Summary for the Clinician

››Every follow-up visit with a glaucoma patient is a chance to underscore the importance of regular use of prescribed medications.

››Education is empowers the patient. Educational brochures and videos are useful. Have your office staff instruct patients on how to instill drops and watch them to ensure that they are doing it properly.

››Your office can provide dated medication schedules to help confused patients. Suggest linking medications to habitual daily activities.

››Simplify drug regimens as much as possible through once daily medications and combination drugs.

››Local support groups should be offered to patients to help them cope with glaucoma and to exchange ideas on how to use their medi­ cations.

››Table 30.3 provides ideas to help augment patient compliance.

References

 1. Berg JS, Dischler J, Wagner DJ, Raja JJ, Palmer-Shevlin N. Medication compliance: a healthcare problem. Ann Pharma­ cother. 1993;27(Suppl 9):S1–24.

 2. Dawn AG, Santiago-Turla C, Lee PP. Patient expectations regarding eye care focus group results. Arch Ophthalmol. 2003;121:762–8.

 3. Friedman DS, Quigley HA, Gelb L, et al. Using pharmacy claims data to study adherence to glaucoma medications: methodology of the glaucoma adherence and persistence study (GAPS). Invest Ophthalmol Vis Sci. 2007;48:5052–7.

 4. Herndon LW, Brunner TM, Rollins JN. The glaucoma research foundation pa tient survey: patient understanding of glaucoma and its treatment. Am J Ophthalmol. 2006;141: S22–7.

 5. Jackevicius CA, Mamdani M, Tu JV. Adherence in statin therapy in elderly patients with and without acute coronary syndrome. JAMA. 2002;288:462–7.

 6. Kass MA, Heuer DK, Higginbotham EJ, et al.; For Ocular Hypertension Treatment Study Group. The Ocular Hypertension Treatment Study: a randomized trial determines that topical ocular hypotensive medication delays or prevents the onset of primary open-angle glaucoma. Arch Ophthalmol. 2002;120(6):701–13.

 7. Kass MA, Meltzer DW, Gordon M, et al. Compliance with topical pilocarpine treatment. Am J Ophthalmol. 1986;101: 515–23.

 8. Kosoko O, Quigley HA, Vitale S, et al. Risk factors for noncompliance with glaucoma follow-up visits. Ophthalmology. 1998;105:2105–11.

 9. Levy G, Zamacona MK, Jusko WJ. Developing compliance

instructions for drug labeling. Clin Pharmacol Ther. 2000; 68:586–91.

10.McDonnell PJ, Jacobs MR. Hospital admissions resulting from preventable adverse drug reactions. Ann Pharmacother. 2002;36:1331–6.

11.Nordstrom B, Friedman D, Mozaffari E, Quigley H, Walker

A.Persistence and adherence with topical glaucoma therapy. Am J Ophthalmol. 2005;140:598–606.

12.Osterberg L, Blaschke T. Adherence to medication. N Engl

JMed. 2005;353:487–95.

13.Owsley C, McGwin G, Scilley K, et al. Perceived barriers to care and attitudes about vision and eye care: focus groups with older African Americans and eye care providers. Invest Ophthalmol Vis Sci. 2006;47:2797–802.

14.Patel SC, Spaeth GL. Compliance in patients prescribed eyedrops for glaucoma. Ophthal Surg. 1995;26:233–6.

15.Reardon G, Schwartz GF, Mozaffari E. Patient persistency with topical ocular hypotensive therapy in a managed care population. Am J Ophthalmol. 2004;137(Suppl 1):S3–12.

16.Senst BL, Achusim LE, Genest RP, et al. Practical approach to determining costs and frequency of adverse drug events in a health care network. Am J Health Syst Pharm. 2001;58: 1126–32.

17.Sloan FA, Brown DS, Carlisle ES, et al. Monitoring visual status: why patients do or do not comply with practice guidelines. Health Serv Res. 2004;39:1429–48.

18.Stewart WC, Konstas AG, Pfeiffer N. Patient and ophthalmologist attitudes concerning compliance and dosing in glaucoma treatment. J Ocul Pharmacol Ther. 2004;20: 461–9.

19.Tsai JC, McClure CA, Ramos SE, Schlundt DG, Pichert JW. Compliance barriers in glaucoma: a systematic classification. J Glaucoma. 2003;12:393–8.

Core Messages

››When patients inquire about the relationship between lifestyle factors and glaucoma the physician should seize upon this interaction to educate them about their disease.

