Correspondence

Spontaneous Hyphema Associated with Ingestion of Ginkgo biloba Extract

N Engl J Med 1997; 336:1108April 10, 1997

Article

To the Editor:

Spontaneous bleeding from the iris into the anterior chamber of the eye is a rare problem.1 We report a case associated with the ingestion of Ginkgo biloba extract, an over-the-counter herbal medication that has recently also been linked to a spontaneous subdural hemorrhage.2,3 A 70-year-old man presented after two days of recurrent blurred vision in the right eye, with each episode lasting 15 minutes, during which he could perceive a red discoloration through his cornea. One week earlier he had begun twice-daily ingestion of a Ginkoba tablet from his health-food store. Each tablet contained 40 mg of concentrated (50:1) extract of the G. biloba tree. The patient's only other medication was aspirin (one 325-mg tablet daily), taken for three years after his coronary-artery bypass surgery. There was no history of eye trauma, ischemia, or vascular occlusion.

The physical examination was entirely normal except for a fine stream of blood oozing down from the 12 o'clock position of the margin of the iris into the inferior angle, where a layering of blood was seen on gonioscopy. The bleeding stopped spontaneously after five minutes. The patient stopped taking the ginkgo extract but continued to take daily aspirin, and there was no recurrence of bleeding over a three-month follow-up period.

G. biloba extract is marketed as a supplement to improve mental alertness and treat peripheral vascular disease. One of its components, ginkgolide B, is a potent inhibitor of platelet-activating factor, which is essential for the induction of arachidonate-independent platelet aggregation. The long-term use of the extract was recently reported to be associated with bilateral subdural hematomas and increased bleeding time in a healthy 33-year-old woman.3

This case report of a hemorrhagic complication of G. biloba ingestion suggests that its short-term use may also have antiplatelet effects. Perhaps there are additional risks if aspirin, another inhibitor of platelet aggregation, is also being ingested.

Marc Rosenblatt, M.D.
Joel Mindel, M.D., Ph.D.
Mount Sinai Hospital, New York, NY 10129

3 References

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   Rowin J, Lewis SL. Spontaneous bilateral subdural hematomas associated with chronic Ginkgo biloba ingestion. Neurology 1996;46:1775-1776
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