Transcript Ophthalmologic Concerns with Alternative Medicinal Therapies

Ophthalmologic Concerns with
Alternative Medicinal Therapies
Caleb Sawyer, M.D.
Advisor: Jorge Corona, M.D.
Disclosure
• Much of the material in this assessment is drawn
from studies of small series of patients and
anecdotal information
• Much of the material in print merits further
scientific validation and verification
• The FDA has not evaluated statements made
about many of these products
• Does not constitute a guideline or policy of the
American Academy of Ophthalmology
• I have my biases, but no financial interest
Alternative Medicine
• “Those treatments and health care practices not taught
widely in medical schools, not generally used in
hospitals, and not usually reimbursed by medical
insurance companies.”-- Alternative medicine according to NIH
• U.S. alternative medicine: $14 billion/yr
• Global herbal medicine: $60 billion/yr
• 1998 AAO Task Force on Complementary Therapy
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Visual training for learning disabilities
Apheresis for AMD
Acupuncture for dry eye syndromes
Marijuana for glaucoma
Dietary Supplements for “whatever ails you”
What is a Dietary Supplement?
• Vitamin, mineral, amino acid, herb, or other
botanical (not tobacco)
• Capsule, powder, tablet, softgel, liquid, gelcap,
fresh decoctions, whole herbs steeped as teas;
tinctures, vinegar extract, syrup, miels,
suppositories, creams, liniments, oils, or
compresses
• Can’t claim any potential health benefit
• No evidence of safety or effectiveness required
How Common are Supplements?
• 700 botanicals & 1000 nutritional products
• 1998: used by ½ of adults in the United States (1/3 used
herbal medicines)
• 2002: 32% of ambulatory surgery patients
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90% took vitamins
43% garlic
32% ginkgo biloba
30% St. John’s Wort
18% Ephedra
12% Echinacea
• 2/3 of patients fail to disclose herbal medicines
Why the Concern?
• Real vs. False Hope
• Quality of supplements varies by
manufacturer
• Pesticides, herbicides or other botanicals
may contaminate herbal products
• Interactions with prescribed meds
• Ocular Toxicity
• Perioperative Implications
Purported to treat Ocular conditions
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Cornflower  conjuctivitis/ophthalmia
Fish berry  nystagmus
Guar gum  night blindness
Male fern  ophthalmic disorders
Bilberry (Vaccinium myrtillus)
• Purported Benefits:
– Stimulates
regeneration of
rhodopsin
– Night vision enhancer
(evidence to the
contrary)
– Positive effect on
capillary fragility
– Lowers blood sugar
• No known side effects
Evening primrose & Borage seed oil
• Mechanism &
Benefits:
– rich in prostaglandin
E1
– Possible treatment for
dry eye
• Potential Side Effects:
– seizure
– Increases coumadin
anticoagulation
Ocular Side Effects
• Black cohosh  visual disturbances
Chamomile (Matricaria recutita)
• Purported Benefits:
– Used to tread styes
& epiphora
• Potential Side
Effects:
– Frequently severe
allergic
conjunctivitis
– May prolong the
effects of
anesthesia
Canthaxanthine
• Carotinoid found in
pink-fleshed fish
• Artificial suntan
• Deposits in macular
retinal layers
– May decrease V.A.
– 37g dose: toxic ½ the
time
– 60g dose: always toxic
– Slowly reversible
Coenzyme Q10 (CoQ10)
• Proposed Benefits:
– used in CHF, angina, and
hypertension
• Potential Side Effects:
– vague photophobia
– may diminish warfarin
anticoagulation
Niacin
• Benefit:
– Proven to lower
cholesterol and
triglycerides
• Side effects:
– CME at 3g/day dose;
resolves within 2
weeks of D/C
– Dry eye, eyelid
edema, proptosis
Jimson Weed (Datura stramonium)
a.k.a. “Spiney Apple Seed”
• Active ingredients:
– atropine, scopolamine
• Purported Benefits:
– Treat ocular
inflammation, cough,
asthma
• Potential Side Effects:
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Mydriasis
Hallucinogen
Anticholinergic crisis
Death
Echinacea (Echinacea purpurea,
pallida, and augustiflora)
• Purported Benefits:
– acute prophylaxis for
viral, bacterial, and
fungal infections
• Potential Side Effects
& Precautions:
– Anaphylactic
conjunctivitis with
topical use
– Increases serum
levels of multiple drugs
Kava kava (Piper methysticum)
• Purported Benefits:
– treatment of anxiety
• Potential Side Effects:
– Red eyes, tearing, and
dilated pupils with a
sluggish light response
– Reduced accommodation
and convergence
– Scaly dermatitis
– Worsen the symptoms of
Parkinson disease
– potential for prolongation of
anesthesia
Licorice (Glycyrrhiza glabra)
• Purported Benefits:
– treat peptic ulcer and
gastritis
• Potential Side Effects
& Precautions:
– Temporary visual
problems may occur
due to retinal blood
vessel spasm (?)
