Unconventional Treatments
Chat Highlights
June 18, 2003

Norma Devine, Editor

On Wednesday, June 18, 2003, Dr. Doug Rhee, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Unconventional Treatments."

Moderator:  Welcome, Dr. Rhee.  We are delighted you could join us.  I understand that you have conducted research on unconventional treatments for glaucoma. 

Dr. Doug Rhee:  Thank you.  I also am a molecular biologist and run a lab here at Wills.

Moderator:  I'm sure you have many great insights to offer.

Dr. Doug Rhee:  You will be the best judge of that.

Moderator:  Could you please begin by describing the difference between alternative medicine and conventional medicine?

Dr. Doug Rhee:  Traditional (or conventional) treatments for glaucoma include medications, laser and incisional surgeries.  Unconventional, or alternative, treatments are simply anything other than those. The problem with most unconventional treatments is that they have not been well studied.

(Editor's note:  "Alternative" means "a choice between two mutually exclusive possibilities; existing outside traditional or established institutions or systems."  "Unconventional" means "deviating from established or accepted standards or norms." American Heritage Dictionary.)

P:  Are unconventional treatments more likely to be tried in underdeveloped countries?

Dr. Doug Rhee:  The answer is no, except for Chinese herbal medicines, which are more likely to be used in China. I have several colleagues in China who are also glaucoma specialists. They tell me that doctors who practice traditional Chinese medicine don't really treat glaucoma.  They typically will refer glaucoma patients to ophthalmologists, who treat them with traditional Western methods.

Moderator:  Is there a reason for that?

Dr. Doug Rhee:  No reason that they shared, aside from the fact that Chinese medicine may not have been shown to have been helpful for glaucoma.

Moderator:  How about acupuncture?

Dr. Doug Rhee:  Acupuncture has been well studied in China and Europe and shown not to be effective for glaucoma.

Moderator:  Can you tell us about your interest and involvement in research concerning unconventional therapies?

Dr. Doug Rhee:  Many of my patients were asking about some of the things they had heard about or were trying themselves.  Their questions prompted us to investigate the published literature on various unconventional treatments.  We also surveyed our patient population to assess how many were trying unconventional therapies and what they were trying.

Moderator:  How many patients were involved in the survey?

Dr. Doug Rhee:  We surveyed over 1,000 of our patients. 

Moderator:  What did you learn from the survey? 

Dr. Doug Rhee:  We found that just under 6% of our patients were trying something in addition to conventional glaucoma treatment.  The most common therapies they were trying were exercise and high-dose vitamins.

Moderator:  Was there any testing of the efficacy of those therapies?

Dr. Doug Rhee:  We did not directly evaluate their effectiveness.  However, others have.

P:  Perhaps that percentage would be much higher in general practice. 

Dr. Doug Rhee:  You raise a good point.  Our patient population is probably biased towards favoring traditional Western medicine.

P:  Did your survey disclose any correlation between patients supplementing conventional treatment with unconventional treatment and the age of the patients?

Dr. Doug Rhee:  Yes. Patients trying unconventional medicines (as supplements to conventional treatment) tended to be younger, Caucasian and better educated.  That is consistent with other surveys of unconventional medicine for other ailments.

P:  Do you use unconventional treatments in addition to conventional treatments in your practice?

Dr. Doug Rhee:  No, because there has not been any convincing evidence.

Moderator:  Is it because there are so few effective unconventional  treatments for glaucoma that so few patients use them, or just that the particular population you studied might have that bias?

Dr. Doug Rhee:  Since we are treating them, our patients obviously believe in Western medicine.  It is quite possible that if you went to an acupuncturist, you might find people with glaucoma there.  

P:  Unconventional treatment sounds risky.  

Dr. Doug Rhee:  You are correct.  At the moment, there is very little evidence to show that these treatments help.  However, they have not been shown to be harmful, either.  One unconventional treatment is exercise.

P:  How much exercise per week, and what kind, do you advise?

