Which drug is associated with pigment on the macula (pigmentary changes)?

• A. Indomethacin
• B. Prednisone
• C. Atropine
• D. Timolol

Answer: (A)

Drug-induced pigmentary changes in the macula occur when a systemic medication affects the retinal pigment epithelium or photoreceptors over time, leading to pigmented patches or mottling in the central retina. Among the listed drugs, indomethacin has been associated with pigmentary changes in the macula with prolonged use. The idea is that certain medications can disrupt macular RPE function or retinal metabolism, which shows up as pigment alterations on exam and can correlate with central vision changes if the exposure is sustained.

The other options are less linked to pigmentary maculopathy. Systemic steroids like prednisone can cause cataracts and optic nerve or pressure-related issues, but not classic pigmentary changes in the macula. Atropine is a cycloplegic that mainly causes blurred vision and photophobia without structural pigment changes. Timolol is a topical beta-blocker used for glaucoma and is not associated with pigmentary macular changes.

If a patient on indomethacin develops new central vision symptoms, a dilated fundus exam with OCT and possibly fluorescein angiography would help assess for macular pigmentary disturbance and guide management, including consideration of stopping the offending medication.