Ophthalmologic Concerns with Alternative Medicinal Therapies

Ophthalmologic Concerns with Alternative Medicinal Therapies

اسلاید 1: www.tabaye.ir

اسلاید 2: Ophthalmologic Concerns with Alternative Medicinal TherapiesCaleb Sawyer, M.D.Advisor: Jorge Corona, M.D.

اسلاید 3: DisclosureMuch of the material in this assessment is drawn from studies of small series of patients and anecdotal informationMuch of the material in print merits further scientific validation and verificationThe FDA has not evaluated statements made about many of these productsDoes not constitute a guideline or policy of the American Academy of OphthalmologyI have my biases, but no financial interest

اسلاید 4: 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 NIHU.S. alternative medicine: $14 billion/yrGlobal herbal medicine: $60 billion/yr1998 AAO Task Force on Complementary TherapyVisual training for learning disabilitiesApheresis for AMDAcupuncture for dry eye syndromesMarijuana for glaucomaDietary Supplements for “whatever ails you”

اسلاید 5: 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 compressesCan’t claim any potential health benefitNo evidence of safety or effectiveness required

اسلاید 6: How Common are Supplements?700 botanicals & 1000 nutritional products1998: used by ½ of adults in the United States (1/3 used herbal medicines)2002: 32% of ambulatory surgery patients90% took vitamins43% garlic32% ginkgo biloba30% St. John’s Wort18% Ephedra12% Echinacea2/3 of patients fail to disclose herbal medicines

اسلاید 7: Why the Concern?Real vs. False HopeQuality of supplements varies by manufacturerPesticides, herbicides or other botanicals may contaminate herbal productsInteractions with prescribed medsOcular Toxicity Perioperative Implications

اسلاید 8: Purported to treat Ocular conditionsCornflower  conjuctivitis/ophthalmiaFish berry  nystagmusGuar gum  night blindnessMale fern  ophthalmic disorders

اسلاید 9: Bilberry (Vaccinium myrtillus)Purported Benefits: Stimulates regeneration of rhodopsinNight vision enhancer (evidence to the contrary)Positive effect on capillary fragilityLowers blood sugar No known side effects

اسلاید 10: Evening primrose & Borage seed oilMechanism & Benefits: rich in prostaglandin E1Possible treatment for dry eyePotential Side Effects: seizureIncreases coumadin anticoagulation

اسلاید 11: Ocular Side EffectsBlack cohosh  visual disturbances

اسلاید 12: Chamomile (Matricaria recutita)Purported Benefits: Used to tread styes & epiphoraPotential Side Effects: Frequently severe allergic conjunctivitisMay prolong the effects of anesthesia

اسلاید 13: CanthaxanthineCarotinoid found in pink-fleshed fishArtificial suntanDeposits in macular retinal layersMay decrease V.A.37g dose: toxic ½ the time60g dose: always toxicSlowly reversible

اسلاید 14: Coenzyme Q10 (CoQ10)Proposed Benefits: used in CHF, angina, and hypertensionPotential Side Effects:vague photophobia may diminish warfarin anticoagulation

اسلاید 15: NiacinBenefit:Proven to lower cholesterol and triglyceridesSide effects:CME at 3g/day dose; resolves within 2 weeks of D/C Dry eye, eyelid edema, proptosis

اسلاید 16: Jimson Weed (Datura stramonium) a.k.a. “Spiney Apple Seed”Active ingredients: atropine, scopolaminePurported Benefits:Treat ocular inflammation, cough, asthmaPotential Side Effects:MydriasisHallucinogenAnticholinergic crisisDeath

اسلاید 17: Echinacea (Echinacea purpurea, pallida, and augustiflora)Purported Benefits: acute prophylaxis for viral, bacterial, and fungal infectionsPotential Side Effects & Precautions: Anaphylactic conjunctivitis with topical useIncreases serum levels of multiple drugs

اسلاید 18: Kava kava (Piper methysticum)Purported Benefits: treatment of anxietyPotential Side Effects:Red eyes, tearing, and dilated pupils with a sluggish light responseReduced accommodation and convergenceScaly dermatitis Worsen the symptoms of Parkinson diseasepotential for prolongation of anesthesia

اسلاید 19: Licorice (Glycyrrhiza glabra)Purported Benefits:treat peptic ulcer and gastritisPotential Side Effects & Precautions: Temporary visual problems may occur due to retinal blood vessel spasm (?)pseudoaldosteronism

اسلاید 20: St. John’s Wort (Hypericum perforatum)Purported Benefits: treat depressionPotential Side Effects & Precautions: Ocular toxicity from lens uptakeSkin photosensitivityAffects elimination of many drugsDecreases the efficacy of ViagraDecreases effectiveness of birth-control pill

اسلاید 21: Ginkgo biloba Mechanism & Benefits: Inhibit platelet aggregationVasodilatationTreats memory loss, cerebrovascular disease, and dementia, as well as poor attention span, tinnitus, fatigue, macular degenerationAnimal studies: improves chloroquine retinal toxicity & limits ischemia-reperfusion injury and diabetic retinal damagePotential Side Effects & Precautions:Spontaneous hyphema and retinal hemorrhagePerioperative retrobulbar hemorrhageSpontaneous intracranial bleeding Additive anticoagulation effect with coumadin

اسلاید 22: Supplements with Perioperative Anticoagulant ConcernsGarlic, ginger, ginseng, ginkgo, feverfew, fish oils, fenugreek, feverfew, licorice, coenzyme Q10, Vitamin E, glucosamine, and evening primrose oilMany enhance or diminish the anticoagulation effects of coumadin, heparin, ASA, or NSAIDSConsider PT/PTT

اسلاید 23: Supplements with Perioperative Cardiovascular ConcernsEphedra is a direct sympathomimeticLicorice increases cardiac glycosides & causes hypokalemiaLily-of-the-valley is a cardiac glycosideSt John’s wort decreases digoxin levelsGinkgo: vaguely defined cardiovascular effects

اسلاید 24: Supplements with Perioperative Anesthesia ConcernsEchinacea and Kava increase hepatoxicity of acetaminophenvalerian, kava, and chamomile increase opioid analgesicsGinseng decreases opioid effectsValerian and kava have potential to prolong effects of anesthesia

اسلاید 25: Information for PatientsAlways read product labels, follow directions, and heed all warningsUnderstand that “Natural” does not equal “Safe”See a doctor if they experience a serious side effect they attribute to a supplementRealize labels stating the product can help diagnose, treat, cure, or prevent a disease are illegal and should be suspectLook for products with the U.S.P. (United States Pharmacopeia) label

اسلاید 26: ConclusionsWidespread use of dietary supplementsPatients don’t disclose them—ASK!Some are harmfulOcular side effects: Canthaxanthine, Chamomile, Jimson weed, Echinacea, Ginkgo, Licorice, Vitamin A, NiacinPerioperative 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

اسلاید 27: 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 smokersMarinol (antiemetic)  no effect on IOPNot as effective or consistent as conventional treatment To consistently lower IOP  must be smoked every 2 hours!!

اسلاید 28: ReferencesAmerican 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-Eye-Surgery-Assessments.pdf Ang-Lee, MK, Moss J, Yuan CS. “Herbal medicines and perioperative care.” JAMA 2001; 286:208-16.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.