Chat Highlights
Unconventional Treatments for Glaucoma
June 28, 2000

Norma Devine, Editor

On Wednesday, June 28, 2000, Dr. George Spaeth, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Unconventional Treatments for Glaucoma." 

Moderator:  Welcome Dr. Spaeth.  Tonight's topic is "Unconventional Treatments for Glaucoma."

P:  I would like to hear what the doctor has to say about therapies for glaucoma that are not standard medical practice.  Some patients believe there are none.

Dr. Spaeth:  Glaucoma was defined years ago as a "sick eye in a sick body."  Clearly, there are lots of ways to keep the body well.  Although there are lots of unconventional treatments for glaucoma, they have not been much studied.

Moderator:  So our bodies are sick as well as our eyes?  

Dr. Spaeth:  It's a tough call. The optic nerve gets damaged more easily in some people than in others.  That relates to the stuff the nerve is made of, to blood supply to the nerve, the regulation of the blood supply, and so forth.  And those are all related to our general health.

P:  What can glaucoma patients do to improve their general health?

Dr. Spaeth:   Losing weight,  eating well, exercising, thinking positively, etc., affect  our general health and all those things affect the nerve.  Attitude is critical.  It affects us in many ways.

P:  Can unconventional treatments for glaucoma be used instead of conventional treatments?

Dr. Spaeth:  Not everybody with glaucoma needs drops or other treatments.  The danger with unconventional treatments is that they are often excuses for not doing what is necessary.  For example, if your pressure is 80, unconventional treatments are not going to help!  Let's be specific. If you are 50 pounds overweight and your IOP is a bit higher than normal and you have early or no glaucoma damage, it is much more important to lose weight than to use drops.  It is important because being overweight leads to high blood pressure, and that damages the vessels that supply the nerve.  It is important because being overweight stresses the heart and takes blood away from the eye that it may need. 

P:  Can exercise ever damage the eyes or increase the IOP? 

Dr. Spaeth:  Exercise done to excess can theoretically damage the eyes by shunting away blood.  I don't think anybody has ever shown that, but it makes sense. But I'm talking about very strenuous exercise -- like competing in a bike race in the Rockies.

P:  I ride a bike in the Rockies, hence the question.

Dr. Spaeth:  Then you should make sure you get really well acclimated first.  The people who usually get hurt by exercise are like the people who stay inside all year except for the 4th of July weekend, when they sunbathe for 12 hours. STUPID!

P:  Can you say how regular exercise helps lower pressures a bit, if it does?

Dr. Spaeth:  That's a super question, because if we could answer it for specific people,  we could improve treatment.  Before too long, there should be user-friendly ways to estimate blood flow. When they are available,  then we can start answering  your question in a way that is relevant to caring for patients.  There is evidence that a certain type of glaucoma in some Japanese people responds well to a drug that dilates blood vessels.  It is likely, though,  that it doesn't help other people.

P:  If regular, vigorous exercise reduces pressure a bit, as my specialist said, then how can you account for that? Because if it's true, there must be a reason, and that reason is  important in understanding glaucoma, right?  

Dr. Spaeth:  Right.  The reason exercise reduces pressure a bit is not known. It may be related to a change in the pH of the blood, to the blood pressure falling, to secretion of certain hormones.  I don't know, but it should be studied because, as you said, it is important to know the reason. 

P:  Do you have any ideas, other than a blood injection, about  raising intraocular pressure that is too low?

Dr. Spaeth:  Sometimes topical steroids can work.  Make sure that drops in the other eye aren't the problem.

P:  Is low blood pressure bad, too?  How about for a skinny girl?

Dr. Spaeth:   Low blood pressure can sometimes be bad, too,  if it is so low that you don't get enough blood supply. But that's rare.  Skinny girls live longer than fat ones.

P:  My blood pressure is 90/40.  Could that cause a problem?  

Dr. Spaeth:  Blood pressure of 90/40 is on the margin. Why is it low?  Do you get lightheaded?

P:  Yes, I get lightheaded.  I don't know why my blood pressure is so low.  It always has been low. 

Dr. Spaeth:  You probably should see if you have some of the things that go along with really low blood pressure.  An internist could possibly help.

P:  Are there many side effects from using laser on the iris to improve drainage?

Dr. Spaeth:  There are almost none, literally.  I take it you mean peripheral iridotomy, yes?  That can cause a ghost image from light coming through the  hole.  

