Best prescription for patients: Healthy lifestyle

Take-home

As consumer interest in alternative therapies grows and considering the potential for harm, ophthalmologists need to be prepared to speak about this topic with their patients.

San Francisco-Market data and other research pointing to the popularity of alternative therapies-combined with evidence that these interventions may not be as benign as consumers believe-underscore the need for ophthalmologists to be prepared to speak about this issue with their patients with glaucoma.

“It’s a shame to see a lot of money being spent on ineffective alternative therapies, but the concern extends beyond the fact that most are useless because there is the potential for them to do harm,” said John Hetherington Jr., MD, clinical professor of ophthalmology, University of California, San Francisco.

“Based on my review of the available evidence, my conclusion is that the best thing our patients can do to protect their ocular health and general well-being is to maintain a healthy lifestyle with proper diet, adequate exercise, and enough sleep,” he said.

According to one report on alternative therapies, 72 million adult Americans spent an estimated $27 billion annually for these agents. However, that particular study is already a few years old, and the current expenditure level is probably higher, Dr. Hetherington said.

Data on use of alternative medications by patients with glaucoma is available from several studies that suggest it is significant. Wan et al. found that one in nine (11%) patients with glaucoma use these agents, while others reported a range between 7% and 17%.

“However, the real percentage is probably even higher, as many patients probably don’t talk about alternative medication use,” Dr. Hetherington added.

What to say

Often, when asked by patients about alternative medicines, physicians may say whether it is fine to use them or not. Recently reported results, however, from a large study investigating the potential for niacin to protect against myocardial infarction and stroke raise concern about such passive responses. The study found niacin had no benefit, but in fact may increase the incidence of cardiovascular damage.

“There is often no evidence to demonstrate efficacy of alternative therapies, but these agents have side effects and drug interactions that can make people [feel] worse,” Dr. Hetherington said.

Alternative therapy and glaucoma

There is little clinical data to support use of any alternative medicines to prevent the onset of glaucoma or its progression. Some evidence shows that the degenerative mechanisms in glaucoma may be similar to those in age-related macular degeneration (AMD) and may provide some justification for the idea that vitamins and mineral supplements-shown to be helpful for preventing AMD progression (i.e., Age-Related Eye Disease Study)-may also be used in managing glaucoma. Additionally, some study data suggest that antioxidants in particular have promise.

However, there is no solid evidence to support recommendations for using these or other nutritional supplements, nor for herbal agents, including gingko biloba, St. John’s wart, and marijuana, that are of interest to patients with glaucoma because of purported effects on IOP or antioxidant properties.

There are a number of studies showing that exercise has IOP-lowering effects, and in some studies, the benefit persisted for some time after exercise ended. Citing some of this evidence, Dr. Hetherington mentioned one study reporting that moderate exercise was associated with a 14% decrease in IOP in patients with normal pressure and patients with glaucoma.

Another study found persons engaged in aerobic exercise for 10 minutes had a 1.7 mm Hg decrease in IOP, and two trials reporting that persons who exercised for 3 months had moderate IOP decreases lasting for 3 weeks after the exercise program ended.

However, Dr. Hetherington acknowledged that the question remains whether the effect of exercise is limited to IOP or actually has an impact on glaucoma.

“Although exercise seems to be associated with lowering of IOP, data are needed to show that it has any benefit for preventing visual field loss or affects blood flow in the back of the eye,” Dr. Hetherington said. “Perhaps compensatory mechanisms prevent beneficial changes in blood flow and any real benefit from exercise.

“However, we know that exercise has other health benefits, and so it seems to be reasonable to recommend it to patients, especially those with normal-pressure glaucoma for whom we often don’t know what else we can do,” Dr. Hetherington concluded.

John Hetherington Jr., MD

E: research@glaucomasf.com

John Hetherington Jr., MD, has no financial interest in the subject matter. This article was adapted from Dr. Hetherington’s presentation during the 17th annual Glaucoma Symposium presented by the Glaucoma Research and Education Group at Glaucoma 360°, in partnership with the Glaucoma Research Foundation and Ophthalmology Times.

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