Consider the patient ‘behind the eye’ in glaucoma prevention, treatment
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Optometrists should adopt a holistic treatment approach and consider ocular, systemic and environmental risk factors that affect glaucoma development and progression, according to a review in the Journal of Current Glaucoma Practice.
“A holistic approach to treating the patient rather than just the IOP is the need of the hour,” Tanuj Dada, MD, professor of ophthalmology and head of glaucoma services at All India Institute of Medical Sciences in New Delhi, and colleagues wrote. “Recently the role of the allostatic load has gained recognition in defining and objectively measuring the role of multiple stressors in many diseases, including glaucoma.”
They added, “A good history and a complete head-to-toe examination will help in identifying and possibly alleviating these stressors to benefit the patient and improve the overall quality of life.”
Dada and colleagues reviewed risk factors associated with primary open- and closed-angle glaucoma to establish an overview of risks for causation and progression of glaucomatous damage. They divided risks into epidemiological and ocular factors, systemic diseases or conditions, dietary considerations and lifestyle-associated risks.
Age, race, socioeconomic status, BMI and family history are epidemiological contributors to glaucoma progression, they wrote. Older patients are more likely to experience glaucoma progression than younger patients with similar IOP levels, and primary open-angle glaucoma (POAG) is more prevalent and progresses faster in Black and Hispanic populations, while Asian populations are more likely to experience closed-angle glaucoma. Researchers also reported that glaucoma has an estimated heritability of 70%, with first-degree relatives having a 22% lifetime risk compared with 2.3% in patients with no family history of glaucoma.
Ocular factors, such as corneal thickness and refractive error, can also play a role. People with thinner corneas are more likely to develop glaucoma and experience more rapid progression and visual field loss, and those with hyperopia or myopia also have an increased risk for POAG.
Several conditions that affect the central nervous system may also increase the risk for glaucoma, including Alzheimer’s disease, Parkinson’s disease and stroke, based on population-based studies, researchers wrote.
In addition, some glaucoma medications, including topical blockers and carbonic anhydrase inhibitors, can cause anxiety and depression, which can negatively affect patient adherence to treatment.
Vascular dysregulation, hypertension and hypotension can also influence glaucoma progression and optic neuropathy, as can respiratory problems like obstructive sleep apnea and interstitial lung disease, they wrote.
Further, lifestyle habits like smoking, caffeine consumption and weightlifting have also been associated with glaucoma development.
“It is important for the treating [eye care provider] ‘to treat the eye as well as the patient behind the eye’ and adopt a holistic approach to improve the overall quality of life of glaucoma patients,” Dada and colleagues wrote.
Perspective
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This is an excellent and orderly summary of the myriad of ocular, systemic, genetic, environmental, nutritional and lifestyle factors that have been associated with or causally related to glaucoma. As a cautionary note, the quality of the research and the relationship strengths summarized in this article vary tremendously and should not be taken as individually absolute. However, this summary underscores the complexity of glaucoma’s pathogenesis and the reality that an evolved understanding that patients with sick eyes concurrently often have sick bodies is not a controversial matter.
A hyper focused approach to management, with an isolated concentration on setting and then achieving a target IOP, is likely insufficient in a modern approach to managing patients with glaucomatous optic neuropathy. Foundationally, this article spurs conversation on the value of an interdisciplinary approach to care in which communication amongst the various health care team members best informs an understanding of the patient’s individual multisystem health status. Once each practitioner comprehensively understands the patient, a truly holistic and patient centric approach can be pursued. The goal is to actively engage the patient in their own health care, hopefully maximizing both vision and systemic health-related quality of life. It is achievable.
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