Acute angle closure glaucoma precipitated by homeopathic eyedrops containing Atropa belladonna.

Acute angle closure glaucoma is a sight-threatening condition that may lead to blindness. This is a case report of a woman who presented to the emergency department (ED) with acute angle closure glaucoma following use of an over-the-counter (OTC) homeopathic eye drop containing atropa belladonna (deadly nightshade). A 55-year-old woman presented to the ED with a 5-day history of left eye redness, swelling, tearing, and foreign-body sensation that had acutely worsened in the last two days. Her exam revealed mild left conjunctival injection with watery tearing and a hazy appearance of her left cornea. Fluorescein staining was negative, while tonometry revealed elevated intraocular pressure on the left, suggestive of acute angle closure glaucoma. She was urgently referred to ophthalmology. The etiology of the acute angle closure glaucoma was initially unclear however, with additional prompting, she revealed that two days prior she had started using homeopathic OTC eye drops. Inspection of the eyedrop's ingredients revealed that atropa belladonna was the primary ingredient and likely precipitated her isolated episode of acute angle closure glaucoma. A high level of clinical suspicion and focused ophthalmic exam including tonometry is essential to identify acute angle closure glaucoma in the ED. We present a case report of acute angle closure glaucoma associated with the use of homeopathic belladonna-containing eyedrops. Our report reinforces the necessity to perform thorough medication and supplement history given the prevalence of physiologically active substances available in OTC medications.

Ciliary Body and Iris Metastases With Anterior Chamber Angle Infiltration: A Rare Complication From Invasive Ductal Breast Cancer.

A 54-year-old woman who presented with photopsia was found to have elevated intraocular pressure in both eyes and optic disc cupping in the right eye. Angle infiltration was noted on gonioscopy. She was previously been diagnosed with metastatic breast cancer. This case report describes a rare case of glaucoma as a complication of ciliary body and iris metastases secondary to invasive ductal breast cancer.

Bilateral acute myopia and angle closure glaucoma induced by Ma-huang (Ephedra): A case report.

RATIONALE: Cases of bilateral acute angle closure have been reported after use of various drugs. PATIENT CONCERNS: A 52-year-old woman visited the emergency room and complained of acute bilateral ocular pain and decreased vision accompanied by headache, nausea, and vomiting. One day before, she had started a herbal medicine containing Ma-huang for weight loss. On examinations, myopic shift, edematous cornea, increased intraocular pressure, shallow anterior chamber, and thickened choroid on both eyes were observed. DIAGNOSES: Angle closure glaucoma induced by drug (Ma-huang). INTERVENTIONS: To promptly quit the offending drug and apply ocular hypotensives and cycloplegics. OUTCOMES: Her symptoms and signs were relieved after antiglaucoma medications and no significant recurrence has been occurred. LESSONS: Physicians prescribing weight loss medications containing Ma-huang must be aware of the potentially sight-threatening adverse effect of bilateral acute angle closure.

Eye drops preservative as the cause of corneal band keratopathy in long-term pilocarpine hydrochloride treatment.

The aim is to present a patient with severe bilateral corneal complications after long-term antiglaucoma treatment with 1% pilocarpine hydrochloride (Pilokarpin, Pliva, Zagreb, Croatia) and its management. A patient with narrow-angle glaucoma treated with 1% topical pilocarpine hydrochloride eye drops for the last twenty years complained of impaired vision, intermittent visual haloes and eye redness. Ophthalmologic examination showed bilateral band keratopathy, peripheral laser iridotomy, medicamentous myosis, brown nuclear cataract, and synchysis scintillans of his right eye. Band keratopathy was thought to have resulted from the presence of the preservative phenylmercuric nitrate in the pilocarpine hydrochloride eye drops. Treatment of the patient consisted of two separate procedures for both eyes, i.e. phaco trabeculectomy and six months later corneal procedure including abrasion of corneal epithelium followed by removal of the superficial stromal calcium deposits by means of a 3.75% ethylenediaminetetraacetic (EDTA) solution. After phaco trabeculectomy, visual acuity was 0.8 on both eyes. Bilateral visual improvement with visual acuity 1.0 was recorded after corneal treatment with EDTA. In conclusion, one must be aware of preservative complications in long-term topical use, such as band keratopathy that can be visually incapacitating. Surgical treatment using EDTA is safe and effective treatment for band keratopathy.

Bilateral simultaneous acute angle closure glaucoma precipitated by non-prescription cold and flu medication.

We present a case of a 63-year-old woman who presented to an ED with bifrontal headache, nausea and vomiting and reduced visual acuity. Examination revealed bilateral elevated intraocular pressures, corneal haze, shallow anterior chambers and poorly reactive, mid-dilated pupils. Diagnosis was made of simultaneous bilateral acute angle closure glaucoma. A complete drug history revealed that she had been using an over-the-counter cold and flu remedy whose active ingredients included atropa belladonna, an herb with anticholinergic properties. It is likely that drug-induced dilatation of the individual's pupils precipitated this angle closure emergency. In the report we discuss the risk factors for angle closure glaucoma, and review the local and systemic drugs known to trigger this sight-threatening emergency.

Configuration of the drainage angle, intraocular pressure, and optic disc cupping in subjects with chronic angle-closure glaucoma.

