Complementary and alternative medicine for glaucoma

Tongqiao Mingmu formula alleviates retinal ganglion cell autophagy through PI3K/AKT/mTOR pathway

Glaucoma is a severe blindness-causing optic nerve disease characterized by a loss of retinal ganglion cells (RGCs). Previous studies have shown that the Tongqiao Mingmu (TQMM) formula can reduce retinal and optic nerve damage, but its mechanism of action requires further elucidation. In this study, an RGC injury model was prepared using glutamate and then treated with serum-containing drug from the TQMM formula (hereafter called "TQMM formula serum"). In the glutamate-induced RGC injury model, cell viability decreased with an increase in glutamate concentration, whereas the expression of autophagy-related biomarkers LC3 and Belicin-1 increased. An adenovirus transfection experiment revealed that glutamate markedly promoted autophagic flux in RGCs. Notably, TQMM formula serum inhibited the expression of autophagy-related biomarkers, reduced autophagy flux, and reversed the damage caused by glutamate to RGCs. Furthermore, the PI3K inhibitor LY294002 was used to intervene in the RGC autophagy model and was found to suppress the PI3K/AKT/mTOR pathway and enhance RGC autophagy. However, TQMM formula serum could generate an opposite effect and upregulate the expressions of the PI3K/AKT/mTOR pathway genes and proteins. In conclusion, the TQMM formula can prevent glutamate-induced autophagy in RGCs, possibly by activating the PI3K/AKT/mTOR pathway and reducing the expression of autophagy-related biomarkers LC3 and Belicin-1 to attenuate autophagy and maintain RGC viability.

Herbal and Natural Treatments for the Management of the Glaucoma: An Update

Glaucoma causes the degeneration of the retinal ganglion cells (RGCs) and their axons, inducing a tissue reshaping that affects both the retina and the optic nerve head. Glaucoma care especially focuses on reducing intraocular pressure, a significant risk factor for progressive damage to the optic nerve. The use of natural treatments, such as herbs, vitamins, and minerals, is becoming increasingly popular today. While plants are a rich source of novel biologically active compounds, only a small percentage of them have been phytochemically examined and evaluated for their medicinal potential. It is necessary for eye care professionals to inform their glaucoma patients about the therapy, protection, and efficacy of commonly used herbal medicines, considering the widespread use of herbal medicines. The purpose of this review is to examine evidence related to the most widely used herbal medicines for the management and treatment of glaucoma, to better understand the potential benefits of these natural compounds as supplementary therapy.

Effect of yoga on intra-ocular pressure in patients with glaucoma: A systematic review and meta-analysis

Glaucoma is the second leading cause of blindness in the world, with an estimated 57.5 million people suffering from glaucoma globally. Treatment of glaucoma focuses on lowering intra-ocular pressure to prevent progression of visual field defects, which is the only proven method for treating this disease. Yoga practices are believed to lower intra-ocular pressure in the eyes and prevent further damage in patients with glaucoma. Therefore, this systematic review was planned to explore the available scientific studies on yoga and intra-ocular pressure in glaucoma patients. PubMed, Cochrane Library, and Google Scholar were the basis for the investigation of the literature. The Jadad Scale was used to assess the quality of included clinical trials, and the JBI Critical Appraisal Checklist was used to assess the quality of included case studies. Based on the quality assessment and eligibility, six studies on yoga and intra-ocular pressure in glaucoma patients carried out between 2007 and 2021 were included in the final review. The results showed a reduction in intra-ocular pressure in patients with glaucoma through Jyoti-trataka (gazing steadily on a point or candle flame) and some other slow yogic breathing techniques, whereas studies on inversion Asanas (yoga postures) showed a rapid increase in intra-ocular pressure soon after starting. The three high-quality RCTs included in the meta-analysis showed a greater improvement in intra-ocular pressure in the yoga groups in both eyes than in the control groups; however, there were some limitations related to a small sample size, study quality, a long-term follow-up period, and variations in the yoga practices. Therefore, further studies with larger sample sizes and long-term follow-up are needed to overcome the limitations for a better understanding.

Evidence for Complementary and Alternative Therapies to Treat Glaucoma

Complementary and alternative medicine is used by approximately 5% of patients with glaucoma, and examples include marijuana, Ginkgo biloba extract, bilberry fruit extract, and acupuncture. Systemic marijuana is not beneficial for glaucoma due to the short duration of action, the lack of evidence that it alters disease progression, and its negative side effect profile. Drops that affect the cannabinoid pathway are still being studied. Ginkgo biloba and bilberry fruit extracts have been shown to decrease oxidative stress and improve perfusion of the optic nerve head. However, these findings are inconsistent throughout the literature and the studies are small, which makes the overall evidence weak. There is no evidence that acupuncture alters glaucoma disease progression or causes a sustained decrease in intraocular pressure. In summary, the literature suggests that there are transient and/or theoretical benefits of complementary and alternative medicine for glaucoma care; however, the overall evidence to support their use is weak.

Effect of Jyoti-Trataka on intraocular pressure, autonomic control, and blood glucose in diabetic patients with high-tension primary open-angle glaucoma: a randomized-controlled trial

OBJECTIVES

Yoga is used as a complementary therapy to control the symptomatic and complicated consequences of type 2 diabetes mellitus (T2DM) but the effect of Jyoti-Trataka yoga (gazing steadily at a 4-feet away-fixed candle flame) on the intraocular pressure (IOP), autonomic control, and fasting blood glucose (FBG) in T2DM patients with high-tension primary open-angle glaucoma (POAG) was not previously investigated. This study aimed to search the effect of Jyoti-Trataka on IOP, systolic blood pressure (SBP), respiratory rate (RR), diastolic blood pressure (DBP), FBG, and pulse rate (PR) in T2DM patients with bilateral high-tension POAG.

METHODS

The patients with a 52- to 67-year range and body mass index below 30 kg/m² were randomly assigned to one of two 30-patient groups, study or control groups. Besides the administered oral hypoglycemic drugs by both groups, the study group only received one month of daily 55-min Jyoti-Trataka session.

RESULTS

A significant decrease (p<0.05) was identified after the comparison between the pre and post SBP, RR, DBP, FBG, IOP of both eyes, and PR in the study group while the control group exhibited no significant changes of all measures (p>0.05). In-favor-of the study group, the between-group post-treatment comparison showed a significant improvement of all measures (p<0.05).

CONCLUSIONS

Jyoti-Trataka is a good yogic complementary therapy that can be used to regulate autonomic functions, blood glucose, and IOP in T2DM patients with high-tension POAG.

