Lifestyle and Glaucoma
by Kon Zagoritis
For many years of practicing optometry, I have been asked by many glaucoma sufferers as to what causes glaucoma. The usual answer they were used to hearing is we don't know. Our research efforts have been weighted far more in the detection and management than in the causes of primary open angle glaucoma (POAG). This is the most common form of glaucoma.
I have always believed strongly in the concept of educating people, as well as being educated, to help prevent problems. This applies to any area of health, including glaucoma. In one of the ophthalmology journals1 Dr Spaeth, who is a well-known glaucoma expert, wrote an editorial outlining what he believes is the essence of an ideal health system. The title of his editorial is : Knowledge about how to care for oneself. The article brings up the important objective of a good health care system ie the empowerment of people to look after themselves through dissemination of knowledge.
Dr Spaeth talks of the lack of such broad measures to educate people to care for themselves and of a deep malaise in the medical profession for not taking a more active role in this regard.
One area that I have found has been sorely lacking in knowledge about how to care for oneself is that of POAG. How can this lack of knowledge empower anyone to care for one self and prevent glaucoma where possible?
After twenty years of working in a primary eyecare practice, where I was able to witness the initial changes towards glaucoma first-hand, I decided to write my findings on POAG as part of my requirements for my ocular therapeutics course in 2002. The main paper I have written is included here as a pdf file.
In this paper I discuss the typical course of a POAG patient over many years of standard contemporary treatment, both from a private and public hospital setting. I then discuss some principles in diagnosis before discussing the principles involved in causality. A flow-diagram is used to refer to most known or suspected factors involved in the genesis of glaucoma. Several other case examples, representative of the common lifestyle factors contributing to glaucoma, are also considered. The principles involved in the prevention of early signs of POAG can also be applied to glaucoma sufferers, as any additional help, through modification of lifestyle factors, will certainly help to reduce dependence on drugs and surgery, but also reduce the likelihood of non-responsiveness to these treatments.
I have not re-attempted a literature review on the causes of POAG since Nov 2002, when this paper was written. However, a couple of papers that I happened to come across lately are worth mentioning.
1) Direct costs of glaucoma and severity of the disease: a multinational long term study of resource utilisation in Europe.
Traverso CE, et al. Br.J.Ophthalmol 2005;89:1245-1249
In addition to the quality of life issues that are discussed in references 2&3 (of my own paper), this paper by Traverso et al demonstrates the substantial cost to the patient, if glaucoma is not prevented or atleast contained to a milder degree.
2) Possible association between heavy computer users and glaucomatous visual field abnormalities: a cross sectional study in Japanese workers. Masayuki Tatemichi et al J.Epidimiol Community Health 2004; 58:1021-1027
In my paper, I have referred to my own findings of a relationship between prolonged close work and increased IOP. I have only briefly touched on the possible mechanism that is involved. I had noticed this association in my early years of practicing as I had worked with many early presbyopes who would strain their eyes without adequate correction. The issue of near work is one of the more important aspects of my patients glaucoma assessment. Other common aspects that I assess are considered in my paper and include assessment of stress, lack of exercise and caffeine intake.
It is interesting that in the Japanese study above, out of the heavy computer users, those that had the glaucomatous changes were also the ones that had refractive errors (particularly myopia). Two important considerations are:
a) Those who become myopic are usually those who perform prolonged close work to the highest degree. (Supports finding)
b) The proposed mechanism that helps to pump aqueous out of the eye (see ref 20 in my paper), is likely to be least effective in myopes as there is little change in accommodation.
I should point out that I have observed the effect not only in myopes but also in hyperopic presbyopes. Hence it is proposed that the strain of prolonged close work induces changes (mainly to the ant ch. outflow system) that will raise IOP even in hyperopes.
Most findings that are included in my paper are based on cinical findings and not on expensive trial studies that are considered of high level evidence by the scientific community. However, as I feel very strongly about the lack of emphasis on prevention/causality in the way that glaucoma is currently approached, I have decided to write my ideas, despite the possible criticisms. Furthermore, if we are to advance in any field and in any way at all, we can't all consider simply that knowledge that has had systematic reviews of randomised controlled trials. Noone would think differently and thus no improvements could be expected.
1.Clinical and Experimental Ophthalmology 2008; 36: 5 doi: 10.1111/j.1442-9071.2008.01678.x
George L Spaeth MD Wills Eye Institute/Jefferson Medical College, Philadelphia, Pennsylvania, USA
Paper 3 - Causality of Glaucoma, written by Kon Zagoritis, ©Copyright November 2002
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