Medications and Cystoid Macular Edema

Introduction to Pentosan Polysulfate (PPS)

The American Urological Association recommends that patients should be counseled about the risk of maculopathy, which can include cystoid macular edema, before starting treatment with Pentosan polysulfate (PPS) 1
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

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

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 2
However, these medications should be used with caution in patients with narrow-angle glaucoma, which can indirectly affect macular health 2
Beta-3 agonists like mirabegron are an alternative to antimuscarinic medications for OAB 2
There is no evidence linking beta-3 agonists to cystoid macular edema, making them potentially safer options for patients with ocular concerns 2

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

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 2
Any patient reporting visual changes while on bladder medications should be promptly referred for ophthalmologic evaluation 1