Medicinal plants effective in the treatment of glaucoma from the perspective of traditional Persian medicine

Traditional Persian medicine (TPM) is one of the richest medical schools in the world, which has nurtured valuable books. From Ibn Sina's law to Heravi's successful medicinal facts, all emphasize the treatment of various diseases, especially eye diseases based on herbal medicines, as well as their prevention. In this study, by reviewing the authoritative books of Traditional Persian Medicine, we are looking for medicinal plants so that they can be used in the treatment of glaucoma or glaucoma. the purpose of this study is not to express the complete cure of glaucoma, but this article seeks to classify plants that from the perspective of Traditional Persian Medicine can be used as complementary medicine alongside conventional medical treatments. Methods and Materials: This is a summative qualitative content analysis that focused on Traditional Persian Medicine (TPM) texts from 2th to 13th AH centuries. Literature was searched during centuries 4th to 13th AH, and after described of glaucoma, extracting and classifying plants. Results: The scholars of TPM have opinions in the field of recognizing, describing and treating eye diseases and defining practical words. In almost all books of general Persian PM, the diagnosis and treatment of eye diseases have been discussed. Glaucoma in Traditional Persian Medicine is called “black water”. Conclusion: Unlike other medical schools in the world, in addition to treating diseases, Persian medicine has a strong recommendation to prevent the occurrence of disease and also to strengthen the body's visual powers by using 6 principles of maintaining health along with herbal medicines"

Discovery of Novel Acetylcholinesterase Inhibitors by Virtual Screening, In Vitro Screening, and Molecular Dynamics Simulations

Alzheimer's disease is the most common neurodegenerative disease and currently poses a significant socioeconomic problem. This study describes the uses of computer-aided drug discovery techniques to identify novel inhibitors of acetylcholinesterase, a target for Alzheimer's disease. High-throughput virtual screening was employed to predict potential inhibitors of acetylcholinesterase. Validation of enrichment was performed with the DUD-E data set, showing that an ensemble of binding pocket conformations is critical when a diverse set of ligands are being screened. A total of 720 compounds were submitted for in vitro screening, which led to 25 hits being identified with IC₅₀ values of less than 50 μM. The majority of these hits belonged to two scaffolds: 1-ethyl-3-methoxy-3-methylpyrrolidine and 1H-pyrrolo[3,2-c]pyridin-6-amine both of which are noted to be promising compounds for further optimization. As various possible binding poses were suggested from molecular docking, molecular dynamics simulations were employed to validate the poses. In the case of the most active compounds identified, a critical, stable water bridge formed deep within the binding pocket was identified potentially explaining in part the lack of activity for subsets of compounds that are not able to form this water bridge.

A Review on Newer Ocular Drug Delivery Systems with an Emphasis on Glaucoma

Glaucoma is an irreversible condition resulting from the increase in intraocular pressure (IOP); which leads to permanent loss of vision with the destruction of retinal ganglion cells (RGCs). The IOP elevations are controlled in normal by the physiological flow of aqueous humour. A population with age above 40 is more susceptible to glaucoma. Other factors like gender, genetics, race etc. plays major roles in the development of the disease. Current treatment methods available for the disease includes drugs come under the classes of beta receptor blockers, carbonic anhydrase inhibitors, cholinergic agonists, prostaglandins etc. N-methyl-D-aspartate (NMDA) antagonists, inducible nitric oxide synthase (iNOS) inhibition, cytoskeletal agents, Rho-kinase inhibitors etc are few novel targets sites which are in research focus for the treatment of the disease. Developments in nanomedicine are also being evaluated for their potential in treating the growing glaucomatous population. Nanosystems are suggested to avoid the difficulties in tackling the various ocular barriers to a limit, help to decrease the instillation frequency of topical medication and can provide drug delivery in a sustained or controlled manner. This review focuses on the current and emerging treatment methods for glaucoma along with some of the nanoformulations for ocular drug delivery.

Use of complementary and alternative therapies by patients with eye diseases: a hospital-based cross-sectional study from Palestine

BACKGROUND

Generally, complementary and alternative therapies (CAT) are accepted methods of treatment by patients with various types of conditions. Their use is becoming especially prevalent among patients with eye problems even in developed countries. Thus, we aimed to determine the pattern of use of CAT in this patient population, to identify the patient characteristics associated with the use of CAT, and to assess the types of CAT used.

METHODS

A descriptive, cross-sectional study was conducted in Palestine at An-Najah National University Hospital between the time periods of October 2019 to May 2020, using questionnaire-based face to face interviews. Data were collected through convenience sampling. Patients responded to the questionnaire, which was focused on information adapted from previous research in this area, covering socio-demographic and clinical characteristics, types of CAT, source of information, and side effects on CAT use.

RESULTS

A total of 86 patients were interviewed for our study. Over two thirds, 67% reported using CAT for the specific purpose of improving their eye condition, and about one third (29.1%) received more than one therapy. The most common therapies reported were duea' (i.e. supplication) (47.1%) and herbal therapies (24.1%). It was shown that patients with bilateral involvement of their eyes were almost twice more likely to describe using CAT than patients with unilateral eye pathology (p = 0.006). Also, patients who underwent surgery as their route of treatment were significantly less likely to use CAT (p = 0.043). Most of our study participants mentioned a non-physician source as their source of information regarding CAT with family members being the most frequently mentioned (30.2%) followed by the internet (25.6%) and friends (19.8%).

CONCLUSIONS

The prevalence of CAT use among patients with eye disease is somewhat high in our study population. Because CAT may trigger adverse reactions, influence the progression of the disease, and interfere with conventional treatment, the ophthalmologist should frequently be asked patients with such diagnostics regarding the use of these therapies. Further work is required to analyze the mechanisms of action and to establish realistic guidelines for the use of these modalities.

Acupuncture for glaucoma

BACKGROUND

Glaucoma is a multi-factorial optic neuropathy characterized by an acquired loss of retinal ganglion cells at levels beyond normal age-related loss and corresponding atrophy of the optic nerve. Although many treatments are available to manage glaucoma, patients may seek complementary or alternative medicine approaches such as acupuncture to supplement their regular treatment. The underlying plausibility of acupuncture is that disorders related to the flow of Chi (traditional Chinese concept of vital force or energy) can be managed by stimulating relevant points on the body surface.

OBJECTIVES

To assess the effectiveness and safety of acupuncture compared with other treatments, no treatment, or placebo in patients with glaucoma.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Eyes and Vision Trials Register (2018, Issue 11); Ovid MEDLINE; Embase.com; the Cumulative Index to Nursing and Allied Health Literature (CINAHL); the Allied and Complementary Medicine Database (AMED); PubMed; Latin American and Caribbean Literature on Health Sciences (LILACS); ZETOC; the metaRegister of Controlled Trials (mRCT); ClinicalTrials.gov; the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP); and the National Center for Complementary and Alternative Medicine (NCCAM) website. We did not use any language or date restrictions in the search for trials. We last searched electronic databases on November 16, 2018, with the exception of NCCAM, which we last searched on July 14, 2010, and the metaRegister of Controlled Trials (mRCT), which we last searched on January 8, 2013. We handsearched Chinese medical journals at Peking Union Medical College Library in April 2007. We searched the Chinese Acupuncture Trials Register, the Traditional Chinese Medical Literature Analysis and Retrieval System (TCMLARS), the Chinese Biological Database (CBM), and the China National Knowledge Infrastructure (CNKI). We last searched Chinese electronic databases on November 19, 2018.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) in which one arm involved acupuncture treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened results, then extracted the data and assessed risk of bias for eligible trials.

