Letter tothe editor

doi:10.1053/rmed.2001.1164, available online at http://www.idealibrary.com on dose inhaler, not with a nebulizer, except for eight newly diagnosed COPD cases (three from group 1 and¢ve from group 2).
We assessed visual acuity, slit-lamp examination, in- The risk of exacerbating pre-existing or undiagnosed traocular pressure (IOP) and iridocorneal angles at the acute angle-closure glaucoma in patients receiving nebu- initial visit, 1 and 4 weeks later and every 3 months lized therapy with b-adrenergic agents and ipratropium each year in all patients.Visual ¢elds were also evaluated bromide (IB) for chronic obstructive pulmonary disease in the ¢rst, sixth and twelfth months.
(COPD) is well documented. Although glaucoma has None of the patients had glaucoma at the initial visit been reported in association with IB alone, case reports and one of them had a family history of glaucoma. How- suggest that an additive e¡ect of combined therapy with ever, with ophthalmologic examination we observed nebulized salbutamol and IB is responsible for precipitat- bilateral rise in IOP and defects of the visual ¢eld in three ing it . All the reports about this subject are case patients (30%) in group 1 during the follow-up. Angle reports except for the double-blind cross-over study, in narrowing was detected in two of these three patients.
which the patients who already had glaucoma were In group 2, there were bilateral rise in IOP, angle narrow- assessed to determine if nebulized salbutamol and IB ing and defects of the visual ¢eld in one patient (10%), therapy had any e¡ect on intraocular pressures To whose mother also had glaucoma. There was no signi¢- our knowledge, there is only one case report about glau- cant di¡erence in IOP increase between the two groups.
coma associated with metered-dose bronchodilator The incidence of glaucoma has been estimated as 1?2% in patients older than 40 years old However, in this study we determined that IB-salbutamol administration metered-dose IB-salbutamol combination can cause even by metered-dose inhaler can cause glaucoma in glaucoma and to compare the results with the use of three of 10 patients (30%). In the control group with for- formoterol via metered-dose inhaler as a control moterol, glaucoma was also observed in one patient with group. Twenty stable COPD patients (M/F :15/5, mean a predisposing factor, namely family history. These pre- age 57?7+12?0 years) who were admitted to our disposing factors include a family history of glaucoma, outpatient department during a period of 6 months, increasing age, female gender, congenitally small anterior were divided into two groups: 10 of them were segments as found in microcornea, nanophthalmos and treated with IB 20 mcg ^ salbutamol 100 mcg combina- tion given every 6 hours (group 1) and the others with formoterol 24 mcg bid (group 2). There was no dif- The raised intraocular pressures seem to be a topical ference between the two groups regarding the age, e¡ect of ipratropium bromide and salbutamol solution sex, duration and severity of COPD and previous use escaping from the face mask of the nebulizer, rather than of bronchodilators (data shown in part in All a systemic e¡ects of these drugs The use of bronch- the patients were using bronchodilators via a metered- odilator agents via metered-dose inhalers was also found TABLE 1. The demographic data of the study and control groups *We used the AmericanThoracic Society criteria.
to cause glaucuma in this study.The most likely possibility 2. Berdy GJ, Berdy SS, Odin LS, Hirst LW. Angle closure glaucoma to explain this is autoinoculation by a ¢nger contami- precipitated by aerosolized atropine. Arch Intern Med 1991; 151: nated with the drug or systemic absorption via the 3. Singh J, O’Brien C, Wright M. Nebulized bronchodilator therapy respiratory tract . We conclude that when metered- causes acute angle closure glaucoma in predisposed individuals.
dose bronchodilators, especially anti-cholinergic agents, are prescribed to the COPD patients who have risk 4. De Saint Jean M, Bourcier T, Borderie V, Moldovan M, Touzeau O, factors for glaucoma, ophthalmologic examinations Laroche L. Acute closure-angle glaucoma after treatment with should be done periodically. But further studies are ipratropium bromide and salbutamol aerosols.J Fr Ophtalmol 2000;23: 603^ 605.
needed to determine whether they have an e¡ect on 5. Packe GE, Cayton RM, Mashhoudi N. Nebulised ipratropium bro- mide and salbutamol causing closed-angle glaucoma. Lancet 1984;2: 691.
ASOGLU*, S. EMRE , F. BACAKOGLU* AND H. ATES 6. Humphreys DM. Acute angle closure glaucoma associated with *Department of Chest Diseases and {Ophthalmology, nebulised ipratropium bromide and salbutamol.BMJ 1992; 304: 320.
7. Malani JT, Robinson GM, Seneviratne EL. Ipratropium bromide in- duced angle closure glaucoma. N Z Med J 1982; 95: 749.
8. Kalra L, Bone MF. The e¡ect of nebulized bronchodilator therapy on intraocular pressures in patients with glaucoma.Chest 1988; 93:739^741.
9. Tuck M, Crick R.The age distribution of primary open angle glauco- ma.Ophthalmol Epidemiol 1998; 5: 173^183.
1. Hall SK. Acute angle-closure glaucoma as a complication of com- bined b-agonist and ipratropium bromide therapy in the emer-gency department. Ann Emerg Med 1994; 23: 884 ^ 887.

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