Lifestyle choices play important role in glaucoma management

Awareness of the impact of lifestyle on glaucoma may yield new insights into causative factors of the disease.

James C. Tsai

The relationship between lifestyle choices and glaucoma has been investigated in numerous studies, revealing interesting associations, according to a specialist.

More awareness of the impact of lifestyle choices on glaucoma might help in developing effective public health strategies and yield new insights into the causative factors of the disease. But it is first of all important because “patients want to know, as they are keen on finding ways of fighting the disease besides medications,” James C. Tsai, MD, professor and chair of ophthalmology and visual science at Yale School of Medicine, U.S.A., said at the World Glaucoma Congress in Paris.

Dr. Tsai emphasized that adopting healthy lifestyle habits is good for patients in many ways, including the positive feeling of having better control of the disease. He said there are simple lifestyle modifications that should be introduced that might be beneficial for a complex disease like glaucoma.

“Certainly aerobic exercise is helpful. I tell my patients to limit their cigarette smoking because, if nothing else, it will improve their general health and hopefully improve their ocular perfusion. In terms of dietary habits, high antioxidants and low fat intake is advocated. And then there are three recommendations I often make: Limit caffeine intake, avoid head-down positions and, because of the possible beneficial effects of resveratrol, drink red wine,” he said.

Lifestyle choices

The effects of lifestyle choices on IOP have been evaluated in several studies. There is evidence that tight neckties, playing high resistance wind instruments, caffeine consumption, total body inversion such as head-down yoga positions and possibly stress may cause raised IOP.

Conversely, aerobic exercise and a healthy diet with moderate alcohol consumption may help lower IOP, studies have found.

Most of the exercise studies have been done with patients who do not have glaucoma. In non-smoking healthy volunteers, exercise has been shown to increase heart rate, systolic blood pressure and ocular perfusion pressure while decreasing IOP and diastolic blood pressure.

Other studies have specifically focused on IOP, showing a clear correlation between dynamic exercise and IOP lowering in young adults, Dr. Tsai said.

Smoking is correlated with acute or chronic IOP elevation, but there is no evidence that it is a risk factor for primary open-angle glaucoma.

“There are 4,000 bioactive substances in cigarettes, so it’s hard to parcel out what are the effects of all of them. However, we do know that cigarette smoking does have effects over the entire health continuum,” Dr. Tsai said.

Diet, other study results

The relationship between IOP and diet is still unclear, but omega-3 and omega-6 fatty acid consumption may be associated with a reduced risk of primary open-angle glaucoma. Improved blood flow regulation is correlated with a diet rich in magnesium, dark chocolate and omega-3 fatty acids. Antioxidants such as ginkgo biloba, melatonin, and the flavonoids contained in tea, coffee and red wine may reduce mitochondrial oxidative stress.

In terms of supplements, ginkgo biloba has been examined as a potential agent for neuroprotection with possible blood flow effects and short-term visual field improvement in patients with normal-tension glaucoma.

With other antioxidants, no definitive efficacy has been shown, but estradiol seems to have a beneficial effect on ocular hemodynamics.

Maintaining a healthy cardiovascular system through a healthy lifestyle is crucial for glaucoma patients, Dr. Tsai said.

“There may be potential vascular risk factors in glaucoma. In some patients, there seem to be abnormal autoregulatory responses to changes on ocular perfusion pressure. Also, ocular circulation has an influence on tissue oxygenation and mitochondrial oxidative stress. Therefore, influencing ocular circulation may be beneficial for the disease,” he said.

Among studies evaluating cardiovascular factors in relation to glaucoma incidence and progression, the Barbados Eye Study showed that lower systolic blood pressure and lower ocular systolic, diastolic and mean perfusion pressure were associated with an increased risk of developing glaucoma.

The Early Manifest Glaucoma Trial looked at the cardiovascular risk factors for primary open-angle glaucoma progression. Lower ocular systolic perfusion pressure, cardiovascular history in patients with higher baseline IOP as well as lower systolic blood pressure in patients with lower baseline IOP were associated with increased progression of glaucoma. – by Michela Cimberle

References:

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• Avunduk AM, Yilmaz B, Sahin N, Kapicioglu Z, Dayanir V. The comparison of intraocular pressure reductions after isometric and isokinetic exercises in normal individuals. Ophthalmologica. 1999;213(5):290-294.
• Baskaran M, Raman K, Ramani KK, Roy J, Vijaya L, Badrinath SS. Intraocular pressure changes and ocular biometry during Sirsasana (headstand posture) in yoga practitioners. Ophthalmology. 2006;113(8):1327-1332.
• Chandrasekaran S, Rochtchina E, Mitchell P. Effects of caffeine on intraocular pressure: the Blue Mountains Eye Study. J Glaucoma. 2005;14(6):504-507.
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• 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.
• Schmidt KG, Mittag TW, Pavlovic S, Hessemer V. Influence of physical exercise and nifedipine on ocular pulse amplitude. Graefes Arch Clin Exp Ophthalmol. 1996;234(8):527-532.
• Teng C, Gurses-Ozden R, Liebmann JM, Tello C, Ritch R. Effect of a tight necktie on intraocular pressure. Br J Ophthalmol. 2003;87(8):946-948.
• Toker E, Yenice O, Akpinar I, Aribal E, Kazokoglu H. The influence of sex hormones on ocular blood flow in women. Acta Ophthalmol Scand. 2003;81(6):617-624.
• Tsai JC. Influencing ocular blood flow in glaucoma patients: The cardiovascular system and healthy lifestyle choices. Can J Ophthalmol. 2008;43(3): 347-350.
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• James C. Tsai, MD, can be reached at the Yale Eye Center, 40 Temple St., Suite 1B, New Haven, CT 06510, U.S.A.; +1-203-785-7233; email: James.tsai@yale.edu.
• Disclosure: Dr. Tsai has no relevant financial disclosures.

Alain Bron

Dr. Tsai raises a fascinating point: May we change the course of a disease with simple lifestyle recommendations? This is a fundamental consideration if we remember that the first two schools of medicine in Europe in the Middle Ages (Salerno in Italy and Montpellier in France) were mainly focused on epidemiology (observing disease and finding risk factors) and the respect of very simple hygiene rules. So, it is important for doctors to be open-minded and to look beyond their daily practice and usual glaucoma treatments.

Control your arterial tension, do not be overweight and do not smoke are very simple rules that will benefit the whole body, not only a single organ or tissue. However, I am less enthusiastic about some “magic” substances that are supposed, based on very weak evidence if any, to treat glaucoma. I am faced now with patients coming to the consultation with pages from the Internet claiming the advantages of vegetable A, fruit B, wine C, etc. Some of them do not accept treatment with our usual armamentarium because of potential side effects. They ask to be treated only with alternative medicines. This is potentially dangerous for them, but nowadays some of our patients are more confident with what they find on the Internet than with their doctor.

— Alain Bron, MD
OSN Europe Edition Editorial Board Member
Disclosure: Dr. Bron has no relevant financial disclosures.