MAIN RESULTS

We included three completed trials and one ongoing trial in the 2019 update of this review. The three completed trials, conducted in Taiwan and the United States, included participants with glaucoma or intraocular hypertension. The interventions investigated varied across trials. One trial compared auricular acupressure－a non-standard acupuncture technique－with the sham procedure in 33 patients. Another trial compared transcutaneous electrical nerve stimulation (TENS) with a sham procedure in 82 patients. The third trial compared 12 sessions of acupuncture on eye-points versus on non-eye-points in 22 patients. All three trials were rated at high risk of bias for at least one domain. The certainty of evidence across all outcomes was very low due to high risk of bias in at least one contributing study; substantial clinical heterogeneity and methodological heterogeneity; and imprecision of results. One trial reported change in the visual field from baseline without any between-group comparison. Because of the quantity of missing data (50%), we did not calculate a between-group comparison, as the quantitative results are difficult to interpret. All three trials reported data for estimation of reduction of intraocular pressure (IOP). However, time points of IOP measurement varied. For the trial comparing acupressure to a sham procedure, the difference in IOP reduction (measured in mm Hg) is estimated to be -3.70 (95% confidence interval [CI] -7.11 to -0.29) for the right eye and -4.90 (95% CI -8.08 to -1.72) for the left eye at four weeks, and -1.30 mm Hg (95% CI -4.78 to 2.18) for the right eye and -2.30 mm Hg (95% CI -5.73 to 1.13) for the left eye at eight weeks. For the trial comparing TENS to sham treatment, the difference reduction is estimated to be -2.81 (95% CI -3.8 to -1.84) for the right eye and -2.58 (95% CI -3.36 to -1.80) for the left eye immediately after treatment, -2.93 (95% CI -3.72 to -2.13) for the right eye and -3.56 (95% CI -4.35 to 2.78) for the left eye 30 minutes after treatment, and finally -3.61 (95% CI -4.47 to -2.75) for the right eye and -3.61 (95% -4.47 to -2.74) for the left eye. For the trial that compared acupuncture on eye-points versus non-eye-points, 11 out of 22 (50%) participants did not complete the treatment. One trial reported data for estimation of visual acuity. When acupressure is compared to sham treatment, the difference in uncorrected visual acuity (UCVA, measured in logMAR) is estimated to be -0.01 (95% CI -0.24 to 0.22) for the right eye and -0.04 (95% CI -0.27 to 0.19) for the left eye at four months, and -0.03 logMAR (95% CI -0.27 to 0.21) for the right eye and -0.16 logMAR (95% CI -0.43 to 0.11) for the left eye at eight months. The difference in best corrected visual acuity (BCVA) is estimated to be 0.10 (95% CI -0.06 to 0.26) for the right eye and 0 (95% CI -0.14 to 0.14) for the left eye at four months, and -0.04 logMAR (95% CI -0.09 to 0.17) for the right eye and -0.04 logMAR (95% CI -0.18 to 0.10) for the left eye at eight months. One trial reported progression of optic disc damage or nerve fiber layer loss without any between-group comparison. Because of the quantity of missing data (50%), we did not calculate a between-group comparison, as the quantitative results are difficult to interpret. One trial reported adverse events in two patients (out of 22) who experienced needle sensitivity. However, the study did not report between-group comparisons. Because of the quantity of missing data (50%), we did not calculate a between-group comparison, as the quantitative results are difficult to interpret.

AUTHORS' CONCLUSIONS

At this time, it is impossible to draw reliable conclusions from available data to support the use of acupuncture for treatment of patients with glaucoma. Because of ethical considerations, RCTs comparing acupuncture alone with standard glaucoma treatment or placebo are unlikely to be justified in countries where the standard of care has already been established.

Posttreatment Intervention With Lycium Barbarum Polysaccharides is Neuroprotective in a Rat Model of Chronic Ocular Hypertension

Purpose

To investigate the neuroprotective effects of Lycium barbarum polysaccharides (LBP) against chronic ocular hypertension (OHT) in rats and to consider if effects differed when treatment was applied before (pretreatment) or during (posttreatment) chronic IOP elevation.

Methods

Sprague-Dawley rats (10-weeks old) underwent suture implantation around the limbus for 15 weeks (OHT) or 1 day (sham). Four experimental groups were studied, three OHT groups (n = 8 each) treated either with vehicle (PBS), LBP pretreatment or posttreatment, and a sham control (n = 5) received no treatment. LBP (1 mg/kg) pre- and posttreatment were commenced at 1 week before and 4 weeks after OHT induction, respectively. Treatments continued up through week 15. IOP was monitored twice weekly for 15 weeks. Optical coherence tomography and ERG were measured at baseline, week 4, 8, 12, and 15. Eyes were collected for ganglion cell layer (GCL) histologic analysis at week 15.

Results

Suture implantation successfully induced approximately 50% IOP elevation and the cumulative IOP was similar between the three OHT groups. When compared with vehicle control (week 4: -23 ± 5%, P = 0.03), LBP pretreatment delayed the onset of retinal nerve fiber layer (RNFL) thinning (week 4, 8: -2 ± 7%, -11 ± 3%, P > 0.05) and arrested further reduction up through week 15 (-10 ± 4%, P > 0.05). LBP posttreatment intervention showed no significant change in rate of loss (week 4, 15: -25 ± 4.1%, -28 ± 3%). However, both LBP treatments preserved the retinal ganglion cells (RGC) and retinal functions up to week 15, which were significantly reduced in vehicle control.

Conclusions

LBP posttreatment arrested the subsequent neuronal degeneration after treatment commencement and preserved RGC density and retinal functions in a chronic OHT model, which was comparable with pretreatment outcomes.

Oculohypotensive effects of various acetozolamide nanopreparations for topical treatment of animal model-induced glaucoma and their impact on optic nerve

Acetozolamide-ACZ, carbonic anhydrase inhibitor- is still the most effective systemic drug for glaucoma treatment. Due to its limited ocular bioavailability, topical formulations are not available yet. This study introduces within the framework of nanotechnology three nanopreparations of acetozolamide for topical application, one of them is liposomal phospholipid vehicle and the other two preparations are propolis and Punica granatum (pomegranate). The hypotensive effect of these different nanopreparations in lowering the increased intraocular pressure that was induced in experimental rabbits is monitored for 130 hrs. Structural characteristics of the optic nerve dissected from all involved groups were studied by Fourier transfrom infrared spectroscopy. The obtained results indicate the impact of the topically applied acetozolamide nanopreparations in lowering the intraocular pressure to its normotensive control value. On the other hand, the optic nerve characteristics were found to be dependent on the way acetozolamide introduced. Glaucoma affects structural components that contain OH group and increases β-turns of the protein secondary structure while, reducing the content of both α-helix and Turns. In the same context, liposomal-acetozolamide and propolis nanopreparations protecting the optic nerve protein secondary structure from these changes associated with glaucoma.

Substances of Interest That Support Glaucoma Therapy

Glaucoma is a multifactorial disease in which pro-apoptotic signals are directed to retinal ganglion cells. During this disease the conventional outflow pathway becomes malfunctioning. Aqueous humour builds up in the anterior chamber, leading to increased intraocular pressure. Both of these events are related to functional impairment. The knowledge of molecular mechanisms allows us to better understand the usefulness of substances that can support anti-glaucoma therapy. The goal of glaucoma therapy is not simply to lower intraocular pressure; it should also be to facilitate the survival of retinal ganglion cells, as these constitute the real target tissue in this disease, in which the visual pathway is progressively compromised. Indeed, an endothelial dysfunction syndrome affecting the endothelial cells of the trabecular meshwork occurs in both normal-tension glaucoma and high-tension glaucoma. Some substances, such as polyunsaturated fatty acids, can counteract the damage due to the molecular mechanisms—whether ischemic, oxidative, inflammatory or other—that underlie the pathogenesis of glaucoma. In this review, we consider some molecules, such as polyphenols, that can contribute, not only theoretically, to neuroprotection but which are also able to counteract the metabolic pathways that lead to glaucomatous damage. Ginkgo biloba extract, for instance, improves the blood supply to peripheral districts, including the optic nerve and retina and exerts a neuro-protective action by inhibiting apoptosis. Polyunsaturated fatty acids can protect the endothelium and polyphenols exert an anti-inflammatory action through the down-regulation of cytokines such as TNF-α and IL-6. All these substances can aid anti-glaucoma therapy by providing metabolic support for the cells involved in glaucomatous injury. Indeed, it is known that the food we eat is able to change our gene expression.

