The Latest Advancements in Glaucoma Treatments
From the Show: UK HealthCast
Summary:
Air Date: 1/14/18
Duration: 10 Minutes
According to the Glaucoma Research Foundation, Glaucoma is a very misunderstood disease. Often people don't realize the severity or who is affected. Glaucoma is a leading cause of blindness. Joshua Evans, MD discuss the latest advances in treatment for Glaucoma. He is an Ophthalmologist with UK HealthCare.
Transcription:
Melanie Cole (Host): According to the Glaucoma Research Foundation, glaucoma is a very misunderstood disease. Often, people don’t realize the severity or who are affected. Glaucoma is a leading cause of blindness. My guest today, is Dr. Joshua Evans. He’s an Ophthalmologist, specializing in glaucoma at UK Advanced Eye Care. Welcome to the show, Dr. Evans. What is glaucoma?
Dr. Joshua Evans (Guest): Thank you, very much, for having me. It’s great to be here. Glaucoma, I think -- like you’d indicated, is very poorly misunderstood, even among glaucoma specialists. In general, glaucoma is believed to be nerve damage – optic nerve damage caused primarily – with primary open-angle glaucoma – primarily by elevated pressure inside the eye that causes damage directly to the nerve. With that, comes the loss of usually, peripheral vision first, in a slow pattern lasting most of the time over periods of years to decades. Eventually, if untreated, results in complete blindness.
Melanie: Who is at risk? Do we know?
Dr. Evans: Most of what our studies are based on, indicate a few major risk factors. Age is one. Family history is a very significant risk factor, so if anybody does have family members that have suffered from glaucoma, particularly at an early age, they are at a much higher risk. It is important that they know their family history. Having an elevated eye pressure, having a thin cornea – which is something that can be tested for at your eye doctor’s office, and there is some racial predilection, as well. African Americans and Hispanic Americans tend to be more affected by the disease, and particularly, in African Americans, it tends to be more aggressive variant glaucoma in those who do actually have glaucoma.
Melanie: So, what happens in the early stages? Are there some symptoms? As you mentioned, it can happen over a period of years, but are there things that we might notice – things that people would send up a red flag that could send them to see an ophthalmologist for testing?
Dr. Evans: There are some things, but overall, glaucoma is considered to be a silent thief of sight. But with some of the more acute versions of glaucoma like angle-closure glaucoma, you will tend to have significant pain. In the more chronic variety, you may have halos or rainbows around lights -- particularly in the twilight hours, watching TV in the dark, these types of things – with some soreness around the eyes. That can be a sign of a slightly different type of glaucoma where the drain is actually being partially occluded or plugged up.
With the regular, open-angle glaucoma variant – that’s the much more common variant – unfortunately, there are not a lot of early symptoms. The pressure tends to elevate over a period of years, and as a result, the eye just becomes accommodating to that pressure. As a result, you don’t really have these symptoms. You don’t have symptoms of pain, and because it is a peripheral vision disease primarily, most people don’t really realize they’ve lost significant vision until they come to their eye doctor and get the appropriate testing.
Melanie: What is the appropriate testing? How is it diagnosed?
Dr. Evans: Sure. There are a couple of different ways to look at it. There is the subjective testing or testing that the patient actively participates in, and there’s more objective testing where we can test them with machines or take pictures and then analyze those.
The first time you come in for a glaucoma evaluation, you can expect that you’ll get a couple of different types of testing. The biggest one is a visual field analysis where we’ll have you sit at a special machine, and the machine will test points in your peripheral visual field, and you’ll indicate whether or not you saw that point or not. By doing so, it creates a map of where there may be some vision loss and where the vision is normal. We can use that then, to guide therapeutic decisions about whether or not the disease is getting worse or it’s staying the same. On top of that, some of us still take pictures – serial pictures at the back of the eye, looking at the nerve so that we can actually then, on a yearly basis, see whether or not there have been visual changes in the nerve itself that we can see with our microscopes.
And then the third would be testing with a new machine that can actually measure the thickness of the nerve tissue as that tissue is coming together to form that optic nerve itself. By looking at that specifically for patterns of thinning and thinning overall, we can see that the thinning usually equates to damage to the optic nerve, and we can use that also as an objective measurement to follow disease progression or whether or not there is a presence of glaucoma. Sometimes, people can get sent in for glaucoma evaluation, and they may have just a normal, anatomic variant. It’s just the way they’re put together. The nerves look a little funny; they look a little bit like glaucoma, but after all of our testing, it shows that the nerve itself is fine and healthy and that they don’t actually have any glaucoma disease.
