1040-5488/14/9112-e298/0 VOL. 91, NO. 12, PP. e298Ye300 OPTOMETRY AND VISION SCIENCE Copyright * 2014 American Academy of Optometry CLINICAL CASE Accidental Overdose of Travoprost Denise Goodwin* and Dina H. Erickson* ABSTRACT Purpose. To report systemic symptoms after an overdose of travoprost. Case Report. We report a patient who, instead of artificial tears, inadvertently used travoprost every 15 minutes for 7 hours after LASIK (laser-assisted in situ keratomileusis) surgery. She experienced abrupt, severe abdominal cramps and sudden, severe menstrual bleeding, which subsided quickly upon discontinuation of the drug. Conclusions. Because of the few systemic adverse effects, prostaglandin analogs are widely used for the treatment of glaucoma. Travoprost should be taken once daily; therefore, overdose is extremely uncommon. Systemic prostaglandins have been found to be mediators of uterine activity and are used to induce labor and terminate pregnancies. The high dose of this topical medication, as well as the compromised cornea, makes this case unique. The unusual circumstances observed in this case greatly expand our knowledge regarding the potential adverse effects of travoprost. (Optom Vis Sci 2014;91:e298Ye300) Key Words: travoprost, bimatoprost, prostaglandin analogs, drug-related side effects, adverse reactions ince the introduction of prostaglandin analogs in the surgery. This case greatly expands our knowledge regarding the mid-1990s, they have become frontline therapy for the adverse effects and potential uses of topical prostaglandins. Streatment of glaucoma and ocular hypertension. The few systemic and ocular adverse effects, as well as the significant ability to reduce intraocular pressure (IOP), brought them to the fore- CASE REPORT front of glaucoma therapy. However, there still exist a number of ocular and systemic adverse effects that are potentially serious to A 25-year-old woman presented for her comprehensive eye the patient. examination with an interest in LASIK surgery. Her ocular and Travoprost ophthalmic solution, 0.004% (Travatan Z, Alcon medical health were unremarkable. With the intent of promoting Laboratories, Inc, Fort Worth, TX), is a topical prostaglandin eyelash growth, she had been using bimatoprost for 3 months eye drop that should be taken once per day in the evening to with minimal eyelash changes. She was given a sample bottle of help reduce IOP. Although not indicated for eyelash growth, travoprost to use at night on the base of her lashes to determine if travoprost has been shown to cause thickening and lengthening of it had better efficacy. However, she was told to discontinue the eyelashes.1Y3 bimatoprost for 4 weeks before the LASIK surgery and to not start Bimatoprost ophthalmic solution, 0.03% (Latisse, Allergan, travoprost until after her 1-week postoperative examination. Inc, Irvine, CA), another topical prostaglandin, is applied to the Bilateral LASIK surgery was uneventful. At the 1-day postop- base of the upper lashes at night to make the eyelashes longer and erative examination, the corneal flap was well placed with minimal darker. Although the commercially available concentration has fluorescein staining around the edge of the wound. It was verified recently been decreased from 0.03 to 0.01%, bimatoprost 0.03% that she was taking the prescribed prednisolone acetate 1% four ophthalmic solution (Lumigan) has also been used once daily to times per day, ciprofloxacin 0.3% four times per day, and reduce IOP. nonpreserved artificial tears every 30 to 60 minutes. Because of the nature of these medications, overdose is ex- Around 2:30 PM, 6 hours after her 1-day postoperative exam- tremely uncommon. We report systemic symptoms in a patient ination, she ran out of the artificial tears and opened what she who, instead of artificial tears, used travoprost every 15 minutes thought was a new bottle of artificial tears. This was later verified for 7 hours after LASIK (laser-assisted in situ keratomileusis) to be travoprost. The eyes continued to feel dry so she started using the drops more and more frequently. She estimated that she was instilling them in both eyes about every 10 to 15 minutes. *OD, FAAO At 5:00 PM, she experienced abrupt, severe abdominal cramps Pacific University College of Optometry, Forest Grove, Oregon (both authors). and sudden, severe menstrual bleeding. She reported that she was Optometry and Vision Science, Vol. 91, No. 12, December 2014 Copyright © American Academy of Optometry. Unauthorized reproduction of this article is prohibited. Accidental Overdose of TravoprostVGoodwin and Erickson e299 bleeding so hard that it was ‘‘dripping into the toilet.’’ She had as the compromised cornea, makes this case unusual. However, never had menstrual cramps previously, and the first day of her patients who are pregnant or trying to become pregnant should be menstruation was generally light. She also reported having a aware of the potential risks of this medication. Because systemic negative home pregnancy test the day before the LASIK procedure prostaglandins can induce abortion, travoprost should be avoided and that it was not her usual menstruating time. in pregnant women or by women attempting to become pregnant. At 9:30 PM, it was discovered that she was using the wrong If their use is necessary during pregnancy, efforts to minimize drops. At that point, more than half the 2.5-mL bottle of systemic absorption can decrease the risk of miscarriage or pre- travoprost was used. About an hour after discontinuation of mature labor. This includes correct dosing, eyelid closure, and travoprost, the symptoms began to resolve. The next morning, the punctal occlusion. abdominal pain was gone and the quantity of bleeding had nor- malized. The eyes had moderate hyperemia, consistent with the appearance of those who use prostaglandin drops for glaucoma ACKNOWLEDGMENTS treatment. The authors have received no outside financial support for this research and declare that no conflicting relationship exists for either author. DISCUSSION Received May 12, 2014; accepted September 1, 2014. Topical travoprost is a prostaglandin used in the treatment and management of glaucoma patients to lower IOP. The most common ocular side effects include conjunctival hyperemia, eye REFERENCES irritation, eyelash lengthening, iris pigmentation changes, eyelid Y 1. Al-Jazzaf AM, DeSantis L, Netland PA. Travoprost: a potent ocular pigmentation, and deepening of the upper eyelid sulcus.1 6 Less hypotensive agent. Drugs Today (Barc) 2003;39:61Y74. common but potentially more visually serious adverse effects in- 2. Li N, Chen XM, Zhou Y, Wei ML, Yao X. Travoprost compared clude anterior uveitis, cystoid macular edema, and the reactivation 4,7 with other prostaglandin analogues or timolol in patients with open- of herpes simplex keratitis. angle glaucoma or ocular hypertension: meta-analysis of randomized Very few systemic adverse effects of ophthalmic prostaglandins controlled trials. Clin Experiment Ophthalmol 2006;34:755Y64. have been reported in the literature. Chest tightness with the use of 3. Mizoue S, Nakano T, Fuse N, Iwase A, Matsumoto S, Yoshikawa K. 8 ocular prostaglandins has been reported. Other systemic adverse Travoprost with sofZia(R) preservative system lowered intraocular events include nasopharyngitis, upper respiratory tract infection, pressure of Japanese normal tension glaucoma with minimal side and headache.6 Prostaglandins are reported to have no effect on effects. Clin Ophthalmol 2014;8:347Y54. heart rate or blood pressure.1,3,9 4. Hollo G. The side effects of the prostaglandin analogues. Expert Oral, sublingual, intramuscular, and intravaginal prostaglan- Opin Drug Saf 2007;6:45Y52. dins have been found to be mediators of uterine activity.10,11 5. Netland PA, Landry T, Sullivan EK, Andrew R, Silver L, Weiner A, Prostaglandins have been used to prompt contraction of the Mallick S, Dickerson J, Bergamini MV, Robertson SM, Davis AA, uterine smooth muscle and cervical ripening during the induc- Travoprost Study Group. Travoprost compared with latanoprost and tion of labor. The prostaglandin misoprostol has been used timolol in patients with open-angle glaucoma or ocular hypertension. to terminate pregnancies by inducing labor.12 It has also been Am J Ophthalmol 2001;132:472Y84. used to complete spontaneous, incomplete miscarriage13 and 6. Parrish RK, Palmberg P, Sheu WP, XLT Study Group. A compar- dilate and soften the cervix a few hours before surgical abortion ison of latanoprost, bimatoprost, and travoprost in patients with procedures.10,14 elevated intraocular pressure: a 12-week, randomized, masked- Y Because animal studies have shown a high incidence of abortion evaluator multicenter study. Am J Ophthalmol 2003;135:688 703. when exposure is 80 times the human dose, the topical prosta- 7. Alm A, Grierson I, Shields MB. Side effects associated with glandins are classified as category C according to the US Food and prostaglandin analog therapy. Surv Ophthalmol 2008;53(Suppl. 1): S93Y105. Drug Administration.15 However, De Santis et al.15 reported that 8. Rajan MS, Syam P, Liu C. Systemic side effects of topical 9 of 10 pregnant women taking latanoprost once daily delivered latanoprost. Eye (Lond) 2003;17:442Y4. normal fetuses. One woman had an early spontaneous abor- 9. Alm A, Stjernschantz J. Effects on intraocular pressure and side tion 2 weeks after discontinuing treatment, and it was deter- effects of 0.005% latanoprost applied once daily, evening or mined that the association between latanoprost and miscarriage 16 morning. A comparison with timolol. Scandinavian Latanoprost was unlikely. Lee reports a single case of abdominal cramping Study Group. Ophthalmology 1995;102:1743Y52. caused by travoprost but not with latanoprost or unoprostone. 10. Bygdeman M. Prostaglandin analogues and their uses. Baillieres The cramping started 30 minutes after topical instillation and Clin Obstet Gynaecol 1992;6:893Y903. lasted for about 2 hours on three consecutive occasions. 11. O’Brien WF. The role of prostaglandins in labor and delivery. Peak systemic plasma concentration of travoprost occurs within Clin Perinatol 1995;22:973Y84. 30 minutes of dosing, and elimination from human plasma is 12.