A (3:58)

That is very cool. I love hearing about how people got to where they are. It's always fascinating story. So I'm looking forward to learning a bit more about glaucoma. And so I'm going to sit back and just take in the knowledge from both of you. So with that, I'm going to turn it over to Ed. I know you have some great questions, Ed.

B (4:22)

Well, thanks, Ricky. Dr. Rosdahl, I wonder if we could just start with the basics. If you could just tell us what is glaucoma and what are maybe some of the common risk factors associated with glaucoma?

C (4:35)

Glaucoma is actually a group of eye diseases. And what they have in common is that the optic nerve, which is the cable that connects the eye to the brain, it's when that optic nerve becomes thinned out because of those neurons, those retinal ganglion cells that I mentioned before, of those neurons dying. When the nerve dies off like that, people lose vision and it usually affects their peripheral or side vision first. Glaucoma, the most common type of glaucoma in the United States is primary open angle glaucoma. And one of the main problems that we have with glaucoma is that people have it and they don't know it because the vision loss happens really slowly, so they don't even notice that it's starting. And once you lose vision from glaucoma, really any type of glaucoma, not just primary open angle glaucoma, or we can't get that vision back. So early detection and diagnosing glaucoma early is really important for saving sight. You asked about risk factors, so they include having a family history of glaucoma. So people in your family, brothers, sisters, aunts, uncles, grandparents and parents. Older age is an important risk factor for glaucoma too. And actually black race and Hispanic ethnicity are risk factors, although a lot of white people can get glaucoma too. So don't think that you shouldn't get glaucoma testing or screening if you are white.

B (6:07)

What's the typical journey of a patient between the time they're diagnosed and they actually see you as a glaucoma specialist? What's the average scenario that a patient experiences?

C (6:18)

I would say the scenario that we hope for is that people are going along in their regular lives and they're getting regular complete eye exams with their local eye doctors and that that local eye doctor recognizes some early sign. Maybe the eye pressure is a little elevated, or maybe the optic nerve looks a little suspicious, or a family history is noted and that savvy local eye doctor either does some of the glaucoma testing themselves or refers them to someone like me as a glaucoma specialist. And then I see them. We do what we call a glaucoma evaluation, which is a pretty lengthy visit in clinic where they get a lot of special testing and an in depth eye exam and we ferret out whether they do have glaucoma or just some risk factors that need to be followed. So that's the scenario that we hope for, where the diseases diagnosed early before really any vision loss has occurred and we can start treatment early and prevent vision loss. So we also get referrals for help in managing patients who've already sustained vision loss from glaucoma or already have advanced glaucoma. And sometimes the reasons that they come to us are because they need surgery or they need some, some additional treatment that that local eye doctor is not able to provide. So there are lots of different ways that patients come to see a glaucoma specialist, but we always hope that they're coming early enough where we can save vision. And that frequently is the case, actually Most people who are diagnosed with glaucoma and treated for glaucoma don't go blind from it.

B (8:12)

And that actually was going to be my next question. I was just going to ask, does glaucoma always result in some vision loss or blindness? Can people with the right kind of treatment prevent having any vision loss at all?

C (8:26)

Oh, that's a great question. So it is possible for someone to have glaucoma and not lose any vision from it. The earliest stage of glaucoma is when there is just changes to their optic nerve, but we're not able to pick up any losses in their peripheral vision, even with automated computerized visual field testing. That would be mild glaucoma, based on the American Academy of Ophthalmology preferred practice patterns. But often people even with mild to moderate glaucoma, where we can identify peripheral field defects with the computerized automated visual field testing, even in those patients, often we can pick up the those areas of vision loss, but they are not noticing it. And so those patients, too, with treatment started, they can really not have vision loss that's affecting their quality of life.

B (9:24)

And before we talk about treatments, is it possible that the vision loss resulting from glaucoma can ever be reversed, or is it a permanent loss of vision?