Melanie: What’s the first line of defense, Doctor, when you do detect that there is some glaucoma present? Do you start with mediational intervention, and does that slow the progression, or is this something that there is no cure? Tell us a little bit about intervention.
Dr. Evans: Sure. Well, it is important to understand that with glaucoma, unlike cataracts, it’s not reversible except in very rare instances -- it is not a reversible process. When tissue is lost – when vision is lost, it will not come back. That’s why early intervention and early diagnosis is key. When we do diagnose somebody with open-angle glaucoma or glaucoma in general, the first step is – or has been, up until recently – medication. Starting a medication, usually one that you take just once at night before you go to bed, and that usually will lower the pressure about 30%, which is what we like to see.
In the past few years, there’s been a rise of some laser procedures that can be done in place of the drops, and it works about 80% of the time. If it does work, it tends to work for a period of about one to five years. That’s great for some patients who really don’t like to use drops or have trouble using drops, arthritis, or they only have one good eye, or they don’t have anybody to help them at home. This can take the place of those drops and allow good disease control without them having to be an active participant in treating the disease themselves.
And then lastly, in some patients that come in and the disease is very advanced. Usually, the first-line-or second-line treatments of medications and lasers would not have enough of an effect that late in the disease. For those individuals then, surgery is usually the best option. Surgery, when successful then, is good at keeping the pressures as low as possible for as long as possible, usually without any drops or with very minimal drops in order to augment that.
Melanie: One of the medications might be beta blockers that you try, and people will say, “Well, I don’t have heart disease or high blood pressure,” so, what is the relationships there?
Dr. Evans: So, the beta blockers that we use – obviously, there are these beta receptors all over the body in all these different tissues. Where they’re located in the eye is in the fluid-producing part, and we use them to suppress the part of the eye that makes the fluid – that is essentially bathing the front part of the eye and the lens. When there’s too much of that fluid, the pressure goes up. We’re kind of turning down the faucet by using those beta blockers. They obviously do have many effects as well, like you had said, effects on the cardiovascular system and the respiratory system.
The drops that we use tend to have very minimal absorption into the entire body. However, patients who have asthma, or obstructive pulmonary disease, poor pulmonary function – poor lung function – we usually try to avoid beta blockers in them just because it can sometimes cause some spasm of the airways and a little bit of deterioration in respiratory status. As far as cardiovascular effects, it really doesn’t have much.
The only other effect that I’d mention is in some patients who are very, very advanced diabetics; it can sometimes cover up a little bit of those hypoglycemia symptoms. These people may not know their blood sugar is getting a little low. In order to combat this, if they absolutely must be used, we practice what we call puncta occlusion. Essentially, any drops that you put in your eyes will run through your tear ducts and into your nose, and that’s really where they get absorbed is through the nasal mucosa because it’s so richly vascular. By plugging – by using a finger to push the side of the nose and prevent those tears from coming in for a minute or so after you use the eye drops, we can dramatically decrease the absorption of the medication into that nasal mucosa and into the rest of the body.
Melanie: What a great explanation, Dr. Evans. Was there anything you’d like listeners to know about things they can do at home? Is there any sort of prevention of lifestyle management, behavioral lifestyle changes that they can make to either prevent it or just to keep good eye health?
Dr. Evans: Sure. There is a lot of research out regarding the impact of exercise and eye pressure. In multiple studies, it has been shown that a regular, aerobic – or a regular cardiovascular exercise program will have a pressure-lowering effect on the eyes. If you have glaucoma, exercise alone is probably not enough to bring the pressure down to a more normal, acceptable range. But for anybody, exercise is never a bad thing. In some of those people where their pressures may be a little on edge, getting out there and a brisk walk, jogging, getting that heart rate up three to four times a week consistently, has shown to decrease that eye pressure.
A couple other more unlikely scenarios – or rarer scenarios in patients that actually do have glaucoma, things like Yoga – which is a really great way to stay in shape, way to keep healthy, way to focus on reducing stress – in some of those yoga stands where you’re on your head, there has been shown to be an increase in your eye pressure when you have all of the blood is rushing to your head like that. We would advise against the type of headstand positions for anybody who is actively into Yoga if they have open-angle glaucoma that’s been diagnosed. That, and if anybody is a SCUBA diver or a bigtime swimmer, the tighter you wear your goggles, the higher it will raise the pressure inside the eye, as well. Again, if you’re on the borderline, or you do have a bad family history, or you do, yourself, have glaucoma, swimming is a great exercise, but try to find goggles that aren’t fitting tightly enough that they’re leaving the red marks around the eyes when you’re all finished swimming.
