Angle closure glaucoma complicating systemic atropine use in the cardiac catheterization laboratory

A Pharmacovigilance Study of Drug-Induced Glaucoma Utilizing the Japanese Adverse Event Reporting System

Purpose

Clinically, glaucoma is a serious problem because it is asymptomatic until a relatively late stage in most cases, which can lead to delays in the diagnosis and treatment of the disease. The purpose of this study was to clarify the rank-order of the association of glaucoma with the causative drugs using a spontaneous reporting system database.

Methods

Data were extracted from the Japanese Adverse Drug Event Report database of the Pharmaceuticals and Medical Devices Agency (Japan). Based on reports of glaucoma caused by all drugs, we calculated the reporting odds ratio (ROR) and 95% confidence interval (CI) for glaucoma.

Results

Among 609 reports of adverse events corresponding to glaucoma (46%, women), the most frequently implicated drug were steroids (prednisolone, betamethasone sodium phosphate, triamcinolone acetonide, and fluorometholone), pregabalin, ranibizumab, crizotinib, tacrolimus hydrate, darbepoetin alfa, and foscarnet sodium hydrate. Among 207 reports involved in angle-closure glaucoma (86%, women), anticholinergic drug and antidepressants ranked high and showed signals. Signals were also detected in bromazepam (ROR, 69.7; 95% CI, 30.9-157.5), oral brotizolam (ROR, 16.6; 95% CI, 6.18-44.8), and oral milnacipran hydrochloride (ROR, 22.8; 95% CI, 8.46-61.4) for angle-closure glaucoma.

Conclusion

A national pharmacovigilance database enabled us to identify the drugs that frequently induce glaucoma. The likelihood of the reporting of glaucoma varied among the drugs, which should be used carefully in clinical practice to avoid it.

Updates on Genes and Genetic Mechanisms Implicated in Primary Angle-Closure Glaucoma

Primary angle-closure glaucoma (PACG) is estimated to affect over 30 million people worldwide by 2040 and is highly prevalent in the Asian population. PACG is more severe and carries three times the higher risk of blindness than primary open-angle glaucoma, thus representing a significant public health concern. High heritability and ethnic-specific predisposition to PACG suggest the involvement of genetic factors in disease development. In the recent past, genetic studies have led to the successful identification of several genes and loci associated with PACG across different ethnicities. The precise cellular and molecular roles of these multiple loci in the development and progression of PACG remains to be elucidated. Nonetheless, these studies have significantly increased our understanding of the emerging cellular processes and biological pathways that might provide more significant insights into the disease’s genetic etiology and may be valuable for future clinical applications. This review aims to summarize and update the current knowledge of PACG genetics analysis research.

Genome-wide association study identifies five new susceptibility loci for primary angle closure glaucoma

Primary angle closure glaucoma (PACG) is a major cause of blindness worldwide. We conducted a genome-wide association study (GWAS) followed by replication in a combined total of 10,503 PACG cases and 29,567 controls drawn from 24 countries across Asia, Australia, Europe, North America, and South America. We observed significant evidence of disease association at five new genetic loci upon meta-analysis of all patient collections. These loci are at EPDR1 rs3816415 (odds ratio (OR) = 1.24, P = 5.94 × 10(-15)), CHAT rs1258267 (OR = 1.22, P = 2.85 × 10(-16)), GLIS3 rs736893 (OR = 1.18, P = 1.43 × 10(-14)), FERMT2 rs7494379 (OR = 1.14, P = 3.43 × 10(-11)), and DPM2-FAM102A rs3739821 (OR = 1.15, P = 8.32 × 10(-12)). We also confirmed significant association at three previously described loci (P < 5 × 10(-8) for each sentinel SNP at PLEKHA7, COL11A1, and PCMTD1-ST18), providing new insights into the biology of PACG.

Pharmacological and environmental factors in primary angle-closure glaucoma

INTRODUCTION OR BACKGROUND

A large number of drug classes have now been reported to provoke angle closure in high-risk individuals. The mechanism of action can be generalized into three main categories: sympathomimetic, parasympatholytic and idiosyndratic reactions.

SOURCES OF DATA

This review of the ophthalmic literature provides a clinical summary of primary angle-closure glaucoma (PACG) and its management.

AREAS OF AGREEMENT

External stimuli (pharmacological and environmental) may induce acute, and more often, asymptomatic angle closure, which carries a significant risk of glaucoma.

GROWING POINTS

Whenever in doubt, patients at risk of PACG who are starting on drug therapy known to provoke angle closure or aggravate the condition should be referred for detailed gonioscopic examination of the anterior chamber by an ophthalmologist. AREAS FOR DEVELOPING RESEARCH: The use of new imaging methods such as anterior segment optical coherence tomography to assess the presence or risk of angle closure is gaining popularity, and may offer a more rapid method of identifying people who are at risk of sight loss from angle-closure glaucoma precipitated by non-ophthalmological medication.

Simultaneous multiple branch retinal artery occlusions after diagnostic cardiac catheterization

PURPOSE

We describe a 53-year-old man with a decrease in visual acuity in the left eye 2 weeks after diagnostic cardiac catheterization.

DESIGN

Interventional case report.

METHODS

A 53-year-old man with a decrease in visual acuity in the left eye 2 weeks after diagnostic cardiac catheterization underwent ophthalmoscopic, angiographic, and laboratory evaluations. Both funduscopy and fluorescein angiography confirmed the diagnosis of simultaneous multiple branch retinal artery occlusions in the left eye.

RESULTS

The left eye had a mildly positive (1+) relative afferent pupillary defect. Slit-lamp biomicroscopy was unremarkable except for 2+ nuclear cataract bilaterally. Intraocular pressure was 12 mmHg in the right eye and 11 mmHg in the left eye by applanation tonometry. Funduscopy revealed a normal right eye.

CONCLUSION

This case report of multiple branch retinal artery occlusions due to cholesterol embolus after diagnostic cardiac catheterization is extremely rare. Visual symptoms after cardiac catheterization should alert both ophthalmologists and cardiologists to this potential post-cardiac catheterization complication.

Skew deviation as a complication of cardiac catheterization

PURPOSE

To report three patients who developed diplopia and skew deviation after cardiac catheterization.

DESIGN

Interventional case series.

METHODS

Three patients complained of diplopia after cardiac catheterization for myocardial infarction (two male patients) or aortic dissection (one female patient). Examination demonstrated skew deviation in each patient.

RESULTS

Diplopia and skew deviation were mild and resolved completely in 4 months (case 1), 16 months (case 2), and 1.5 months (case 3). Sensitive signs of minor ischemic damage to the brain stem that cause such disorders are not detectable by neuroimaging.

CONCLUSION

Rarely, cardiac catheterization may be complicated by diplopia and skew deviation.

Persistent mydriasis following intravenous atropine in a neonate

A neonate whose mother had recently taken amitriptyline developed fixed dilated pupils after a modest dose of intravenous atropine. Interaction of atropine with neonatal amitriptyline levels is suggested and evidence of neonatal effects from maternal antidepressant use is examined. There were no neurological sequelae, and the neonate's pupils became reactive again after 7 h.