**Background:** Ocular complaints are a diagnostic challenge for non-ophthalmic providers, and a thorough medication history can help identify potential ocular side effects. This narrative review provides a comprehensive overview of vision-threatening complications from systemic medications, including corticosteroids, chloroquine/hydroxychloroquine, pentosan polysulfate sodium, amiodarone, ethambutol, topiramate, tetracyclines, vitamin A/retinoids, niacin, fingolimod, and vigabatrin. It also discusses screening guidelines for high-risk medications.
**Methods:** This is a narrative review that synthesizes existing literature on ocular adverse effects of systemic medications. It does not describe a specific search strategy or inclusion criteria but cites multiple references (e.g., [1]-[50]) to support its statements. The review includes tables summarizing adverse effects, screening recommendations, and incidences of chemotherapeutic-related effects.
**Key Results:** Key findings include: Corticosteroids increase risk of posterior subcapsular cataracts and glaucoma, with intraocular pressure (IOP) steroid response occurring in approximately 1/3 of the population. Hydroxychloroquine maculopathy risk is <1% after 5 years and <2% after 10 years at recommended doses, rising to 20% after 20 years. Pentosan polysulfate sodium maculopathy occurs after a median of 14.5 years, with rates of 12.7%, 30.0%, and 41.7% at cumulative exposures of 500-999 g, 1000-1500 g, and >1500 g, respectively. Amiodarone-associated optic neuropathy affects 1.76% of users, with 60% improving after discontinuation. Ethambutol optic neuropathy prevalence is 1% at ≤15 mg/kg/day, 5-6% at 25 mg/kg/day, and 50% at 60-100 mg/kg/day. Topiramate-induced acute angle closure has an estimated prevalence of 3 per 100,000 patients, with 96.5% bilateral and 85% occurring within the first 2 weeks. Tetracycline-associated intracranial hypertension incidence is 63.9 per 100,000 person-years vs. <1 in the general population. Niacin maculopathy incidence is 0.67%, resolving within 4-8 weeks after discontinuation. Fingolimod-associated macular edema incidence is ~0.4% at 0.5 mg/day, with 68% occurring within 3-4 months. Vigabatrin-associated visual field loss occurs in 30-50% of patients, typically after over one year of treatment.
**Clinical Implications:** The review emphasizes that many ocular side effects are irreversible if not detected early, making routine screening critical for high-risk medications. Specific screening guidelines are provided for chloroquine/hydroxychloroquine (baseline and annual after 5 years), corticosteroids (IOP monitoring for chronic users), ethambutol (baseline and every 2 months), fingolimod (baseline and at 3-4 months), pentosan polysulfate sodium (baseline and annual as cumulative dose approaches 500 g), and vigabatrin (baseline and every 3 months). For medications like topiramate, tetracyclines, and retinoids, symptomatic screening is recommended, with urgent referral for vision changes. The review also highlights risk factors such as renal disease, tamoxifen use, and preexisting macular disease that increase toxicity risk.