What medications used for bladder conditions can cause cystoid macular edema?

Medications Used for the Bladder That Can Cause Cystoid Macular Edema

Pentosan polysulfate (PPS) is the primary bladder medication associated with maculopathy, which can include cystoid macular edema, and patients should be counseled about this risk before starting treatment. 1

Pentosan Polysulfate (PPS)

• PPS is the only FDA-approved oral agent for the treatment of interstitial cystitis/bladder pain syndrome (IC/BPS) 1
• Recent reports have identified a unique retinal pigmentary maculopathy associated with PPS use, which can include cystoid macular edema 1
• The FDA approved a new warning label for PPS in June 2020 highlighting these ocular risks 1
• The prevalence of maculopathy appears to be related to the cumulative amount of PPS exposure 1

Clinical Recommendations for PPS Use

• A detailed ophthalmologic history should be obtained in all patients prior to starting treatment with PPS 1
• For patients with preexisting ophthalmologic conditions, a comprehensive baseline retinal examination is recommended prior to starting therapy 1
• A retinal examination is suggested for all patients within six months of initiating treatment and periodically while continuing treatment 1
• If pigmentary changes in the retina develop, the risks and benefits of continuing treatment should be reevaluated, since these changes may be irreversible 1

Prostaglandin Analogs and CME

• Topical prostaglandin analogs used for glaucoma (which may sometimes be prescribed for bladder conditions off-label) have been associated with cystoid macular edema 2, 3
• The mechanism appears to be related to increased vascular permeability and breakdown of the blood-retinal barrier 2
• This risk is particularly elevated in patients who have had recent cataract surgery 2

Other Antimuscarinic Medications

• Common antimuscarinic medications used for overactive bladder (OAB) such as oxybutynin, tolterodine, solifenacin, darifenacin, and fesoterodine have not been specifically linked to cystoid macular edema 1
• However, these medications should be used with caution in patients with narrow-angle glaucoma, which can indirectly affect macular health 1

Beta-3 Agonists

• Beta-3 agonists like mirabegron are an alternative to antimuscarinic medications for OAB 1
• There is no evidence linking beta-3 agonists to cystoid macular edema, making them potentially safer options for patients with ocular concerns 1

Risk Factors and Monitoring

• Patients with a history of inflammatory eye conditions, recent ocular surgery, or diabetes may be at higher risk for developing medication-induced CME 4
• Regular ophthalmologic monitoring is essential for patients on PPS, especially those with additional risk factors 1
• Symptoms of maculopathy include difficulty reading, slow adjustment to low or reduced light environments, and blurred vision 1

Clinical Approach to Patients Requiring Bladder Medications

• For patients with IC/BPS who need medication therapy, consider the risk-benefit profile of PPS, especially in those with preexisting ocular conditions 1
• For patients with OAB, beta-3 agonists may be preferred over antimuscarinic medications in patients with ocular risk factors 1
• Any patient reporting visual changes while on bladder medications should be promptly referred for ophthalmologic evaluation 1, 2