››Any alternative treatment for glaucoma should, at the very least, do no harm and not detract from conventional measures to manage the condition.

››There may be activities to avoid for glaucoma patients, although more work is needed to determine if these activities predispose to glaucoma or contribute to the progression of the pre-existing disease.

››The Ocular Hypertension Treatment Study is the only trial that demonstrates the efficacy of a strategy to primarily prevent primary openangle glaucoma (POAG). There are no other proven alternative strategies to prevent the development of POAG.

››The Collaborative Normal Tension Glaucoma Study and the Early Manifest Glaucoma Study are the only trials that demonstrate the efficacy of a strategy to favorably alter the natural history of open-angle glaucoma (OAG). There are no other proven strategies to prevent the progression of OAG.

L.R. Pasquale

Department of Ophthalmology, Harvard Medical School,

243 Charles Street, Boston, MA 02114, USA

e-mail: Louis_Pasquale@meei.harvard.edu

31.1  Is There Anything the Patient

Can Do to Improve the Outcome

of Their Disease Besides Using

Conventional Treatments

(Medications and Surgery)?

When patients ask this sort of a question, seize this opportunity to bond with them. Do not dismiss such a question in a trivial manner. Such a question typically comes from newly diagnosed glaucoma patients who are in the initial phases of acquiring knowledge about their condition and learning about you, the physician. The question is usually not meant to challenge your knowledge about glaucoma. Use this question as a stepping-stone to explain the natural history of glaucoma and what one can expect from conventional therapy. If the patient senses an aloof approach from you, how will they respond if you actually recommend something invasive like a trabeculectomy, even when such a recommendation is totally appropriate? Glaucoma is a life-long condition and providing knowledgeable answers to this type of question will go a long way toward building a healthy patient–physician relationship.

When considering your response to this question, realize that you cannot dismiss an unconventional therapy that a patient may inquire about simply because there is no data that addresses the question. Relatively speaking, there are very few randomized clinical trials (RCTs) that assess the role of conventional therapy vs. observation in glaucoma. The Ocular Hypertension Treatment Study is the only RCT that assesses whether a specific strategy (lowering intraocular pressure (IOP)) prevents glaucoma and this study was performed in a population that was at high risk for developing primary open-angle glaucoma (POAG) by virtue of having

elevated IOP at baseline [1]. The European Glaucoma Prevention Study was the only other glaucoma primary prevention trial and it was placebo-controlled. It showed that when IOP lowering was limited to a specific agent (dorzolamide 2%), one could not prevent POAG among patients with ocular hypertension [2]. The only RCTs that assessed the role of conventional therapy in retarding disease progression are The Collab­ orative Normal Tension Glaucoma Study [3] and the Early Manifest Glaucoma Trial [4]. Collectively these two studies showed that lowering IOP with medicine, laser trabeculoplasty or incisional surgery favorably alters the natural progression of open-angle glaucoma (OAG) that occurred across a spectrum of IOP. The other glaucoma RCTs assessed, if one form of IOPlowering therapy was superior to another in the management of the disease (the relevant trials include The Glaucoma Laser Trial [5], The Advanced Glaucoma Intervention Study [6], The Collaborative Initial Glau­ coma Treatment Study [7]). There are no RCTs to demonstrate if any strategy, conventional or otherwise, prevents glaucoma in a population that is not at a high risk of developing the disease.

To provide a comprehensive answer to this question one must also consider that certain lifestyle activities may elevate IOP and there are hints some of these activities could predispose to POAG in subsets of patients. Patients rarely look at the issue of lifestyle and glaucoma from this perspective. It is reasonable for clinicians to be aware of lifestyle activities that elevate IOP and understand the magnitude and duration of their ocular hypertensive effect and their potential impact on glaucoma. For example, playing high wind musical instruments that require the generation of high intrathoracic pressures can produce an IOP that is double the baseline level in a short time period [8]. Luckily IOP returns to baseline fairly quickly after playing ceases. Nonetheless, it is theoretically possible that if someone plays an instrument such as the saxophone regularly for prolonged time periods, a clinically significant increase in IOP could result. While there is no strong evidence that playing these instruments predisposes to glaucoma, it is reasonable to alert a glaucoma patient who happens to play these instruments of this effect, particularly if the patient is developing progressive disease at seemingly normal IOP.