C (9:35)

So it is a permanent loss of vision with the treatments that we have at this point. I am very hopeful that we will have treatments in the future that reverse vision loss from glaucoma. But at this point, that vision loss occurs from the death of those retinal ganglion cells. And we don't have ways yet to renew or replace or really recharge or regenerate those nerves at this time. So it is unfortunately a permanent loss of vis.

B (10:09)

And what are normally the kinds of treatments that you prescribe for folks with glaucoma?

C (10:14)

So the main treatment for glaucoma is to lower eye pressure. And we have a lot of different ways to do it. Typically, we'll start with eyedrop medications or a laser treatment to the drain of the eye. And then there are also surgical treatments that we typically reserve for cases where we cannot control the glaucoma with the drops or laser or where those treatments are just not effective or not possible. For example, a patient who has a lot of eye drop allergies cannot tolerate any of the drops. Then surgery might be considered for a more mild case as well.

B (10:55)

And I know with eye drops, I've worked with people that are not necessarily as conscientious about compliance as maybe they should. Be so how important is it that the person follow through with your exact prescription and your instructions for medication?

C (11:09)

Oh, I'm so glad that you brought up the topic of adherence to treatment regimens. It's really, really important that patients follow those eye drop treatment regimens. I like to say to my patient, this eye drop is a very powerful way to lower eye pressure, but it does not work if it is sitting in the bottle. It needs to go into your eye. There are a lot of different types of eye drops that we prescribe and so the regiments can vary quite a bit and they also can be quite complex. And so I certainly understand when patients have trouble adhering to these regimens. I would say the most simple one would be a once a day eye drop that you might use at bedtime. But sometimes we have patients on three or even four eyedrop medications. Some of them need to be dosed three, two or even three times per day. And it's quite a feat getting them all in at the right times. But it's really quite important those eye drops lower eye pressure for a certain amount of time after they're instilled. And then that eye pressure will go back up once that eye drop medication has kind of worn off. And so that next dose is timed to really maintain that lower eye pressure. And we think that maintaining a lower eye pressure and really keeping it low without those kind of big fluctuations can really help protect the optic nerve, help preserve that site.

B (12:38)

Are there any kind of. I think I've had someone tell me that there's some lifestyle changes that maybe people need to be aware of too. Like I think someone told me inverted yoga positions for instance. Are people are advised against those kinds of activities. Do you recommend lifestyle changes to go with medication or is that dependent on, on the individual?

C (12:57)

I would say that most patients probably don't need any particularly extreme lifestyle modifications. However, if I do have a patient who is progressing despite a regimen that we think really should be adequate, or a patient who's really motivated to do every single possible thing they can think of to prevent their disease, then we do talk about lifestyle modifications. And the things that I talk about with patients include that yoga concern that you brought up. We do think that prolonged head down postures like doing headstands, that that can increase the pressure in the eye just from that elevated venous pressure, tight neckties as well, and interestingly, prolonged wind instrument playing where you're blowing against a reed and again, kind of increased pressure in your head from those prolonged periods of holding your breath and Breathing against that wind instrument. We think that those might potentially result in some potential progression of glaucoma. I would say that I don't like to tell people not to do yoga, however, because I think that it's a really good way to relax, recharge and good for your health. So it's really those prolonged head down postures. There are a couple other lifestyle modifications too to consider. One of them is to eat a diet with a lot of leafy green vegetables with antioxidants. We think that might help the optic nerve in glaucoma. Healthy lifestyle in general with a heart. Healthy diet with lots of vegetables, fruits, whole grains and lean proteins. Getting some exercise, getting enough sleep, having healthy relationships with loved ones. Those are things that are good for your overall health and so they're going to be good for your eyes. And then there's one that's kind of interesting around sleeping with a wedge type pillow, having your head elevated around 30 degrees. That's something that's been shown to decrease progression and really advance glaucoma in some studies as well. And so that's something else that I'll bring up with a patient who might be progressing despite what we think is adequate pressure control.

