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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

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ophthalmologic concerns with alternative medicinal therapies

Ophthalmologic Concerns with Alternative Medicinal Therapies

Caleb Sawyer, M.D.

Advisor: Jorge Corona, M.D.

  • 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
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”
what is a dietary supplement
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
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
why the concern
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
Purported to treat Ocular conditions
  • 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

Bilberry (Vaccinium myrtillus)
evening primrose borage seed oil
Mechanism & Benefits:

rich in prostaglandin E1

Possible treatment for dry eye

Potential Side Effects:


Increases coumadin anticoagulation

Evening primrose & Borage seed oil
ocular side effects
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

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

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:



Anticholinergic crisis


Jimson Weed (Datura stramonium)a.k.a. “Spiney Apple Seed”
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

Echinacea (Echinacea purpurea, pallida, and augustiflora)
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

Kava kava (Piper methysticum)
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 (?)


Licorice (Glycyrrhiza glabra)
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

St. John’s Wort (Hypericum perforatum)
ginkgo biloba
Mechanism & Benefits:

Inhibit platelet aggregation


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
supplements with perioperative anticoagulant concerns
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
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
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
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
  • 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!!
  • 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.