Melanie: So, wrap it up for us, Dr. Evans – it’s been a fascinating segment – with your best advice about glaucoma and glaucoma awareness, and what you want us to know about your team at UK Healthcare.
Dr. Evans: Certainly. Number one, I think with today’s electronic medical records and everyone being more of a participant in their healthcare, it’s never been more important to know your family history. This is the time to have conversations with grandma and grandpa, mom and dad. A lot of the time, people didn’t go to the doctor for everything in the past. People that lost sight, they just figured it was because they were getting old. If you can figure these things out now, it can really give you a head start on whether or not you should be in seeing an eye doctor on a regular basis or if you should call and make an appointment right now. Knowing one’s family history is extremely important, number one.
Number two, yearly eye exams for everybody, especially if you have a history of diabetes or high blood pressure – other medical comorbidities like that. The eyes are the one place where a doctor can examine your blood vasculature – your blood vessels, arteries, and veins – inside the body, functioning in their normal environment. They can’t do that in any other specialty without using either machines or testing. There are a lot of diseases that can really show their first pathology in your body by looking in the eyes. It’s very important because they really can be a window to better health.
And three, here at UK, we have a huge multidisciplinary team that specializes in everything from the front to the back part of the eye. For the glaucoma team, there’s myself and two other glaucoma specialists. It’s a very exciting time for glaucoma right now because there is a new renaissance where more early intervention type of surgical procedures where we’re doing micro-invasive procedures with small stent devices, with lasers, these types of things that in the past, they weren’t really an option. I think we’ll start seeing a shift in intervention to intervene earlier with folks that have more minimal or moderate disease and use some of these new tools to lower their pressures, keep them off drops, keep them happier longer, and keep their eyesight excellent as long as we possibly can with this disease.
Here at the UK, we have really embraced that. It’s not a disease where we wait until the very end of the disease to do any type of surgical procedure now. It really is transforming into early intervention and a three-pronged approach of medicine, laser, and surgery.
Melanie: Thank you so much, Dr. Evans, for being with us, today. If you’d like to make an appointment with Dr. Evans or any of our specialists at UK Advanced Eye Care, please call 859-323-5867, that’s 859-323-5867. This is UK Health Cast with the University of Kentucky Healthcare. For more information, you can go to UKHealthcare.UKY.edu, that’s UKHealthcare.UKY.edu. This is Melanie Cole. Thanks so much, for listening.
Melanie Cole (Host): According to the Glaucoma Research Foundation, glaucoma is a very misunderstood disease. Often, people don’t realize the severity or who are affected. Glaucoma is a leading cause of blindness. My guest today, is Dr. Joshua Evans. He’s an Ophthalmologist, specializing in glaucoma at UK Advanced Eye Care. Welcome to the show, Dr. Evans. What is glaucoma?
Dr. Joshua Evans (Guest): Thank you, very much, for having me. It’s great to be here. Glaucoma, I think -- like you’d indicated, is very poorly misunderstood, even among glaucoma specialists. In general, glaucoma is believed to be nerve damage – optic nerve damage caused primarily – with primary open-angle glaucoma – primarily by elevated pressure inside the eye that causes damage directly to the nerve. With that, comes the loss of usually, peripheral vision first, in a slow pattern lasting most of the time over periods of years to decades. Eventually, if untreated, results in complete blindness.
Melanie: Who is at risk? Do we know?
Dr. Evans: Most of what our studies are based on, indicate a few major risk factors. Age is one. Family history is a very significant risk factor, so if anybody does have family members that have suffered from glaucoma, particularly at an early age, they are at a much higher risk. It is important that they know their family history. Having an elevated eye pressure, having a thin cornea – which is something that can be tested for at your eye doctor’s office, and there is some racial predilection, as well. African Americans and Hispanic Americans tend to be more affected by the disease, and particularly, in African Americans, it tends to be more aggressive variant glaucoma in those who do actually have glaucoma.
Melanie: So, what happens in the early stages? Are there some symptoms? As you mentioned, it can happen over a period of years, but are there things that we might notice – things that people would send up a red flag that could send them to see an ophthalmologist for testing?
Dr. Evans: There are some things, but overall, glaucoma is considered to be a silent thief of sight. But with some of the more acute versions of glaucoma like angle-closure glaucoma, you will tend to have significant pain. In the more chronic variety, you may have halos or rainbows around lights -- particularly in the twilight hours, watching TV in the dark, these types of things – with some soreness around the eyes. That can be a sign of a slightly different type of glaucoma where the drain is actually being partially occluded or plugged up.