Cannabinoids for treatment of glaucoma

PURPOSE OF REVIEW

The purpose of this article is to review the current status of cannabis in the treatment of glaucoma, including the greater availability of marijuana in the USA.

RECENT FINDINGS

The potency of marijuana, as measured by the concentration of Δ-tetrahydrocannabinol, has increased from ∼2 to 3% in the 1970s to ∼20% today. Many US states have passed laws allowing either medicinal or recreational use of marijuana.

SUMMARY

The pharmacology of marijuana and its effect on intraocular pressure has not changed since the research in the 1970s and 1980s. Marijuana is an effective ocular hypotensive agent. However, cardiovascular and neurological effects are observed at the same dose, and may theoretically reduce the beneficial effect of lowering intraocular pressure by reducing ocular blood flow. The clinician must be cognizant of this potential in diagnosis, prognosis, and therapy.

Medical marijuana patient counseling points for health care professionals based on trends in the medical uses, efficacy, and adverse effects of cannabis-based pharmaceutical drugs

The purpose of this report is to present a review of the medical uses, efficacy, and adverse effects of the three approved cannabis-based medications and ingested marijuana. A literature review was conducted utilizing key search terms: dronabinol, nabilone, nabiximols, cannabis, marijuana, smoke, efficacy, toxicity, cancer, multiple sclerosis, nausea, vomiting, appetite, pain, glaucoma, and side effects. Abstracts of the included literature were reviewed, analyzed, and organized to identify the strength of evidence in medical use, efficacy, and adverse effects of the approved cannabis-based medications and medical marijuana. A total of 68 abstracts were included for review. Dronabinol's (Marinol) most common medical uses include weight gain, chemotherapy-induced nausea and vomiting (CINV), and neuropathic pain. Nabiximol's (Sativex) most common medical uses include spasticity in multiple sclerosis (MS) and neuropathic pain. Nabilone's (Cesamet) most common medical uses include CINV and neuropathic pain. Smoked marijuana's most common medical uses include neuropathic pain and glaucoma. Orally ingested marijuana's most common medical uses include improving sleep, reducing neuropathic pain, and seizure control in MS. In general, all of these agents share similar medical uses. The reported adverse effects of the three cannabis-based medications and marijuana show a major trend in central nervous system (CNS)-related adverse effects along with cardiovascular and respiratory related adverse effects. Marijuana shares similar medical uses with the approved cannabis-based medications dronabinol (Marinol), nabiximols (Sativex), and nabilone (Cesamet), but the efficacy of marijuana for these medical uses has not been fully determined due to limited and conflicting literature. Medical marijuana also has similar adverse effects as the FDA-approved cannabis-based medications mainly consisting of CNS related adverse effects but also including cardiovascular and respiratory related adverse effects. Finally, insufficient higher-order evidence to support the widespread use of medical marijuana was found, but a limited amount of moderate-level evidence supports its use in pain and seizure management.

Preserving neural retina through re-emerging herbal interventions

Eye related diseases such as glaucoma, diabetic retinopathy, cataract, conjunctivitis are very common worldwide. With the current scenario India will be among the top five countries in the number of glaucoma cases. Limited discovery of successful drugs for the treatment of such diseases led scientists to look towards the use of conventional sources for treatment. Herbal extracts from Ayurveda have remained an important part of treatment regime in many parts of world even today. For this reason, local herbs possessing curative properties are still being used by local inhabitants due to its anti-inflammatory and antioxidant properties. Because retinal damage involves alterations in oxidative enzymes, blood flow changes and increase in apoptotic signals, herbal extracts are being tested for their ability to moderate antioxidant machinery and trigger neuroprotective pathways. The present review summarizes some of such herbal extracts which have been tested for their neuroprotective role in eye related diseases. The active components that exert neuroprotective effects have also been discussed along with possible mechanisms of action.

Canadian ophthalmologists' opinions concerning complementary and alternative medicine (CAM) use in glaucoma

PURPOSE

Our goal is to investigate the opinion and practice pattern of Canadian ophthalmologists regarding the use of and recommendations for complementary and alternative medicine (CAM) for their glaucoma patients.

METHODS

Institutional review board approval for this prospective, cross-sectional survey was obtained from the Research Ethics Board of Sunnybrook Health Sciences Centre. The survey was sent to all ophthalmologists in Canada electronically through the e-mail lists of 4 ophthalmology associations.

RESULTS

A total of 241 ophthalmologists representing all provinces in Canada responded to the questionnaire. Twenty-two percent felt that CAM does have a role in glaucoma therapy with specialists being more likely to believe there is a role (P<0.05). Of the total respondents, 26% ask their patients if they use CAM with those in practice for <20 years more likely to encourage use (P<0.05). Of the respondents, 9% recommend CAM and if an ophthalmologist was in practice for <20 years he/she was significantly more likely to recommend CAM (P<0.01). Respondents (62%) in general do not discourage CAM with younger ophthalmologists (younger than 50 y, P<0.02) and ophthalmologists in practice for <20 years (P<0.05) being less likely to discourage CAM use. Respondents (41%) believe that CAM rarely ever affects compliance with ophthalmologists from an urban practice (P<0.01) and academic practice (P<0.05) more likely to deny effect on compliance. Respondents believe that CAM sometimes (46%) results in patient morbidity with ophthalmologists being in practice for <20 years believing that morbidity is less likely (P<0.05).

CONCLUSION

A substantial minority of respondents believe that CAM has a role in glaucoma therapy, recommend its use, and ask their patients if they use CAM. Younger doctors are more likely to encourage alternatives; those in practice for <20 years are more likely to ask about alternative medicine use, recommend its use, and believe that morbidity usually does not result from the use of alternative treatments.

Efficacy and safety of 1% forskolin eye drops in open angle glaucoma - An open label study

PURPOSE

Current treatment for glaucoma includes beta-blockers and prostaglandin analogues which have their own disadvantages. Thus a need exists for new ocular hypotensive agents that are more efficacious and have fewer side effects. Therefore, forskolin eye drops 1%, through herbal product; a clinical trial was carried out for the safety and efficacy in the treatment of open angle glaucoma.

METHODS

Ninety adult male/female patients of 18-60 years of age, of either sex, suffering from open angle glaucoma with an intraocular pressure (IOP) of more than 24 mm Hg were enrolled in the study. Patients were advised to instill 2 drops thrice a day (8:00 h, 14:00 h and 20:00 h) and tonometric readings were recorded on baseline visit and on Visit 2, i.e. end of 1st week, Visit 3-2nd week, Visit 4-3rd week, and Visit 5-4th week. The reduction in IOP across each time point from untreated baseline visit and reduction in IOP across various study visits were measured.

RESULTS

The mean (95% CI) difference in reduction in IOP was 4.5 mm Hg (P < 0.05) in the right eye and was 5.4 mm Hg (p < 0.05) in the left eye from baseline visit (Visit 1) to final visit (Visit 5).

CONCLUSIONS

Forskolin 1% eye drops can be a safe alternative to beta blockers in glaucoma patients having concomitant asthma.

