Could cevimeline (Evoxac) be causing blurry vision in a patient with a history of cystoid macular edema (CME) and Sjögren's syndrome?

From the Guidelines

The patient should hold cevimeline to see if her blurry vision improves, as visual disturbances, including blurry vision, are known side effects of cevimeline due to its cholinergic effects, and this may be more pronounced or concerning in a patient with pre-existing cystoid macular edema (CME) 1.

Clinical Considerations

When considering the potential cause of blurry vision in a patient with a history of CME and Sjögren's syndrome who is taking cevimeline, it's essential to weigh the benefits of the medication against the potential risks. Cevimeline is used to treat dry mouth symptoms in Sjögren's syndrome by stimulating muscarinic receptors, which can also affect the eye. Key points to consider include:

• The mechanism of action of cevimeline and its potential effects on the eye, including changes in pupil size and accommodation.
• The patient's history of CME, which could make them more susceptible to visual disturbances caused by cevimeline.
• The fact that the patient did not notice blurry vision when taking cevimeline inconsistently in the past, but this does not rule out the possibility that consistent use could lead to such side effects.

Evidence-Based Decision

The decision to hold cevimeline is based on the potential for cevimeline to cause or exacerbate blurry vision, as suggested by its mechanism of action and side effect profile 1. While the study primarily discusses pilocarpine, another cholinergic agonist, the principles of muscarinic receptor stimulation and potential effects on the eye are relevant to cevimeline as well. The improvement in symptoms of blurred vision seen with pilocarpine in patients with Sjögren syndrome underscores the importance of considering the ocular effects of these medications.

Management Recommendations

Given the potential for cevimeline to contribute to the patient's blurry vision, holding the medication and monitoring for improvement is a prudent step. This approach allows for the assessment of whether cevimeline is indeed contributing to the patient's symptoms without immediately switching to alternative treatments. Regular follow-up with an ophthalmologist is crucial to monitor the patient's CME and adjust the treatment plan as necessary to prioritize the patient's vision and overall quality of life.

From the FDA Drug Label

The following events were reported in Sjögren’s patients at incidences of <3% and ≥1%: ... abnormal vision, ... eye pain, ... eye infection, ... eye abnormality, ... xerophthalmia The FDA drug label mentions abnormal vision as an adverse event reported in Sjögren’s patients at an incidence of <3% and ≥1%. Given this information, it is possible that cevimeline could be contributing to the patient's blurry vision. However, the relationship between cevimeline and blurry vision is not clearly established, and the patient's history of cystoid macular edema is a significant factor to consider. Key points:

• Cevimeline may be associated with abnormal vision
• Patient has a history of cystoid macular edema
• The patient's blurry vision could be related to cevimeline, but the evidence is not conclusive It may be reasonable to consider holding cevimeline to see if the patient's blurry vision improves, but this decision should be made in consultation with the patient's healthcare provider, taking into account the patient's individual circumstances and medical history 2.

From the Research

Cevimeline and Blurry Vision

• There is no direct evidence in the provided studies that cevimeline causes blurry vision in patients with a history of cystoid macular edema (CME) and Sjögren's syndrome 3, 4, 5, 6, 7.
• Cevimeline is a muscarinic receptor agonist that is indicated for the treatment of symptoms of dry mouth in patients with Sjogren's syndrome, and it has been shown to improve symptoms of dry eye in patients with Sjögren's syndrome 4.
• The most commonly reported adverse events associated with cevimeline are related to its pharmacological action, such as sweating, gastrointestinal symptoms, dizziness, and rigors, but blurry vision is not mentioned as a common adverse event 3, 5, 6.
• It is possible that the patient's blurry vision is related to her underlying condition, such as CME, rather than cevimeline itself.
• Holding cevimeline to see if the blurry vision improves may be considered, but it is essential to weigh the potential benefits of cevimeline in managing the patient's Sjögren's syndrome symptoms against the potential risk of worsening dry mouth symptoms if the medication is discontinued 3, 6.

Cevimeline's Effects on the Eyes

• Cevimeline has been shown to improve symptoms of dry eye in patients with Sjögren's syndrome, including subjective symptoms, tear dynamics, and condition of the corneoconjunctival epithelium 4.
• There is no evidence to suggest that cevimeline would exacerbate CME or cause blurry vision in patients with a history of CME 3, 4, 5, 6, 7.
• The patient's history of CME and Sjögren's syndrome should be considered when evaluating the potential causes of her blurry vision, and a comprehensive eye examination may be necessary to determine the underlying cause of her symptoms.