Lifestyle changes to recommend to your patients.

Often, patients ask me, “What can I do, on top of taking these medications, to prevent vision loss?” The patients who ask this might be newly diagnosed, or they might be patients who are compliant and well controlled with medications, but they are seeing vision changes or their pressures are getting worse. Of course, emphasizing the importance of medication compliance and routine follow-up is paramount, but there are other things patients can do.

Recommendations

Patients who are very compliant and looking for ways not to lose vision will often be motivated to make lifestyle changes to help prevent vision loss. Overall, a healthy lifestyle lived in moderation is key. I tell patients that weight management can help. There are conflicting reports about the connection between obesity and glaucoma,^1,2 but we do know that obesity is linked to higher intraocular pressure.³ I discuss this with them not for the direct effects of weight loss, but due to the downstream benefits.

I explain that metabolic syndrome will affect their microvasculature,⁴ and if you think of glaucoma as a perfusion issue in addition to a pressure issue, there’s a potential they could allay some ganglion cell death by vessels not providing oxygen to the nerve cells.

Aerobic exercise has been shown to reduce eye pressure,^5,6 and given the health benefits of exercise, I suggest recommending this to patients. Very compliant patients are commonly those who go the extra mile and might be more motivated to exercise. But it is worth recommending to every glaucoma patient, especially overweight or obese patients, because exercise can help reduce weight and decrease cardiovascular risk, and potentially improve ocular perfusion.

Ask patients on antihypertensives to take them during the day to avoid dropping their blood pressure unnecessarily at night.⁷ Patients might also want to address obstructive sleep apnea issues, because the transient hypoxia and increased vascular resistance it causes results in a reduction of ocular perfusion pressure and decreased oxygenation to the optic nerve, which eventually leads to glaucoma.⁸ Another important point to make to patients is that they can protect themselves from damage from other blinding diseases, and they can stop smoking and use protective eyewear.

What Not To Do

Alcohol in moderation can drop pressure, but not enough to make any significant difference in glaucoma.^5,9,10 Given associated risks with alcohol consumption, we should not recommend this to patients. Yoga with a head-down posture can increase IOP, so I would not recommend this, either.

Playing high-resistance wind instruments can increase IOP, and it is reasonable to discuss this with patients who play these instruments yet are losing vision from glaucoma despite good IOP control.¹¹

Lifestyle Changes

We are always thinking of ways to improve care for our patients, and this goes beyond medicine and surgery. We want to maximize the effect of their therapy. Above all, tell patients to keep their weight and blood pressure under control, and definitely exercise. GP

References

1. Leske MC, Connell AM, Wu SY, Hyman LG, Schachat AP. Risk factors for open-angle glaucoma. The Barbados Eye Study. Arch Ophthalmol. 1995;113(7):918-924.
2. Ramdas WD, Wolfs RC, Hofman A, de Jong PT, Vingerling JR, Jansonius NM. Lifestyle and risk of developing open-angle glaucoma: the Rotterdam study. Arch Ophthalmol. 2011;129(6):767-772.
3. Shiose Y. The aging effect on intraocular pressure in an apparently normal population. Arch Ophthalmol. 1984;102(6):883-887.
4. Newman-Casey PA, Talwar N, Nan B, Musch DC, Stein JD. The relationship between components of metabolic syndrome and open-angle glaucoma. Ophthalmology. 2011;118(7):1318-1326.
5. Buckingham T, Young R. The rise and fall of intraocular pressure: The influence of physiological factors. Ophthalmic Physiol. 1986;6:95-99.
6. Passo MS, Goldberg L, Elliot DL, Van Buskirk EM. Exercise training reduces intraocular pressure among subjects suspected of having glaucoma. Arch Ophthalmol. 1991;109:1096-1098.
7. Krasińska B, Karolczak-Kulesza M, Krasiński Z, et al. Effects of the time of antihypertensive drugs administration on the stage of primary open-angle glaucoma in patients with arterial hypertension. Blood Press. 2012;21(4):240-248.
8. Bilgin G. Normal-tension glaucoma and obstructive sleep apnea syndrome: A prospective study. BMC Ophthalmol. 2014;14:27.
9. Houle RE, Grant WM. Alcohol, vasopressin, and intraocular pressure. Invest Ophthalmol. 1967;6:145-154.
10. Harris A, Swartz D, Engen D, et al. Ocular hemodynamic effects of acute ethanol ingestion. Ophthalmic Res. 1996;28:193-200.
11. Schuman JS, Massicotte EC, Connolly S, Hertzmark E, Mukherji B, Kunen MZ. Increased intraocular pressure and visual field defects in high resistance wind instrument players. Ophthalmology. 2000;107(1):127-133.

Arsham Sheybani, MD, is an assistant professor of ophthalmology and visual sciences at Washington University School of Medicine in St. Louis, Missouri. He reports consultancy to Allergan, Glaukos, Katena, and Alcon, and speaker's fees from Allergan and Alcon. Reach him at sheybaniar@wustl.edu.