Salvia miltiorrhiza extracts protect against retinal injury in a rat glaucoma model

Glaucoma is a serious progressive degenerative disorder of the eye that leads to the continuous loss of retinal ganglion cells. Traditional Chinese medicine provides an important source for new drug screening and identification. The present study used Salvia miltiorrhiza (Danshen) extracts to examine the potential neuroprotective effects for the eye in a rat model of experimental glaucoma. The results of the study indicated that Salvia miltiorrhiza extracts were unable to prevent intraocular pressure increase in the laser-induced glaucoma model, but the treatment did reduce cell loss during glaucoma progression. Therefore, the results provide the basis for the development of a novel therapeutic agent that exhibits neuroprotective effects against glaucoma. In the future, further studies are required to purify the extracts and determine the effective bioactive components of Salvia miltiorrhiza.

The effect of low-concentration atropine combined with auricular acupoint stimulation in myopia control

OBJECTIVES

To compare the effect of myopia control between patients treated with low-concentration atropine eye drops combined with auricular acupoint stimulation and those treated with atropine alone.

DESIGN AND SETTINGS

Single-blinded randomized controlled clinical trial in a regional teaching hospital.

INTERVENTIONS

The patients received either topical 0.125% atropine nightly plus auricular acupoint stimulation (0.125A + ACU group) or topical 0.125% atropine alone nightly (0.125A group).

MAIN OUTCOME MEASURES

The changes in spherical equivalent (SE), axial length (AL), anterior chamber depth (ACD), and intraocular pressure (IOP) per year were compared between the two groups.

RESULTS

Seventy-three of 110 total patients (66.4%) completed at least 6 months of follow-up. Patients in the 0.125A + ACU group had less myopic progression and AL elongation (-0.41 diopter and 0.24 mm/year) than those in the 0.125A group (-0.66 diopter and 0.32 mm/year) (mean follow-up 14.7 months, p < 0.0001 and p = 0.02, respectively). The ACD increased more in the 0.125A + ACU group than in the 0.125A group (0.076 mm vs. 0.023 mm/year, p = 0.0004). IOP decreased more in the 0.125A + ACU group than in the 0.125A group (-1.01 mmHg vs. -0.13 mmHg/year, p = 0.007). A decrease of 1 mmHg of IOP correlated with a decrease of myopic progression of 0.021 diopter/year (p = 0.006).

CONCLUSIONS

Patients treated with 0.125% atropine eye drops plus auricular acupoint stimulation had less myopic progression, less axial length elongation, more anterior chamber deepening, and greater IOP reductions than those treated with 0.125% atropine alone. Auricular acupoint stimulation in combination with low-concentration topical atropine was beneficial for myopia control.

Lipid peroxidation: pathophysiological and pharmacological implications in the eye

Oxygen-derived free radicals such as hydroxyl and hydroperoxyl species have been shown to oxidize phospholipids and other membrane lipid components leading to lipid peroxidation. In the eye, lipid peroxidation has been reported to play an important role in degenerative ocular diseases (age-related macular degeneration, cataract, glaucoma, diabetic retinopathy). Indeed, ocular tissues are prone to damage from reactive oxygen species due to stress from constant exposure of the eye to sunlight, atmospheric oxygen and environmental chemicals. Furthermore, free radical catalyzed peroxidation of long chain polyunsaturated acids (LCPUFAs) such as arachidonic acid and docosahexaenoic acid leads to generation of LCPUFA metabolites including isoprostanes and neuroprostanes that may further exert pharmacological/toxicological actions in ocular tissues. Evidence from literature supports the presence of endogenous defense mechanisms against reactive oxygen species in the eye, thereby presenting new avenues for the prevention and treatment of ocular degeneration. Hydrogen peroxide (H2O2) and synthetic peroxides can exert pharmacological and toxicological effects on tissues of the anterior uvea of several mammalian species. There is evidence suggesting that the retina, especially retinal ganglion cells can exhibit unique characteristics of antioxidant defense mechanisms. In the posterior segment of the eye, H2O2 and synthetic peroxides produce an inhibitory action on glutamate release (using [(3)H]-D-aspartate as a marker), in vitro and on the endogenous glutamate and glycine concentrations in vivo. In addition to peroxides, isoprostanes can elicit both excitatory and inhibitory effects on norepinephrine (NE) release from sympathetic nerves in isolated mammalian iris ciliary bodies. Whereas isoprostanes attenuate dopamine release from mammalian neural retina, in vitro, these novel arachidonic acid metabolites exhibit a biphasic regulatory effect on glutamate release from retina and can regulate amino acid neurotransmitter metabolism without inducing cell death in the retina. Furthermore, there appears to be an inhibitory role for neuroprostanes in the release of excitatory amino acid neurotransmitters in mammalian retina. The ability of peroxides and metabolites of LCPUFA to alter the integrity of neurotransmitter pools provides new potential target sites and pathways for the treatment of degenerative ocular diseases.

Acupuncture for glaucoma

BACKGROUND

Glaucoma is a multifactorial optic neuropathy characterized by an acquired loss of retinal ganglion cells at levels beyond normal age-related loss and corresponding atrophy of the optic nerve. Although many treatments are available to manage glaucoma, glaucoma is a chronic condition. Some patients may seek complementary or alternative medicine approaches such as acupuncture to supplement their regular treatment. The underlying plausibility of acupuncture is that disorders related to the flow of Chi (the traditional Chinese concept translated as vital force or energy) can be prevented or treated by stimulating relevant points on the body surface.

OBJECTIVES

The objective of this review was to assess the effectiveness and safety of acupuncture in people with glaucoma.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 12), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to January 2013), EMBASE (January 1980 to January 2013), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to January 2013), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (January 1937 to January 2013), ZETOC (January 1993 to January 2013), Allied and Complementary Medicine Database (AMED) (January 1985 to January 2013), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov), the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en) and the National Center for Complementary and Alternative Medicine web site (NCCAM) (http://nccam.nih.gov). We did not use any language or date restrictions in the search for trials. We last searched the electronic databases on 8 January 2013 with the exception of NCCAM which was last searched on 14 July 2010. We also handsearched Chinese medical journals at Peking Union Medical College Library in April 2007.We searched the Chinese Acupuncture Trials Register, the Traditional Chinese Medical Literature Analysis and Retrieval System (TCMLARS), and the Chinese Biological Database (CBM) for the original review; we did not search these databases for the 2013 review update.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) in which one arm of the study involved acupuncture treatment.

DATA COLLECTION AND ANALYSIS

Two authors independently evaluated the search results and then full text articles against the eligibility criteria. We resolved discrepancies by discussion.

MAIN RESULTS

We included one completed and one ongoing trial, and recorded seven trials awaiting assessment for eligibility. These seven trials were written in Chinese and were identified from a systematic review on the same topic published in a Chinese journal. The completed trial compared auricular acupressure-a nonstandard acupuncture technique-with the sham procedure for glaucoma. This trial is rated at high risk of bias for masking of outcome assessors, unclear risk of bias for selective outcome reporting, and low risk of bias for other domains. The difference in intraocular pressure (measured in mm Hg) in the acupressure group was significantly less than that in the sham group at four weeks (-3.70, 95% confidence interval [CI] -7.11 to -0.29 for the right eye; -4.90, 95% CI -8.08 to -1.72 for the left eye), but was not statistically different at any other follow-up time points, including the longest follow-up time at eight weeks. No statistically significant difference in visual acuity was noted at any follow-up time points. The ongoing trial was registered with the International Clinical Trials Registry Platform (ICTRP) of the World Health Organization. To date this trial has not recruited any participants.