With the regular, open-angle glaucoma variant – that’s the much more common variant – unfortunately, there are not a lot of early symptoms. The pressure tends to elevate over a period of years, and as a result, the eye just becomes accommodating to that pressure. As a result, you don’t really have these symptoms. You don’t have symptoms of pain, and because it is a peripheral vision disease primarily, most people don’t really realize they’ve lost significant vision until they come to their eye doctor and get the appropriate testing.
Melanie: What is the appropriate testing? How is it diagnosed?
Dr. Evans: Sure. There are a couple of different ways to look at it. There is the subjective testing or testing that the patient actively participates in, and there’s more objective testing where we can test them with machines or take pictures and then analyze those.
The first time you come in for a glaucoma evaluation, you can expect that you’ll get a couple of different types of testing. The biggest one is a visual field analysis where we’ll have you sit at a special machine, and the machine will test points in your peripheral visual field, and you’ll indicate whether or not you saw that point or not. By doing so, it creates a map of where there may be some vision loss and where the vision is normal. We can use that then, to guide therapeutic decisions about whether or not the disease is getting worse or it’s staying the same. On top of that, some of us still take pictures – serial pictures at the back of the eye, looking at the nerve so that we can actually then, on a yearly basis, see whether or not there have been visual changes in the nerve itself that we can see with our microscopes.
And then the third would be testing with a new machine that can actually measure the thickness of the nerve tissue as that tissue is coming together to form that optic nerve itself. By looking at that specifically for patterns of thinning and thinning overall, we can see that the thinning usually equates to damage to the optic nerve, and we can use that also as an objective measurement to follow disease progression or whether or not there is a presence of glaucoma. Sometimes, people can get sent in for glaucoma evaluation, and they may have just a normal, anatomic variant. It’s just the way they’re put together. The nerves look a little funny; they look a little bit like glaucoma, but after all of our testing, it shows that the nerve itself is fine and healthy and that they don’t actually have any glaucoma disease.
Melanie: What’s the first line of defense, Doctor, when you do detect that there is some glaucoma present? Do you start with mediational intervention, and does that slow the progression, or is this something that there is no cure? Tell us a little bit about intervention.
Dr. Evans: Sure. Well, it is important to understand that with glaucoma, unlike cataracts, it’s not reversible except in very rare instances -- it is not a reversible process. When tissue is lost – when vision is lost, it will not come back. That’s why early intervention and early diagnosis is key. When we do diagnose somebody with open-angle glaucoma or glaucoma in general, the first step is – or has been, up until recently – medication. Starting a medication, usually one that you take just once at night before you go to bed, and that usually will lower the pressure about 30%, which is what we like to see.
In the past few years, there’s been a rise of some laser procedures that can be done in place of the drops, and it works about 80% of the time. If it does work, it tends to work for a period of about one to five years. That’s great for some patients who really don’t like to use drops or have trouble using drops, arthritis, or they only have one good eye, or they don’t have anybody to help them at home. This can take the place of those drops and allow good disease control without them having to be an active participant in treating the disease themselves.
And then lastly, in some patients that come in and the disease is very advanced. Usually, the first-line-or second-line treatments of medications and lasers would not have enough of an effect that late in the disease. For those individuals then, surgery is usually the best option. Surgery, when successful then, is good at keeping the pressures as low as possible for as long as possible, usually without any drops or with very minimal drops in order to augment that.
Melanie: One of the medications might be beta blockers that you try, and people will say, “Well, I don’t have heart disease or high blood pressure,” so, what is the relationships there?
Dr. Evans: So, the beta blockers that we use – obviously, there are these beta receptors all over the body in all these different tissues. Where they’re located in the eye is in the fluid-producing part, and we use them to suppress the part of the eye that makes the fluid – that is essentially bathing the front part of the eye and the lens. When there’s too much of that fluid, the pressure goes up. We’re kind of turning down the faucet by using those beta blockers. They obviously do have many effects as well, like you had said, effects on the cardiovascular system and the respiratory system.
The drops that we use tend to have very minimal absorption into the entire body. However, patients who have asthma, or obstructive pulmonary disease, poor pulmonary function – poor lung function – we usually try to avoid beta blockers in them just because it can sometimes cause some spasm of the airways and a little bit of deterioration in respiratory status. As far as cardiovascular effects, it really doesn’t have much.