P:  Yes.  How often does that happen?  Is once usually enough at age 43 for an iridotomy?

Dr. Spaeth:   The light comes through the hole and shines on the retina. It is NOT a problem.  

P:  Does the ghost image affect driving.  Is it common?

Dr. Spaeth:  The ghost image is rare, and it won't affect anything. 

P:  Can an iridotomy help lower IOP? 

Dr. Spaeth:   Iridotomies don't lower IOP, unless the angle is closed and the iridotomy opens the angle.

P:  Yes,  the angle is closed and I'm age 43.

Dr. Spaeth:  If your angle is closed, why haven't you had an iridotomy already?  

P:  Dr. Myers recommended an iridotomy, which surprised me because no one else caught it.  

Dr. Spaeth:  Did Myers say your angle was narrow or closed?  There's a big difference!

P:  Dr. Myers said the angle had changed to narrow. 

Dr. Spaeth:  Narrow angle is not closed angle.  Iridotomy will not lower IOP when the angle is narrow.

P:  If Dr. Myers recommends an iridotomy, should I have it done right away?

Dr. Spaeth:  Do what he says.  He knows his craft.

P:  When you rate angles for drainage B and D, what does that mean?

Dr. Spaeth:  B means that the angle is very narrow and D means it is deep.  The letters actually refer to where the iris sticks onto the inside wall of the eye.

P:  Do you recommend laser with the B and D when a  field test is normal?

Dr. Spaeth:  The field test has nothing to do with the need for an iridotomy.  The angle is three dimensional.  B, C, and D refer to only one dimension.  You need to know much more than that before you decide what to do.

P:  Will an iridotomy fix the drainage problem?

Dr. Spaeth:  Iridotomy does nothing except allow the aqueous to go from the back of the iris to the front. If there already is a relative pupillary block, then an iridotomy relieves that and allows the iris to lose a forward convexity.

P:  Is an iridotomy painful?

Dr. Spaeth:  There's instantaneous discomfort for one millionth of a second.  Angle closure glaucoma causes excruciating pain for hours.  Not much of a choice there!

P:  Can you tell for sure if an iridotomy is still open?

Dr. Spaeth:  Yes, you  just look and see if the PI (peripheral iridotomy) is open.

P:  There's some question about whether my iridotomies are still open. They were done three years ago with YAG.  My doctor  has suggested doing laser surgery just to make sure they are still open, but I thought that could be determined through trans-illumination.  

Dr. Spaeth:  Trans-illumination is not sure. You have to see the whole. That can be tough in some cases. If there is a question of whether the PI is open, it is best to say I don't know whether your PI is open.  Let's do a new one or make the old one larger. 

P:  Are there studies showing that Timolol can reduce blood flow to the optic nerve? And what do you think of the merit of those studies, if they exist?

Dr. Spaeth:  There are studies that purport to show that Timolol reduces blood flow to the nerve. The are not convincing to me.  But I think they should not be ignored.

P:  In theory, could Timolol reduce blood flow? And blood pressure?

Dr. Spaeth:  What should one do?  Theory is the enemy of good care. If you are using Timolol  and your glaucoma gets better, then keep taking it.  If your are using Timolol and your glaucoma gets worse,  then Timolol may not be the best drug for you.  What's good for the goose is often bad for the gander.  Some drugs are good for some, and bad for others.  Timolol is a drug which has different effects in different people, as is true for all drugs.

P:  Very interesting.  I guess it concerns genetic differences. 

Dr. Spaeth:  You're right on target. And also differences that occur because of the environment. 

P:  Dr. Spaeth, when can we expect to read the book you wrote for us glaucoma patients? 

Dr. Spaeth:  That's a big disappointment for me. The book was sent to the publisher (J. Hopkins Press), who requested I write it. The loved it, they said. They sent it out to a reviewer, who advised them not to publish it because it said things like it is better to try to have the body heal itself than to try to heal it with medicines.  So, I will look for another publisher.  It is good stuff!

End of highlights for June 28th chat.

On July 5th, Dr. Jonathan Myers and Dr. Courtland Schmidt discussed "Hyptony - Low Eye Pressure" in the Chat room. Click here for highlights of that meeting.

Click here for the most recent glaucoma chat highlights and links to the chat archives.

Click here for upcoming glaucoma chat events.