OBJECTIVE: To investigate the relationship between drainage angle configuration with untreated intraocular pressure (IOP) and optic disc cupping in subjects with chronic angle-closure glaucoma (CACG). DESIGN: Prospective, observational study. PARTICIPANTS: Two hundred seventy-five Asian subjects with CACG who participated in a randomized controlled trial that investigated the IOP-reducing effect of latanoprost and timolol. METHODS: Chronic angle-closure glaucoma was defined as the presence of glaucomatous optic neuropathy (with or without a visual field defect), an anterior chamber angle in which the pigmented trabecular meshwork was not visible for at least 180 degrees on gonioscopy, and evidence of peripheral anterior synechiae (PAS) in association with elevated IOP of 21 mmHg or more. Static and dynamic gonioscopy were performed, the angles were graded in each quadrant according to the Shaffer scheme, and the number of clock hours of PAS was recorded. The untreated IOP and vertical cup-to-disc ratio were correlated with mean angle width and extent of PAS. MAIN OUTCOME MEASURES: Mean angle width, clock hours of PAS, IOP, and vertical cup-to-disc ratio. RESULTS: Most subjects were female (75%), and the mean age was 62.9+/-9.4 years. The mean angle width was 0.77+/-0.53 and the mean number of clock hours of PAS was 4.77+/-3.2 hours. Untreated IOP correlated with angle width (r = -0.23; P<0.001) and clock hours of PAS (r = 0.22; P<0.001). Vertical cup-to-disc ratio also correlated with angle width (r = -0.17; P = 0.004) and PAS (r = 0.28; P<0.001). Performing a multiple linear regression using baseline IOP as the outcome variable with age, gender, clock hours of PAS, and angle width as predictors, there was a 0.39-mmHg (95% confidence interval, 0.15-0.63) increase in baseline untreated IOP for each unit increase in clock hours of PAS (P = 0.002). CONCLUSIONS: In subjects with CACG, the extent of PAS and a narrower width of the drainage angle were associated with higher untreated IOP and a larger vertical cup-to-disc ratio.

Argon laser peripheral iridoplasty versus conventional systemic medical therapy in treatment of acute primary angle-closure glaucoma : a prospective, randomized, controlled trial.

OBJECTIVE: To study whether argon laser peripheral iridoplasty (ALPI) is as effective and safe as conventional systemic medications in treatment of acute primary angle-closure glaucoma (PACG) when immediate laser peripheral iridotomy is neither possible nor safe. DESIGN: Prospective, randomized, controlled trial. PARTICIPANTS: Seventy-three eyes of 64 consecutive patients with their first presentation of acute PACG, with intraocular pressure (IOP) levels of 40 mmHg or more, were recruited into the study. INTERVENTION: The acute PACG eye of each consenting patient received topical pilocarpine (4%) and topical timolol (0.5%). The patients were then randomized into one of two treatment groups. The ALPI group received immediate ALPI under topical anesthesia. The medical treatment group was given 500 mg of intravenous acetazolamide, followed by oral acetazolamide 250 mg four times daily, and an oral potassium supplement until IOP levels normalized. Intravenous mannitol also was administered to the latter group if the presenting IOP was higher than 60 mmHg. The acute PACG eye of both groups continued to receive topical pilocarpine (1%) until peripheral iridotomy could be performed. MAIN OUTCOME MEASURES: Intraocular pressure profile, corneal clarity, symptoms, visual acuity, angle status by indentation gonioscopy, and complications of treatment. RESULTS: Thirty-three acute PACG eyes of 32 patients were randomized to receive immediate ALPI, whereas 40 acute PACG eyes of 32 patients had conventional systemic medical therapy. Both treatment groups were matched for age, duration of attack, and IOP at presentation. The ALPI-treated group had lower IOP levels than the medically treated group at 15 minutes, 30 minutes, and 1 hour after the start of treatment. The differences were statistically significant. The difference in IOP levels became statistically insignificant from 2 hours onward. The duration of attack did not affect the efficacy of ALPI in reducing IOP in acute PACG. No serious laser complications occurred, at least in the early postlaser period. CONCLUSIONS: Argon laser peripheral iridoplasty significantly is more effective than conventional systemic medications in reducing IOP levels in acute PACG in eyes not suitable for immediate laser peripheral iridotomy within the first 2 hours from the initiation of treatment. Argon laser peripheral iridoplasty is a safe and more effective alternative to conventional systemic medications in the management of acute PACG not amenable to immediate laser peripheral iridotomy.

Clinical decision making based on data from GDx: one-year observations.

PURPOSE: To determine whether information derived from the GDx scanning laser polarimeter aids in the clinical decision-making process for patients with various types of glaucoma. METHODS: Over a 4-month period, 342 consecutive patients with primary open-angle glaucoma, ocular hypertension, angle-closure glaucoma, or secondary glaucomas or in whom the diagnosis of glaucoma was uncertain were evaluated with the GDx scanning laser. After 1 year, 153 patients with glaucoma underwent GDx analysis again. Chart review revealed that 42 of the 153 patients had a change in therapy as a result of the GDx evaluation combined with analysis of visual fields, optic disc cupping, and intraocular pressure (IOP). Outcomes were then compared. RESULTS: The group who had a change in therapy had a higher average GDx number (51.5 +/- 26.1 vs 37.0 +/- 23.5 [P = .001]) at the initial visit and higher IOP (18.2 +/- 4.6 vs 16.0 +/- 3.2 mm Hg [P = .005]). In spite of a change in therapy, at an average of 344 days later, IOP was unchanged (18.3 +/- 5.3 vs 15.7 +/- 3.2 mm Hg [P = .001]) and GDx values in the altered therapy group were higher than at baseline (57.3 +/- 27.9 vs 36.7 +/- 23.4 [P = .001]), although the differences within each group did not achieve statistical significance. CONCLUSION: GDx analysis may be helpful in determining patients at risk for damage from glaucoma, even in eyes in which cup-disc ratio and field loss have not progressed. Changing medications without significantly reducing IOP may be insufficient to halt increases in GDx numbers and may indicate a need for more aggressive therapy.