Ophthalmologic Concerns with Alternative Medicinal Therapies

1. Ophthalmologic Concerns with Alternative Medicinal Therapies Caleb Sawyer, M.D. Advisor: Jorge Corona, M.D.

2. 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

3. 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 • Visual training for learning disabilities • Apheresis for AMD • Acupuncture for dry eye syndromes • Marijuana for glaucoma • Dietary Supplements for “whatever ails you”

4. 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

5. 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 • 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

6. 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

7. Purported to treat Ocular conditions • Cornflower  conjuctivitis/ophthalmia • Fish berry  nystagmus • Guar gum  night blindness • Male fern  ophthalmic disorders

8. 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 Bilberry (Vaccinium myrtillus)

9. Mechanism & Benefits: rich in prostaglandin E1 Possible treatment for dry eye Potential Side Effects: seizure Increases coumadin anticoagulation Evening primrose & Borage seed oil

10. Ocular Side Effects • Black cohosh  visual disturbances

11. Purported Benefits: Used to tread styes & epiphora Potential Side Effects: Frequently severe allergic conjunctivitis May prolong the effects of anesthesia Chamomile (Matricaria recutita)

12. 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 Canthaxanthine

13. Coenzyme Q10 (CoQ10) • Proposed Benefits: • used in CHF, angina, and hypertension • Potential Side Effects: • vague photophobia • may diminish warfarin anticoagulation

14. 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 Niacin

15. Active ingredients: atropine, scopolamine Purported Benefits: Treat ocular inflammation, cough, asthma Potential Side Effects: Mydriasis Hallucinogen Anticholinergic crisis Death Jimson Weed (Datura stramonium)a.k.a. “Spiney Apple Seed”

16. 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 Echinacea (Echinacea purpurea, pallida, and augustiflora)

17. 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 Kava kava (Piper methysticum)

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

19. 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 St. John’s Wort (Hypericum perforatum)

20. 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 ischemia-reperfusion 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 Ginkgo biloba

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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!!

27. References • 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-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.