The only other effect that I’d mention is in some patients who are very, very advanced diabetics; it can sometimes cover up a little bit of those hypoglycemia symptoms. These people may not know their blood sugar is getting a little low. In order to combat this, if they absolutely must be used, we practice what we call puncta occlusion. Essentially, any drops that you put in your eyes will run through your tear ducts and into your nose, and that’s really where they get absorbed is through the nasal mucosa because it’s so richly vascular. By plugging – by using a finger to push the side of the nose and prevent those tears from coming in for a minute or so after you use the eye drops, we can dramatically decrease the absorption of the medication into that nasal mucosa and into the rest of the body.
Melanie: What a great explanation, Dr. Evans. Was there anything you’d like listeners to know about things they can do at home? Is there any sort of prevention of lifestyle management, behavioral lifestyle changes that they can make to either prevent it or just to keep good eye health?
Dr. Evans: Sure. There is a lot of research out regarding the impact of exercise and eye pressure. In multiple studies, it has been shown that a regular, aerobic – or a regular cardiovascular exercise program will have a pressure-lowering effect on the eyes. If you have glaucoma, exercise alone is probably not enough to bring the pressure down to a more normal, acceptable range. But for anybody, exercise is never a bad thing. In some of those people where their pressures may be a little on edge, getting out there and a brisk walk, jogging, getting that heart rate up three to four times a week consistently, has shown to decrease that eye pressure.
A couple other more unlikely scenarios – or rarer scenarios in patients that actually do have glaucoma, things like Yoga – which is a really great way to stay in shape, way to keep healthy, way to focus on reducing stress – in some of those yoga stands where you’re on your head, there has been shown to be an increase in your eye pressure when you have all of the blood is rushing to your head like that. We would advise against the type of headstand positions for anybody who is actively into Yoga if they have open-angle glaucoma that’s been diagnosed. That, and if anybody is a SCUBA diver or a bigtime swimmer, the tighter you wear your goggles, the higher it will raise the pressure inside the eye, as well. Again, if you’re on the borderline, or you do have a bad family history, or you do, yourself, have glaucoma, swimming is a great exercise, but try to find goggles that aren’t fitting tightly enough that they’re leaving the red marks around the eyes when you’re all finished swimming.
Melanie: So, wrap it up for us, Dr. Evans – it’s been a fascinating segment – with your best advice about glaucoma and glaucoma awareness, and what you want us to know about your team at UK Healthcare.
Dr. Evans: Certainly. Number one, I think with today’s electronic medical records and everyone being more of a participant in their healthcare, it’s never been more important to know your family history. This is the time to have conversations with grandma and grandpa, mom and dad. A lot of the time, people didn’t go to the doctor for everything in the past. People that lost sight, they just figured it was because they were getting old. If you can figure these things out now, it can really give you a head start on whether or not you should be in seeing an eye doctor on a regular basis or if you should call and make an appointment right now. Knowing one’s family history is extremely important, number one.
Number two, yearly eye exams for everybody, especially if you have a history of diabetes or high blood pressure – other medical comorbidities like that. The eyes are the one place where a doctor can examine your blood vasculature – your blood vessels, arteries, and veins – inside the body, functioning in their normal environment. They can’t do that in any other specialty without using either machines or testing. There are a lot of diseases that can really show their first pathology in your body by looking in the eyes. It’s very important because they really can be a window to better health.
And three, here at UK, we have a huge multidisciplinary team that specializes in everything from the front to the back part of the eye. For the glaucoma team, there’s myself and two other glaucoma specialists. It’s a very exciting time for glaucoma right now because there is a new renaissance where more early intervention type of surgical procedures where we’re doing micro-invasive procedures with small stent devices, with lasers, these types of things that in the past, they weren’t really an option. I think we’ll start seeing a shift in intervention to intervene earlier with folks that have more minimal or moderate disease and use some of these new tools to lower their pressures, keep them off drops, keep them happier longer, and keep their eyesight excellent as long as we possibly can with this disease.
Here at the UK, we have really embraced that. It’s not a disease where we wait until the very end of the disease to do any type of surgical procedure now. It really is transforming into early intervention and a three-pronged approach of medicine, laser, and surgery.
Melanie: Thank you so much, Dr. Evans, for being with us, today. If you’d like to make an appointment with Dr. Evans or any of our specialists at UK Advanced Eye Care, please call 859-323-5867, that’s 859-323-5867. This is UK Health Cast with the University of Kentucky Healthcare. For more information, you can go to UKHealthcare.UKY.edu, that’s UKHealthcare.UKY.edu. This is Melanie Cole. Thanks so much, for listening.