B (15:23)

Now, if people are adhering to their treatment and taking all their drops the way they should, does glaucoma ever just stop? Does it go away or do they have to get treated for this condition for the rest of their lives?

C (15:37)

That is a really common question, and I'm glad that you asked that. Glaucoma is a lifelong condition. Once you have it, we have lots of good treatments, but we really don't have a cure. And so typically patients do have it for the rest of their lives. However, treatments change. Responses to treatments change as well. And so it is something that has to be monitored for the patient's life. Often, though, it is controlled and people do not go blind.

B (16:09)

If I'm diagnosed with glaucoma, do I have to start being concerned about my kids or potential grandkids? Is genetic counseling involved with this? When would my children, for instance, need to start being tested for glaucoma if I've been diagnosed?

C (16:24)

Well, glaucoma does run in families and so it's a really good idea if you are diagnosed with glaucoma, that you let blood relatives know about that diagnosis. And they don't necessarily need to run out and see a glaucoma specialist right away, but they should have complete eye exams on a regular basis. And when they see their eye doctor, they should tell them about that family history of glaucoma. And if the doctor sees anything of concern, more testing is needed, like a visual field test or a computerized picture of the optic nerve, then they might need to see a glaucoma specialist. So I would say if you had children and you were diagnosed with glaucoma, then I'd recommend that they have a complete dilated eye exam with a local eye doctor if they haven't had one recently, and to let the doctor know about your diagnosis.

B (17:16)

Are there any kinds of just sort of misapprehensions and false knowledge out there about glaucoma and treatment that you see, that patients come to you with, that you'd like to dispel?

C (17:27)

Well, the most important one, I think, is one that we've touched on already, that fear of blindness. When people first get the diagnosis, they think that, oh my gosh, I will be going blind. But like we discussed, most people who are treated for glaucoma don't go blind. So the message should really be one of hope. The biggest misapprehension about glaucoma treatment, I would say, is about the effects of treatment. Most people expect that glaucoma eye drops will make their eyes feel better or help them to see better, but that really isn't the case. Eye drops for glaucoma help to lower the eye pressure to prevent future vision loss. So they help keep your vision, but they don't make vision better. And they can have some side effects. Most of them are manageable. People do great on their drops, but there can be some stinging or redness. And sometimes we do need to even stop or change drops because of side effects. So that misapprehension about the effects of treatment, that's one that I'd like people to know about, too.

B (18:33)

And once folks start seeing you as their glaucoma specialist, do they still need to see their local optometrist or their local ophthalmologists as well, or do you kind of handle their care, their primary eye care, from that point forward?

C (18:48)

Optometrists and the comprehensive ophthalmologists are really important partners for us. I would say some of my patients do just see me for their eye care and kind of transfer things over to me. Many of them have other eye problems like dry eye or glasses and need for contacts. And those are things that the optometrist or that comprehensive doctor is helping with. They'll stay still, see them for those reasons. Some patients have to travel quite a distance to see Me. And so we'll partner with that local eye doctor, for example. They'll get their eye pressure checks every three or four months locally and then come to see me once a year for the visual field testing, the optic nerve imaging and the dilated exam. As long as everything's been stable at those interim visits with their local doctor,

B (19:42)

that makes perfect sense. This is a question I was interested in asking you. I've worked in the past with a lot of people with age related macular degeneration, the dry type, particularly now that they've been told, well, there's just really nothing that can be done. And I'll visit them. I'll notice, for instance, on their chart that they also have glaucoma. And I'll say, have you seen a glaucoma specialist? And they commonly tell me, well, I know nothing can be done about my vision, so why should I bother? What would you say to patients like that?

C (20:15)

I often have patients who have both macular degeneration and glaucoma, and I partner with my retina colleagues to care for those patients. I think these are some of the patients where glaucoma care is really so important. Patients with macular degeneration typically have losses in their central vision, but their peripheral vision might still be intact and be helping them with mobility and seeing to do a lot of the things that they need to do to live their lives. And so the glaucoma care is really essential to help them preserve that functional peripheral vision that's allowing them to live the lives that they want to live like they are. And so that glaucoma care is really essential.

