamoxifen, quetiapine, cyclooxygenase (COX)-2 inhibitors are known to produce ocular toxicity. [2] Toxic keratopathy and maculopathy, comeal microdeposits,lens opacities, optic neuropathy has been 28

described with amiodarone treatment. [3-6] Event simultaneous multisystem involvement is also reported with long term use of amiodarone. [7-8] Although ocular toxicity with amiodarone is well reported but some of the ocular damages produced by it are irreversible. This warrants a need to create awareness for extensive ocular screening and follow up of such patient on amiodarone. Thus, the case is worth reporting Case Report A 36-year-old man presented with symptoms of visual "shining," glare, color vision anomalies, and gradually decreased vision soon after initiation of amiodarone HCl (200 mg/day) prescribed for WPW syndrome by the cardiologist. Eye examination revealed classical picture

J Rational Pharmacother Res

Vol. 2 No.1,January - March 2014


Fig.1 Showing the classical picture of amiodarone toxicity showing presence of bilateral arborising horizontal lines in the corneal epithelium in a pattern resembling cat's whiskers. This whorl like pattern originates from point below the pupil and swirls outwards, sparing the limbus.

of amiodarone toxicity showing presence of bilateral arborising horizontal lines in the corneal epithelium in a pattern resembling cat's whiskers. This whorl like pattern originated from point below the pupil and swirls outwards, sparing the limbus. Amiodarone was discontinued after discussion with the cardiologist and tablet flecanide 100 mg in morning and 50 mg in night was prescribed as an alternative treatment. On follow up, the patient reported disappearance of symptoms with 7 days. Visual acuity had improved. Ishihara color plates showed normal color vision with in 15 days. The patient had no history of smoking, alcohol or drug abuse. There was no associated pathology or history of concurrent drug intake. He had no similar family history. Clinical examination revealed normal pulse rate, blood pressure was 128/88 mm of Hg, chest examination, abdomen and CNS examination were also within normal limits. Laboratory investigations showed, haemoglobin 10.2 gm/dl, total leukocyte count-11000 cu3mm, blood sugar fasting-90 mg/dl, thyroid profile - normal, erythrocyte sedimentation rate-12 mm/hr, serum ureaVol. 2 No. 1, January - March 2014

21 mg/dl, serum creatinine-0.7 mg/dl, HIV-I&II - non reactive, serum bilirubin - 0.4 mg/dl, aspirate transferase32 mg/dl, alanine transferase 42 mg/dl, electrolytes were within normal limits, X-ray, ultrasonography abdomen & CT Scan head were normal. Discussion The temporal relationship, brief de-challenge improved the condition and re-challenge was not done in this case due to ethical and clinical constrain. Furthermore, the appearance of ocular changes could not be explained by any concurrent disease, drug or chemical. ADR was probable as assessed by WHO Uppasla Monitoring Centre causality scale and Naranjo's score came out to be six. [9, 10] The ADR was not studied for dose dependent response and in view of its uncertain mechanism it is difficult to comment on type of ADR. Amiodarone is a benzofuran derivative that has been effective for the treatment of both supraventricular and ventricular tachyarrhythmias. Due to ocular, dermatologic, gastrointestinal, neurologic, cardiovascular, thyroid and


29


pulmonary toxicity, amiodarone should be reserved for use in patients with refractory and/or life-threatening arrhythmias. Furthermore current case report highlights and recommends the ocular screening to avoid major loss of visual function in patient taking amiodarone.

5.

Castells DD1, Teitelbaum BA, Tresley DJ. Visual changes secondary to initiation of amiodarone: a case report and review involving ocular management in cardiac polypharmacy. Optometry 2002 ; 73(2):113-21.

6.

Chassang B1, Bonnin N2, Moisset X3, Citron B4, Clavelou P3, Chiambaretta F5.Two cases of bilateral amiodaroneassociated optic neuropathy. J Fr Ophtalmol 2014 ;37(3):231-6.

References 1.

2.

3.

4.

Naccarelli GV, Rinkenberger RL, Dougherty AH, Giebel RA. Amiodarone: pharmacology and antiarrhythmic and adverse effects. Pharmacotherapy 1985 ;5(6):298-313.

7.

Multisystem Side Effects of Amiodarone. Am J Med Sci. 2014 Feb 6. [Epub ahead of print]

Santaella RM1, Fraunfelder FW. Ocular adverse effects associated with systemic medications : recognition and management. Drugs 2007;67(1):75-93.

8.

Bratulescu M, Zemba M, Gheorghieva V, Andrei S, Cucu B, Dobrescu N. [Ocular manifestation in amiodarone toxicity--case report]. Oftalmologia 2005;49(4):18-23.

9.

Erdurmus M1, Selcoki Y, Yagci R, Hepsen IF.Amiodaroneinduced keratopathy: full-thickness corneal involvement. Eye Contact Lens 2008 ;34(2):131-2.

10.

Source of Support

Nil

Conflict of Interest

Not Declared

Ul Rehman S, Siddiqui N, Khan NS, Sobia R, Assaly R.

Chuang CL1, Chern MS, Chang SC. Amiodarone toxicity in a patient with simultaneous involvement of cornea, thyroid gland, and lung. Am J Med Sci 2000 ; 320(1):64-8. Naranjo CA, Busto U, Sellers EM, Sandor P, Ruiz I, Roberts EA, et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981; 30:239-45 Edwards IR, Arsonson JK. Adverse drug reactions: Definitions, diagnosis and management. Lancet 2000; 356:1255-9

How to Cite This Article : Gupta S, Tandon VR, Khajuria V, Mahajan V, Rani N, Roshi. Amiodarone Induced Ocular Toxicity. J Rational Pharmacother Res 2014; 2(1): 28-30

30


Vol. 2 No.1,January - March 2014