Bilateral Acute Angle Closure Related To Herbal Remedies Intake

Adrenergic receptors found on the iris sphincter and dilatator muscle are involved in iris movements. Certain herbal teas and over-the-counter (OTC) drugs are known for their impact on muscle contractions and therefore prohibited in pregnancy to avoid uterus contractions. A thorough literature review revealed the possible impact of tea ingredients Tannis and Ononis spinosa on the activity of ß-adrenergic receptors. Valeriana supposedly affects both ɑ1 and ɑ2 adrenergic receptors as well as muscarinic receptors. We present a case of bilateral acute angle closure possibly related to the herbal remedies intake.

University Eye Clinic, University Hospital “Sveti Duh”, Sveti Duh 64, Zagreb, Croatia; Faculty of Dental Medicine and Health Osijek, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia; Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia

A 55-year-old female was referred for a three-day-long headache, pain, photophobia in both eyes and progressive vision decline. The patient was otherwise healthy, taking no medication. Bilateral acute angle closure with irregular dilated pupil and circular posterior synechiae was diagnosed. The patient reported only intake of herbal tea for urinary discomfort and Valeriana OTC drug for anxiety for two weeks before the onset of symptoms.

At referral, best corrected visual acuity (BCVA) was counting fingers in the right eye and hand motion in the left eye. Right eye intraocular pressure was 43mmHg, and the left eye 49mmHg with typical clinical findings for acute angle closure. Ultrasound examination was unremarkable. Parabulbar dexamethasone was administered for four consecutive days which resolved the corneal edema. A gonioscopy confirmed the angle closure. A shallow anterior chamber, a wide, irregular pupil, an angle closure and a large intumescent lens were found on ultrasound biomicroscopy. With topical IOP lowering medication and acetazolamide orally, IOP was within the normal range.

As a precautionary measure, cessation of any herbal remedies was advised and uneventful cataract surgery was performed in both eyes. Postoperative BCVA on both eyes was 1.0 and IOP was within the normal range with topical and oral antiglaucoma therapy. The simultaneous intake of the herbal tea for urinary discomfort and Valeriana OTC drug for anxiety may have caused threatening semimydriasis and subsequent acute angle closure by their impact on different adrenoreceptor and muscarinic signaling pathways.