AUTHORS' CONCLUSIONS

At this time, it is impossible to draw reliable conclusions from available data to support the use of acupuncture for the treatment of glaucoma. Because of ethical considerations, RCTs comparing acupuncture alone with standard glaucoma treatment or placebo are unlikely to be justified in countries where the standard of care has already been established. Because most glaucoma patients currently cared for by ophthalmologists do not use nontraditional therapy, clinical practice decisions will have to be based on physician judgments and patient preferences, given this lack of data in the literature. Inclusion of the seven Chinese trials in future updates of this review may change our conclusions.

Acetylcholinesterase inhibitors: pharmacology and toxicology

Acetylcholinesterase is involved in the termination of impulse transmission by rapid hydrolysis of the neurotransmitter acetylcholine in numerous cholinergic pathways in the central and peripheral nervous systems. The enzyme inactivation, induced by various inhibitors, leads to acetylcholine accumulation, hyperstimulation of nicotinic and muscarinic receptors, and disrupted neurotransmission. Hence, acetylcholinesterase inhibitors, interacting with the enzyme as their primary target, are applied as relevant drugs and toxins. This review presents an overview of toxicology and pharmacology of reversible and irreversible acetylcholinesterase inactivating compounds. In the case of reversible inhibitors being commonly applied in neurodegenerative disorders treatment, special attention is paid to currently approved drugs (donepezil, rivastigmine and galantamine) in the pharmacotherapy of Alzheimer's disease, and toxic carbamates used as pesticides. Subsequently, mechanism of irreversible acetylcholinesterase inhibition induced by organophosphorus compounds (insecticides and nerve agents), and their specific and nonspecific toxic effects are described, as well as irreversible inhibitors having pharmacological implementation. In addition, the pharmacological treatment of intoxication caused by organophosphates is presented, with emphasis on oxime reactivators of the inhibited enzyme activity administering as causal drugs after the poisoning. Besides, organophosphorus and carbamate insecticides can be detoxified in mammals through enzymatic hydrolysis before they reach targets in the nervous system. Carboxylesterases most effectively decompose carbamates, whereas the most successful route of organophosphates detoxification is their degradation by corresponding phosphotriesterases.

Relationship between complementary/alternative treatment use and illicit drug use among a cohort of women with, or at risk for, HIV infection

OBJECTIVES

Two of the most pressing public health challenges in the United States are treating human immunodeficiency virus (HIV) infection and illegal substance use. High rates of complementary and alternative medicine (CAM) use have been reported by individuals who suffer from both of these diseases. The goal of this study was to examine the relationship between CAM use and illegal substance use in a cohort of women with HIV or at risk for HIV disease. Based on previous research, it was hypothesized that CAM use may decrease substance use.

DESIGN

This was a longitudinal cohort study.

SUBJECTS

The subjects comprised Women in the Women's Interagency HIV Study.

OUTCOME MEASURES

The role of CAM use in illegal substance use was examined. Due to the hierarchical structure of the dataset, logistic regression analysis adjusting for repeated measurements (generalized estimating equation model) was carried out to assess associations of CAM use and illicit drug use.

RESULTS

There were 2176 women included in the analysis. After excluding for marijuana use, CAM use was associated with less drug use (odds ratio 0.82; 95% confidence interval: 0.73, 0.90).

CONCLUSIONS

The results supported our hypothesis that CAM users are more health conscious and thus less likely to use illicit drugs. Future studies should target both specific drugs and CAM modalities to help finalize this association.

Short-Term Effect of Acupuncture on Intraocular Pressure in Healthy Subjects

Purpose

To evaluate the short-term effect of acupuncture on the intraocular pressure (IOP) in healthy subjects.

Methods

A randomised controlled double-blinded trial was performed. 48 healthy volunteers (94 eyes) were randomly allocated to three groups: acupuncture group—19 subjects (38 eyes) were submitted to a 20 min session of acupuncture (GB1, GB14 and BL1); sham group—14 subjects (27 eyes) were submitted to a 20 min session of acupuncture with needles inserted in false points; and control group—15 subjects (29 eyes) who underwent no intervention. All subjects had the IOP measured by a masked investigator using Goldmann applanation tonometry immediately before intervention, as well as 20 min and 24 h after.

Results

The mean (SD) IOP in the acupuncture group was 17.9 (3.3) mm Hg at baseline, 16.4 (3.9) mm Hg at 20 min and 16.3 (3.3) mm Hg at 24 h. The mean (SD) IOP in the sham group was 18.6 (3.3) mm Hg at baseline, 17.7 (2.6) mm Hg at 20 min and 15.9 (3.6) mm Hg at 24 h. The mean (SD) IOP in the control group was 16.9 (3.5) mm Hg at baseline, 16.5 (3.8) mm Hg at 20 min and 15.8 (3.3) mm Hg at 24 h. There was no statistically significant difference in the IOP variation (post-intervention minus baseline measurements) between groups after 20 min (p=0.13) and 24 h (p=0.21).

Conclusion

Acupuncture in the studied points did not produce significant short-term effect on the IOP of healthy individuals in comparison with control groups. Clinical Trials Registration Number: NCT00639977

The association between self-reported glaucoma and ginkgo biloba use

PURPOSE

To assess the association between Ginkgo biloba extract (GBE) use and glaucoma.

METHODS

Self-reported data on the past 12 months of GBE use and the presence of glaucoma were obtained from the 2002 National Health Interview Survey, a nationally-representative population-based sample. Crude and adjusted associations between GBE use and glaucoma were estimated.

RESULTS

Those who reported having glaucoma were 26% less likely to report GBE use; however, this was not statistically significant. After adjustment for potentially confounding demographic and medical characteristics, there was no difference in GBE use among those who did and did not report having glaucoma.

CONCLUSIONS

The results of this study fail to support a significant relationship between GBE use over the past 12 months and having glaucoma, though this finding requires replication in a prospective study. Moreover, whether GBE is efficacious in treating glaucoma patients remains an issue for future research.

Reduced-serum vitamin C and increased uric acid levels in normal-tension glaucoma

BACKGROUND

Vitamin A, B(9), C, E, and uric acid are well-known antioxidants and may prevent age-related eye disorders. The aim of the present study was to investigate the levels of antioxidant vitamins, A, B(9), C, E, and antioxidative substance, uric acid in the serum of Japanese patients with normal-tension glaucoma and compare the results with normal controls.

METHODS

All subjects with suspicion of primary open-angle glaucoma who came to the glaucoma subspeciality clinic of Keio University Hospital were enrolled in this study. Sixty patients (28 males, 32 females; mean age +/- standard deviation: 59.9 +/- 9.8 years) with newly diagnosed primary open-angle glaucoma patients were consecutively enrolled in this study. After the diagnosis of primary open-angle glaucoma, the patients underwent 24-h IOP measurements. Forty-seven newly diagnosed consecutive normal-tension glaucoma patients (18 males, 29 females; mean age +/- standard deviation: 59.5 +/- 10.2 years) were enrolled in this study. The control subjects were recruited from subjects who came to the clinic for annual refractive check-up. The 44 consecutive control subjects of the current study, (16 males, 28 females; 62.7 +/- 14.8 years) did not have any ocular diseases. The serum levels of vitamins A, B(9), C, E, and uric acid were measured. The values were compared between the normal-tension glaucoma and control groups by the Mann-Whitney U test.