Dr. Doug Rhee:  Participants in the studies rode a stationary bike three to four times a week for 20 minutes. Exercise was shown to statistically lower intraocular pressure by 1 mm Hg in over 60% of patients.  That is one unconventional treatment that I do recommend.  Although 1 mm Hg may not be significant for some glaucoma patients, it can help others.  Besides, exercise has so many other positive benefits, it is a great thing for everyone to do.

P:  One proponent of unconventional treatment for glaucoma, an optometrist who calls himself a physician, claims that exercise lowers intraocular pressure as effectively as glaucoma medication. He neglected to say how long the effect of exercise lasted. Comment?

Dr. Doug Rhee:  Exercise is not as effective as drops.  Regarding the duration, in the study I just referred to, the effect of exercise lasted up to three months after stopping exercise.

P:  Do different types of glaucoma respond differently to exercise? 

Dr. Doug Rhee:  For one type of glaucoma -- pigment dispersion syndrome -- exercise is actually not helpful.  The mechanism is pigment release from contact between the support structure of the lens and the iris.  That can be aggravated by high-impact physical activity.  In fact, blurring of vision and headaches following exertion are symptoms of pigment dispersion syndrome.

P:  How does exercise lower intraocular pressure?  

Dr. Doug Rhee:  No one knows for sure, but it is not related to the hormone, epinephrine. It is believed that the loss of fluid increases the salt concentration of the blood, drawing fluid from the eye.  However, I am sure that the mechanism is more complicated, but we don't understand if fully yet.

P:  If higher concentrations of salt in the blood may benefit certain glaucoma patients who exercise regularly, might diets higher in salt also be beneficial in lowering IOP?

Dr. Doug Rhee:  Logical question, but no, high- salt diets do not help  glaucoma and are dangerous for your blood pressure. 

P:  What about relaxation, meditation, and prayer?

Dr. Doug Rhee:  Relaxation, meditation, and prayer have been studied.  There are two papers in the old literature that supported relaxation.  However, the studies were very poorly done and their results did not support their conclusions.  Nearly every epidemiologic study looking for the prevalence of glaucoma has looked at stress as a possible risk factor.  No study has ever shown stress (the opposite of relaxation) to be a risk factor for glaucoma.

Moderator:  But is relaxation (the opposite of stress) good for glaucoma?

Dr. Doug Rhee:  There has been no well-performed study looking at relaxation and glaucoma.

P:  Many glaucoma patients associate stress with their glaucoma.  That optometrist I mentioned earlier claims stress causes glaucoma. 

Dr. Doug Rhee:  That optometrist is wrong.  Most patients believe that stress will raise their eye pressure.  That is because stress and anxiety can definitely raise blood pressure.  However, stress does not raise eye pressure.

P:  Are there any FDA (Food and Drug Administration) rules regarding unconventional therapies?

Dr. Doug Rhee:  Many of the over-the-counter products are unregulated, because they are not classified as drugs.  That lack of regulation is part of the problem.

P:  Do you know whether some medical insurance companies have begun to pay for unconventional treatments, which are less expensive than conventional treatment?

Dr. Doug Rhee:  I do not know if any insurance companies are paying for unconventional treatments for glaucoma.  I have heard that some may be paying for chiropractic care for back pain.

P:  Are there any unconventional treatments that are showing promise?

Dr. Doug Rhee:  Initial studies indicated that ginkgo biloba may have a beneficial effect.  However, further studies have not shown it to be helpful.

P:  Ginkgo biloba is often mentioned as a neuro-protective agent.  Is there any evidence of that?  

Dr. Doug Rhee:  Initial studies in New York with ginkgo showed some promise.  However, studies directly looking at ginkgo in glaucoma patients showed no benefit after one year.  So, at the moment, I would not recommend ginkgo for glaucoma.

P:   Do you see any benefit of regularly taking aspirin, children's or adult's, because it might affect circulation at the optic nerve head? And would this be contraindicated in someone already taking ginkgo daily?

Dr. Doug Rhee:  Ginkgo can definitely thin the blood.  There have been a few reports of patients taking high doses of ginkgo who suffered cerebral hemorrhage.  Generally, ginkgo should be avoided in patients on blood thinners.  Aspirin is a very powerful blood thinner.