Along a similar theme, certain yoga exercises that place the eye below the heart causes an increase in IOP

that is quite alarming [9]. As soon as the subject assumes a normal posture the IOP returns to baseline. Many glaucoma specialists have anecdotally noted cases of “normal tension glaucoma” in which a careful history revealed frequent performance of inverted position yoga exercises. These anecdotes are supported by published reports of glaucoma progression among yoga practitioners [10, 11]. Figure 31.1 illustrates the documentation of an IOP rise during a headstand performed by a yoga instructor. This particular patient sought an alternative medical opinion to confirm a diagnosis of normal tension glaucoma. In the seated position, her IOP was 10 mmHg, OU but increased to 50 mmHg OU while assuming an inverted position. Ophthalmic examination revealed glaucomatous cupping and corresponding visual field deficits. After

Fig. 31.1  Documentation of IOP readings with a Perkins tonometer in a yoga instructor with presumed “normal tension glaucoma.” This patient sought several opinions regarding glaucoma before it was discovered that she was a yoga instructor. IOP while seated was 10 mmHg but rose to 50 mmHg during inverted posture. Treatment with medical therapy blunted the IOP during head down posture positions (case courtesy of Dr. Oscar Albis, Asociación para Evitar la Ceguera en México)

initiating bimatoprost 0.004% nightly, IOP with inverted posture was in the mid-twenties and there has been no progressive optic nerve or visual field change after 4 years of follow-up. While the well-documented effect of increased IOP after assuming an inverted posture and case reports suggesting visual field worsening in yoga practitioners are intriguing, observational studies linking inverted yoga exercises and POAG are lacking. However, it pays to warn glaucoma patients about IOP elevations that are associated with inverted posture positions. Furthermore, physicians should consider prolonged performance of such activities as an occasional cause of “normal tension glaucoma” or disease progression despite seemingly excellent IOP control.

Caffeine or trimethylxanthine is a commonly ingested CNS stimulant that is generally regarded as safe by the FDA. Caffeine is consumed by a high percentage of the general public and there is generally, a fairly wide spread overall consumption reported in the general population. Caffeine is an adenosine receptor antagonist and adenosine receptors are involved in aqueous humor dynamics [12, 13]. Most studies [14–18] with some exceptions [19, 20] demonstrate that after caffeine consumption from beverages such as caffeinated coffee there is a modest increase of IOP (~2 mmHg) that lasts for about 2 h. In a large prospective observational study, Kang and colleagues found that while caffeine consumption did not increase risk of POAG, overall, there was an increased risk for high tension POAG among those with a positive family history of glaucoma [21]. While this finding requires confirmation, it suggests that POAG subjects with a family history for the disease may want to examine their caffeine consumption pattern as a way to modify their IOP while also adhering to conventional therapy as suggested by their treating ophthalmic physician.

Summary for the Clinician

››When patients ask about alternative therapies for their glaucoma it should be looked upon as an opportunity to educate the patient about glaucoma.

››Certain lifestyle choices – playing high-resistance wind instruments, practicing Yoga, and consuming caffeine – may have effects on IOP.

31.2  When a Patient Asks About

the Effect of Lifestyle on Glaucoma, How Can I Answer this with Regard to Exercise, Smoking, Alcohol,

and Diet?

There are many studies regarding how specific lifestyle factors affect IOP and there are some high quality cross sectional and prospective studies that assess the relation between selected lifestyle behaviors and OAG. Indisputably IOP is a strong risk factor for OAG and modifying IOP with conventional therapy can alter the natural course of the disease. Thus another objective in addressing patient-related questions regarding lifestyle and glaucoma, is, to be generally knowledgeable of the literature regarding the relation between specific lifestyle behaviors, IOP and glaucoma. Of course, in the absence of clinical trials, one needs to be cautious about the conclusions that can be reached from such observational studies. The literature for each of these lifestyles activities is summarized briefly below. Also specific recommendations regarding these activities in glaucoma are provided based on the existing evidence.

31.2.1  Exercise

Patients with glaucoma will frequently ask whether aerobic exercise is “good for glaucoma.” There is strong evidence that aerobic exercise lowers IOP [22–26]. Furthermore, people who are more conditioned to regular strenuous activity have lower IOP than their sedentary counterparts [27]. Isometric exercise like lifting weights may produce a small IOP increase during exertion [28] that is followed by a modest decline in IOP [29]. Currently there are no cohort studies that have evaluated the relation between exercise in any form and glaucoma. Nonetheless, moderate aerobic exercise has many health benefits and should be encouraged. Physicians often wonder if exercise will induce significant IOP elevation in pigmentary glaucoma patients, but the literature suggests this concern is not supported [30, 31]. Of course, if a pigmentary glaucoma patients report symptoms consistent