RESULTS

Serum levels of vitamin C were significantly lower in normal-tension glaucoma patients than in normal healthy controls (P = 0.04; normal-tension glaucoma; 4.6 +/- 4.0 microg/ml control; 6.3 +/- 3.9 microg/ml). Uric acid level was significantly higher in normal-tension glaucoma patients than in controls (P = 0.01; normal-tension glaucoma; 5.8 +/- 1.5 mg/dl control; 4.9 +/- 1.4 mg/dl). No statistically significant difference was seen in vitamin A (P = 0.41; normal-tension glaucoma; 82.1 +/- 26.7 microg/dl control; 77.1 +/- 30.1 microg/dl), B(9) (P = 0.37; normal-tension glaucoma; 8.7 +/- 4.3 ng/ml control; 8.0 +/- 3.1 ng/ml)and E (P = 0.83; normal-tension glaucoma; 1.5 +/- 0.6 control; 1.5 +/- 0.6) levels between normal-tension glaucoma and control groups.

CONCLUSION

Normal-tension glaucoma patients had lower serum levels of vitamin C and increased levels of uric acid. These observations may pave the way for possible alternative treatment for normal-tension glaucoma.

LONG-TERM EFFECTS OF MILD EXERCISE ON INTRAOCULAR PRESSURE IN ATHLETES AND SEDENTARY SUBJECTS

The long-term effects of acute submaximal exercise on intraocular pressures (IOPs) of right-and left-eyes and recovery times to basement levels of IOP in postexercise periods in sedentary and physically fit subjects were investigated. Twenty-five sedentary and 24 physically fit subjects, ranging in age 17 to 22 years, participated. Intraocular pressures were measured by a pneumotonometer. Measurements were taken in the morning at about nine (at rest) and immediately, 30 min and 2 h after acute submaximal exercise. In sedentary subjects, IOPs of both right- and left-eyes decreased immediate after exercise, but, these decreases in both eyes continued 30 min and 2 h after exercise. In physically fit subjects, IOPs of both right- and left-eyes increased immediate after exercise, but decreased after 30 min exercise compared to basement levels, and this decrease continued 2 h after exercise. Acute submaximal exercise decreased IOPs of right and left eyes over a period 2 h in sedentary and physically fit subjects. IOP reducing after exercise was different between right- and left-eyes in sedentary subjects. These results suggest that exercise can be used in ocular hypertension treatment.

Acupuncture for glaucoma

BACKGROUND

Glaucoma is a multifactorial optic neuropathy in which there is an acquired loss of retinal ganglion cells at levels beyond normal age-related loss and corresponding atrophy of the optic nerve. Although there are many existing treatments, glaucoma is a chronic condition. Some patients may seek complementary or alternative medicine such as acupuncture to supplement their regular treatment. The underlying plausibility of acupuncture is that disorders related to the flow of Chi (the traditional Chinese concept translated as vital force or energy) can be prevented or treated by stimulating the relevant points on the body surface.

OBJECTIVES

The objective of this review was to assess the effectiveness and safety of acupuncture in people with glaucoma.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, ZETOC, CINAHL, AMED (Allied and Complementary Medicine Database), TCMLARS (Traditional Chinese Medical Literature Analysis and Retrieval System), CBM (Chinese Biological Database), the Chinese Acupuncture Trials Register and the National Center for Complementary and Alternative Medicine web site (http://nccam.nih.gov/) in February 2006. We ran update searches of CENTRAL, MEDLINE, EMBASE, LILACS and ZETOC in July 2007. We also handsearched Chinese medical journals at Peking Union Medical College Library in April 2007.

SELECTION CRITERIA

We planned to include randomized and quasi-randomized clinical trials in which one arm of the study involved acupuncture treatment.

DATA COLLECTION AND ANALYSIS

Two authors independently evaluated the search results against the inclusion and exclusion criteria. Discrepancies were resolved by discussion.

MAIN RESULTS

We found no randomized clinical trials and subsequently no meta-analysis was conducted. Evidence was limited to a few case series of small sample size.

AUTHORS' CONCLUSIONS

At this time, it is impossible to draw reliable conclusions from the available data to support the use of acupuncture for the treatment of glaucoma. Since most glaucoma patients currently cared for by ophthalmologists do not use non-traditional therapy, the clinical practice decisions will have to be based on physician judgement and patients' value given this lack of data in the literature.

Influence of Ginkgo biloba on ocular blood flow

PURPOSE

To investigate the effect of Ginkgo biloba extract (EGb761) on ocular blood flow.

METHODS

This randomized, double-masked, placebo-controlled, two-way crossover study included 15 healthy male volunteers. Measurements were taken with laser Doppler flowmetry, laser Doppler velocimetry, a retinal vessel analyser, laser interferometry and applanation tonometry, before and up to 3 hours after oral intake of 240 mg EGb761.

RESULTS

At baseline, no significant differences in ocular and systemic haemodynamic parameters were observed between the two study days. Ginkgo biloba significantly decreased retinal venous diameters (p < 0.05 versus baseline), but there was no significant difference between the two groups. Blood pressure, retinal arterial and venous diameters, choroidal blood flow, fundus pulsation amplitude, intraocular pressure and retinal blood flow remained unchanged in both groups and did not differ between groups. Optic nerve head blood flow significantly increased in response to Ginkgo biloba (p < 0.002 versus baseline), but this effect was not significant compared with that of placebo.

CONCLUSIONS

The results of this study indicate that a single administration of Ginkgo biloba does not influence ocular blood flow to a relevant degree. Whether the drug may influence ocular blood flow in patients with ocular vascular disease after longterm treatment remains to be investigated in a randomized, placebo-controlled clinical trial.

Estudo da utilização no pré-operatório de medicamentos ou drogas fitoterápicas que alteram a coagulação sangüínea

OBJETIVO: Verificar com que freqüência medicamentos e\ou drogas fitoterápicas que interferem na coagulação sangüínea são utilizados por pacientes que serão submetidos à intervenção cirúrgica e cujo uso não é relatado ao cirurgião; ou quando este é informado não se recomenda a sua interrupção antes da operação. MÉTODO: Estudo quantitativo com variáveis qualitativas, transversal, sobre o uso de medicamentos (AAS e Vitamina E) e fitoterápicos (Ginkgo biloba, Alho, Ginseng e Gengibre) por parte de 416 pacientes em programação pré-operatória. Desenvolvido no Hospital Universitário de Taubaté (HUT) no Hospital Regional de Taubaté (HRT) e em um Consultório Particular de Cirurgia Plástica. Estes dados foram obtidos por meio de questionário com perguntas relacionadas ao uso ou não das drogas referidas no último ano e nos 10 dias que antecediam a operação, se o cirurgião foi informado do fato e se houve recomendação médica para a sua suspensão. RESULTADOS: do total pesquisado 58,89% não fizeram uso de alguma das drogas em questão, 39% as usaram no último ano e 13,83% usaram nos últimos 10 dias. O AAS foi o medicamento mais utilizado e dentre os fitoterápicos, o Ginkgo biloba. Do total pesquisado 73,69% dos pacientes não informaram ao cirurgião o uso destas drogas. CONCLUSÕES: Na população estudada é elevada a porcentagem do uso de drogas que interferem na coagulação sanguínea, sendo as mais utilizadas o AAS, a vitamina E e o Ginkgo biloba. A maioria dos pacientes pesquisados não informou ao cirurgião a sua utilização. Deve-se enfatizar a necessidade de pesquisar o uso dessas drogas no pré-operatório, com o objetivo de reduzir possíveis complicações hemorrágicas per e pós-operatórias, pelas suas complicações médicas e eventuais implicações legais.