– pseudoaldosteronism
St. John’s Wort (Hypericum
perforatum)
• Purported Benefits:
– treat depression
• Potential Side Effects &
Precautions:
– Ocular toxicity from lens
uptake
– Skin photosensitivity
– Affects elimination of many
drugs
– Decreases the efficacy of
Viagra
– Decreases effectiveness of
birth-control pill
Ginkgo biloba
• Mechanism & Benefits:
– Inhibit platelet aggregation
– Vasodilatation
– Treats memory loss, cerebrovascular
disease, and dementia, as well as poor
attention span, tinnitus, fatigue, macular
degeneration
– Animal studies: improves chloroquine
retinal toxicity & limits ischemiareperfusion injury and diabetic retinal
damage
• Potential Side Effects & Precautions:
– Spontaneous hyphema and retinal
hemorrhage
– Perioperative retrobulbar hemorrhage
– Spontaneous intracranial bleeding
– Additive anticoagulation effect with
coumadin
Supplements with Perioperative
Anticoagulant Concerns
• Garlic, ginger, ginseng, ginkgo, feverfew,
fish oils, fenugreek, feverfew, licorice,
coenzyme Q10, Vitamin E, glucosamine,
and evening primrose oil
• Many enhance or diminish the
anticoagulation effects of coumadin,
heparin, ASA, or NSAIDS
• Consider PT/PTT
Supplements with Perioperative
Cardiovascular Concerns
• Ephedra is a direct sympathomimetic
• Licorice increases cardiac glycosides &
causes hypokalemia
• Lily-of-the-valley is a cardiac glycoside
• St John’s wort decreases digoxin levels
• Ginkgo: vaguely defined cardiovascular
effects
Supplements with Perioperative
Anesthesia Concerns
• Echinacea and Kava increase hepatoxicity
of acetaminophen
• valerian, kava, and chamomile increase
opioid analgesics
• Ginseng decreases opioid effects
• Valerian and kava have potential to
prolong effects of anesthesia
Information for Patients
• Always read product labels, follow directions,
and heed all warnings
• Understand that “Natural” does not equal “Safe”
• See a doctor if they experience a serious side
effect they attribute to a supplement
• Realize labels stating the product can help
diagnose, treat, cure, or prevent a disease are
illegal and should be suspect
• Look for products with the U.S.P. (United States
Pharmacopeia) label
Conclusions
• Widespread use of dietary supplements
• Patients don’t disclose them—ASK!
• Some are harmful
– Ocular side effects: Canthaxanthine, Chamomile,
Jimson weed, Echinacea, Ginkgo, Licorice, Vitamin A,
Niacin
– Perioperative setting: D/C 2-3 weeks prior to surgery
CoQ10, Echinacea, Ephedra, Fenugreek, Feverfew,
Garlic, Ginkgo, Ginseng, Goldenseal, Kava, Licorice,
St. John’s Wort, Valerian, Yohimbe
Marijuana
(Pot, herb, grass, weed, Mary Jane, reefer, Aunt Mary, skunk, boom,
gangster, kif, ganja, Maui wowie, Chronic, Texas tea)
• Medical use legal in 12 states (not
Texas)
• 400 chemicals
• Lowers IOP in 65% of smokers
• Marinol (antiemetic)  no effect
on IOP
• Not as effective or consistent as
conventional treatment
• To consistently lower IOP  must
be smoked every 2 hours!!
References
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American Academy of Ophthalmology. “Complementary Therapy Assessment. Nutritional
Supplements: Perioperative Implications for Eye Surgery.” November
2003.http://www.aao.org/aao/education/library/cta/upload/Perioperative-Implications-for-EyeSurgery-Assessments.pdf
Ang-Lee, MK, Moss J, Yuan CS. “Herbal medicines and perioperative care.” JAMA 2001; 286:20816.
Burke N. The Modern Herbal Primer. The Old Farmers' Almanac. Alexandria, VA: Time-Life, 2000.
Fraunfelder, Frederick W., “Ocular Side Effects From Herbal Medicines and Nutritional
Supplements,” AJO 2004; 138:639-647.
Guide to Popular Natural Products. Facts and Comparisons. In: DerMarderosian A, ed. Facts and
Comparisons. St. Louis, MO, 1999.
Muth ER, Laurent JM, Jasper P. The effect of bilberry nutritional supplementation on night visual
acuity and contrast sensitivity. Altern Med Rev 2000;5:164-73.
Scott GN, Elmer GW. Update on natural product--drug interactions. Am J Health Syst Pharm
2002;59:339-47.
US FDA website http://www.cfsan.fda.gov/~dms/supplmnt.html
Shults CW, Oakes D, Kieburtz K, et al. Effects of coenzyme Q10 in early Parkinson disease:
evidence of slowing of the functional decline. Arch Neurol 2002;59:1541-50.
Tran MT, Mitchell TM, Kennedy DT, Giles JT. Role of coenzyme Q10 in chronic heart failure,
angina, and hypertension. Pharmacotherapy 2001;21:797-806.
Evidence-Based Herbal Medicine. Philadelphia: Hanley & Belfus, Inc., 2002; 134-8.
World Health Organization (WHO). WHO guidelines on good agricultural and collection practices
for medicinal plants. Geneva, Switzerland: WHO; 2004.