P:  When people hear you have glaucoma, one of the first responses is usually something about smoking marijuana.  What can you tell us about the effects on the eye and the body of smoking marijuana?  What is your opinion about using it in place of, or in conjunction with, traditional glaucoma medication?  

Dr. Doug Rhee:  Marijuana can lower eye pressure.  Marijuana has been very well studied.  Marijuana will lower intraocular pressure  approximately 20% in nearly 60% of people who try it.  However, it is only effective for two hours.  A 60% response rate is terrible compared to the rate for modern eye drops.  A 20% lowering is also terrible compared to modern eye drops. 

Moderator:  How about the side effects?

Dr. Doug Rhee:  The mental status changes, pulmonary dysfunction from the smoke, etc., are not good when considering that the average age of a patient with glaucoma is 64 years.  To summarize, although marijuana can lower IOP in some people, it is very poor compared to modern treatments with regard to effectiveness, non -response rate, and side effects.  That it is also illegal is another important issue. 

Moderator:  So, aside from its illegality, you would not recommend marijuana for use during an acute-angle attack? 

P:  I wish I had had marijuana when I had an attack of acute-angle closure.

Dr. Doug Rhee:  I would not recommend marijuana under any circumstances.   We have much more effective treatments.  If you have an acute attack, you need to get to an emergency room as fast as you can.

P:  I tried an unconventional therapy. I stopped all my eye medications because I was getting sick, emotionally and physically.  All my headaches stopped and my intraocular pressure did not change one iota!

Dr. Doug Rhee:  I hope that you are still following up with your ophthalmologist to continue to monitor your visual field and optic nerve.

P:  Can a patient with open-angle glaucoma have an acute attack and what would the general symptoms be?

Dr. Doug Rhee:  Usually patients with open-angle glaucoma do not get acute attacks.  However, there are many special circumstances where it could occur.  The symptoms of an acute attack are redness of the eye, seeing halo's around lights, an extreme pressure sensation around the eye, and blurring of vision.  Usually the headache/pain is rather severe.

P:  I am sorry doctor, but I am new at having glaucoma and I think every thing is hit-and-miss with drops.

Dr. Doug Rhee:  You are right.  Even modern eye drops will not work for everyone.  For many people, drops fail and it is necessary to try laser or incisional surgery.

P:  What you are saying is that there really is not much in the way of unconventional treatment that shows definite results?

Dr. Doug Rhee:  You are correct, aside from, perhaps, exercise.

P:  Is there any study to indicate how many patients stop their drops because of side effects?  Patients know what they are feeling, but I wonder if the doctors just don't have anything else to offer.  I feel there are too few options -- just surgery and drops that may make you sick and do not help your IOP.  Not to be negative, but just trying to be real.

Dr. Doug Rhee:  Your sentiments are shared by many ophthalmologists.  Glaucoma is a very difficult condition to treat.  None of our treatments -- medicine, laser, surgery -- are perfect.  However, every few years, they get better and better.  There are many more options for treatment now than there were even in the 1990's.

P:  Could you comment more on the use of high doses of vitamins and how they may be beneficial?

Dr. Doug Rhee:  No mega-vitamin treatments have been shown to be helpful.  There was some Russian literature indicating that vitamin E may be helpful, but again, the study was poorly done.  By poorly done, I mean that the evidence/data does not support the author's conclusions. 

P:  I have Chandler's disease in my left eye.  I recently had a tube-shunt procedure for elevated intraocular pressure and closed drainage. Now my glaucoma specialist has started me on Valtrex.  I believe that is more experimental than alternative.  Do you have any comment on that?

Dr. Doug Rhee:  I am not familiar with Valtrex outside the setting of herpetic or zoster related keratouveitic glaucoma.  I would highly recommend that you speak to your doctor.  You should feel comfortable asking your doctor about any treatments you are on.

P:  Do you plan any further research on unconventional treatments?  If so, which ones?

Dr. Doug Rhee:  I have been trying to collaborate with practitioners of various unconventional treatments.  So far, none have accepted my offer to try to do some research with them.