Visual Function with Acupuncture Tested by Visual Evoked Potential

Visual evoked potential (VEP) testing is used frequently and is an important ophthalmologic physiological test to examine visual functions objectively. The VEP is a complicated waveform consisting of negative waveform named N75 and N135, and positive waveform named P100. Delayed P100 latency and greatly attenuated amplitude on VEP are known characteristics for diagnosing optic nerve disease. Acupuncture has been used to treat wide clinical symptoms with minimal side effects. The confirmation of the efficacy of acupuncture generally relies on subjective symptoms. There is not much scientific evidence supporting the acupuncture treatments for eye diseases up to today. However, the VEP test can evaluate objectively and numerically the efficacy of the treatment by the acupuncture. We analyzed 19 healthy subjects (38 eyes). The P100 latencies in the group of less than 101.7 msec (total average) before acupuncture stimulations were not different than those after treatment (98.2 +/- 3.0 msec, 98.2 +/- 4.0 msec, respectively, p = 0.88, n = 17), but the latencies in those subjects with longer or equal to 101.7 msec were statistically different after acupuncture (104.6 +/- 2.8 msec, 101.9 +/- 3.7 msec, respectively, p = 0.006, n = 21). These results show that the acupuncture stimulation contributes to the P100 latencies of pattern reversal (PR)-VEP to some subjects who have delayed latencies, and this electrophysiological method is a valuable technique in monitoring the effectiveness of acupuncture therapy in the improvements of visual functions. The purpose of this study is to evaluate the physiological effects by acupuncture stimulations using PR-VEP in normal subjects.

Evidence for the use of nutritional supplements and herbal medicines in common eye diseases

PURPOSE

To provide a perspective by reviewing the evidence for the role of nutritional supplements and herbal medicines in the common causes of visual impairment.

DESIGN

Retrospective literature review.

METHODS

Published studies and information found in PubMed, International Bibliographic Information of Dietary Supplements, and selected websites were reviewed for the role of nutritional and herbal medicines in the treatment of age-related macular degeneration, cataract, diabetic retinopathy, and glaucoma. The studies were evaluated systematically for their study design, study population, benefits, risks, biases, and criteria for the categorization of the level of evidence.

RESULTS

The available evidence does support the use of certain vitamins and minerals in patients with certain forms of age-related macular degeneration. For cataracts, the available evidence does not support these supplements to prevent or treat cataracts in healthy individuals. For diabetic retinopathy and glaucoma, the available evidence does not support the use of these supplements. In the category of herbal medicines, the available evidence does not support the use of herbal medicines for any of these ocular diseases.

CONCLUSION

Because of the widespread use of nutritional supplements and herbal medicines, ophthalmologists should be aware of their use so that they can inform patients properly when the supplements and herbal medicine are being used for eye disease.

Acupuncture For Patients With Glaucoma

CONTEXT

Research of the effects of one acupuncture method for patients with glaucoma, focusing on intraocular pressure (IOP) and visual acuity.

OBJECTIVE

To explore the possibility of using acupuncture for patients with glaucoma.

DESIGN

Pilot study utilizing a one-group preintervention, postintervention design.

SETTING

Eleven patients with glaucoma were recruited through advertisement at the clinic for glaucoma.

INTERVENTION

Acupuncture was carried out twice a week over 5 weeks.

OUTCOME MEASURES

IOP, visual acuity, and subjective symptoms were observed at 15 minutes before and after acupuncture once a week and in a four-week follow-up.

RESULTS

IOP was significantly improved at 15 minutes after acupuncture, at one week, two weeks, and five weeks and tended to be lower weekly. Uncorrected visual acuity was significantly improved at three weeks, four weeks, and five weeks, and best corrected visual acuity was significantly improved at five weeks. However at the four-week follow-up, significance remained only in uncorrected visual acuity.

CONCLUSIONS

Although these results should be interpreted cautiously, acupuncture can be used to supplement the conventional therapy for glaucoma.

[Patient characteristics in a tertiary glaucoma center. Circumstances of treatment and attitudes of patients]

BACKGROUND

In order to look for conceptual improvements in the practical management of patients sent to our glaucoma department, we analyzed the structures, behaviour, and knowledge about the disease in this patient group.

METHODS

Glaucoma patients who were sent for the first time to our department were included prospectively. Before being examined 129 patients were asked to answer a questionnaire concerning their individual characteristics, their behaviour, and patterns of treatment.

RESULTS

Of the patients 74% had open-angle glaucoma (including normal tension, exfoliative, and pigment glaucoma), 22% had secondary glaucoma (including neovascular, congenital, and chronic closed-angle glaucoma), and 4% had suspected glaucoma. Written documentation of previously performed intraocular pressure measurements was not available for 84% of the patients. Younger patients had significantly more knowledge about glaucoma and used more possibilities to get information about the disease than elder patients.

CONCLUSION

Education about glaucoma disease should be optimized especially for elder glaucoma patients. Documentation of intraocular pressure measurements is insufficient in our patient group.

The effects of antiglaucoma and systemic medications on ocular blood flow

Based on the body of evidence implicating ocular blood flow disturbances in the pathogenesis of glaucoma, there is great interest in the investigation of the effects of antiglaucoma drugs and systemic medications on the various ocular vascular beds. The primary aim of this article was to review the current data available on the effects of antiglaucoma drugs and systemic medications on ocular blood flow. We performed a literature search in November 2002, which consisted of a textword search in MEDLINE for the years 1968-2002. The results of this review suggest that there is a severe lack of well-designed long-term studies investigating the effects of antiglaucoma and systemic medications on ocular blood flow in glaucomatous patients. However, among the 136 articles dealing with the effect of antiglaucoma drugs on ocular blood flow, only 36 (26.5%) investigated the effects of medications on glaucoma patients. Among these 36 articles, only 3 (8.3%) were long-term studies, and only 16 (44.4%) were double-masked, randomized, prospective trials. Among the 33 articles describing the effects of systemic medications on ocular blood flow, only 11 (33.3%) investigated glaucoma patients, of which only one (9.1%) was a double-masked, randomized, prospective trial. Based on this preliminary data, we would intimate that few antiglaucoma medications have the potential to directly improve ocular blood flow. Unoprostone appears to have a reproducible antiendothelin-1 effect, betaxolol may exert a calcium-channel blocker action, apraclonidine consistently leads to anterior segment vasoconstriction, and carbonic anhydrase inhibitors seem to accelerate the retinal circulation. Longitudinal, prospective, randomized trials are needed to investigate the effects of vasoactive substances with no hypotensive effect on the progression of glaucoma.

Laboratory assessment of diurnal and nocturnal ocular perfusion pressures in humans

We estimated diurnal and nocturnal levels of ocular perfusion pressure at rest in both young and older adults in a clinical sleep laboratory. Measurements of blood pressure and intraocular pressure (IOP) were obtained every 2 hours for 24 consecutive hours in 16 healthy young adults (ages 18-25 years) and 16 older adults (ages 47-74 years). In the 16-hour diurnal wake period, blood pressure and IOP were measured after a 5-minute sitting rest. In the 8-hour nocturnal period, measurements were taken with subjects in the supine position. Sitting and supine ocular perfusion pressures in the diurnal and nocturnal periods were calculated respectively based upon the blood pressure and IOP. Ocular perfusion pressure was found to be higher in the older group than in the younger group throughout the 24 hours. The peak of ocular perfusion pressure was in the nocturnal period for both groups. Within each subject group, the average nocturnal ocular perfusion pressure in the supine position was higher than the average diurnal ocular perfusion pressure in the sitting position. The diurnal-to-nocturnal increase of ocular perfusion pressure was larger in the older group than in the younger group.