P:  Why do you think that is?

Dr. Doug Rhee:  I am not sure why they did not want to participate.

P:  Do you know of any studies on vitamin C and glaucoma?

Dr. Doug Rhee:  Intravenous vitamin C can lower IOP by dehydrating the eye.  However, IV administration is very dangerous.  High-dose oral vitamin C does not affect eye pressure.

P:  I understand a pill to protect the optic nerve is due out next year.  Is that credible information? 

Dr. Doug Rhee:  I am not sure to which pill you refer.  Wills is one of the sites testing a drug called memantine.  However, we do not yet know if memantine is effective.  I expect the study will be completed in one to two years, but I don't yet know what the results are.

P:  What are your feelings toward this new possibility?

Dr. Doug Rhee:  I don't know what the results of the memantine study will be.  But I am confident that in the future we will have non-pressure-related treatments for glaucoma.

P:  Does caffeine have any effect on IOP?  

Dr. Doug Rhee:  Some studies showed caffeine raised the IOP. However, further studies showed that it was actually the volume of fluid drunk at one time.  Drinking large quantities of any fluid at one time can raise the IOP.

P:  Could you tell us anything about research using Paxil or Prozac to help glaucoma?

Dr. Doug Rhee:  I am not aware of any studies that have been done on taking Paxil or Prozac for glaucoma.

Moderator:  Dr. Rhee, thank you so much; you've been great. We hope your first visit won't be your last.  

Dr. Doug Rhee:  Thanks, all.  My pleasure.

End of highlights for June 18, 2003.

Dear Glaucoma Chat Room Participants,

In order to provide you with the most accurate information possible, I would like to make the following amendments and corrections to some of the topics that we had the opportunity to chat about on June 18th on the subject of alternative/unconventional treatments.

The most important correction is that I misattributed studies on gingko biloba (GBE) and visual field performance to Dr. Robert Ritch.  Dr. Ritch and colleagues studied the effect of GBE on ocular blood flow (not visual fields).  Using orbital color Doppler imaging, his group found an increase in the velocity of blood flow in the ophthalmic artery in nonglaucomatous individuals and increased velocity of blood flow in the central retinal artery in patients with normal-tension glaucoma.   Using a Heidelberg Retina Flowmeter on patients with open-angle glaucoma, there was no change in any of the HRF measurements following treatment with GBE.  It is important to note that increased blood velocity does not necessarily mean improved blood flow.  To determine blood flow, blood velocity measurements must be made concurrently with measurements of the caliber of the involved vessels. At this time, there is no way to accomplish this for the orbital vessels.  Additionally, there has been no evidence to date that proves that improved blood flow would improve glaucoma, but it does seem to make logical sense.

GBE’s effect on visual fields has been studied recently by Dr. Luciano Quaranta. He and his group report an improvement in visual field defects following oral treatment with GBE in patients with normal tension glaucoma.  I would like to extend my apologies to Drs. Ritch and Quaranta for my inexact recollection of their respective research.

I also discussed the concept of “retinal sensitivity.”  I had stated that the classic example was epinephrine.  Rather, the phenomena of improved visual field performance based on increased alertness rather than a true improvement of optic nerve function (possible because the test requires a patient’s feedback), has been reported following exercise, oral diamox/acetazolamide and antihistamines.

I would like to add a little more detail to my discussion on exercise and IOP.  As I mentioned, regular exercise can chronically lower IOP up to 1 mmHg in non-glaucomatous individuals, but this lowering can be up to 4 mmHg in non-glaucomatous individuals with higher eye pressures.  To my knowledge, the chronic effect of regular exercise has not been studied in people with glaucoma.

Although I have some corrections and modifications in my chat room comments, my original recommendations regarding these subjects are unchanged.  At this time, I do not recommend ginkgo biloba to my patients because I feel that there is not yet enough evidence (one paper is not enough) to warrant using GBE especially since gingko can cause life-threatening complications from thinning of the blood.  I do believe that regular exercise is beneficial for most individuals.

Best Regards,
Doug
Douglas J. Rhee, M.D.
Philadelphia, PA

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