B (21:03)

Okay, great advice. I know it's scary how common that is and how much I've heard that, though. Are there any treatments on the horizon for glaucoma that show promise that might be more effective than what you're using now?

C (21:17)

Well, there is a lot happening in glaucoma treatment right now. It's been a really exciting time for us. In the last couple of years, we had two new medications approved for glaucoma treatment. And the two mechanisms of action are new as well. So they're quite additive to the eye drops that we currently have. They are considered second line, however, so they're not necessarily better than what we have, but they can be added in a really powerful way to help us with our patients. And in 2020, a new way of delivering glaucoma medications was approved by the fda. And it's an implant that we can inject right in to the front part of the eye, it's tiny, tinier than the letter I on a dime. And then that medication sits in the front of the eye and elutes over a period of four to six months before wearing off. So that's a really exciting development in medications. And then there has also been a lot of focus on developing safer surgeries for glaucoma and advances in what are called minimally invasive glaucoma surgeries, or migs. However, they really do seem best for people with mild to moderate glaucoma who also have a cataract that's ready for cataract surgery and want to be on fewer eye drops. So we still really need safer alternatives for our patients with more advanced glaucoma who really need those lower pressures. The migs surgeries aren't quite there for us for those patients yet. And we still need those nerve regenerative therapies to bring vision back for our patients. But we have a lot of scientists and researchers around the world who are working hard to develop those treatments for our patients. But unfortunately, we're still waiting for those.

B (23:13)

But Dr. Rosdahl, you've talked about treatments, and I just wanted to ask you one quick question that's come up with folks that I've worked with in the past, particularly folks who may not have the insurance or the money to pay for eye drops, et cetera, and that's medical marijuana. And how efficacious is medical marijuana in treating glaucoma? And should people depend on that as opposed to actually seeking out treatments from a glaucoma specialist?

C (23:39)

You know, Ed, I'm glad you asked that because I think a lot of patients might be afraid to ask that question. But it is a really important question because I really would ask that patients not use marijuana for treatment of glaucoma because it has not been shown to be effective or safe for treating glaucoma and preventing vision loss. There are certainly anecdotal accounts of pressure lowering and potentially different parts of marijuana, different components that might eventually be part of an approved treatment for glaucoma, but not at this time. And so it really isn't a good way to prevent vision loss. I hope, though, that we will have marijuana based eye drops in the future, because I think that that is going to really boost adherence for glaucoma treatment in the future. But at this point, medical marijuana is not an approved treatment for glaucoma. Eyedrops, laser surgery, those are the things that we know work if patients are struggling with the cost of their glaucoma care. There are actually a lot of great programs that a lot of the drug companies offer to help patients get the medications that they need. And so I'd encourage those folks to ask their doctor about different programs that these pharmaceutical companies have available for patients who can't afford them.

B (25:12)

Well, that's terrific information because I know that is a concern. So thanks very much and I'm glad I asked the question.

A (25:17)

Yeah, that's great knowledge to have. As is all of this. I've actually learned quite a bit even with some limited knowledge of glaucoma. I've certainly added to that today. So I certainly appreciate the opportunity to sit back and listen as you all discussed this as we're wrapping up here, just want to ask, are there places that you would recommend, either of you, either Ed or Dr. Rosdahl, places that patients can go if they want to read a bit more about glaucoma, whether it's treatment or perhaps if they're looking for a glaucoma specialist, place the places that they can go just to do some of their own research.

C (26:04)

So the websites that I recommend for learning about glaucoma include the American Academy of Ophthalmology patient education website that is called ismart.org e y e s m a r t.org it is a great resource for patients. The National Eye Institute also has a lot of great information about glaucoma and some of the more scientific advancements that are going on right now. And if you're looking for a glaucoma specialist, of course the best way is going to be to ask your local eye doctor for a recommendation for someone that they work well with and that they know. But if you're online and you're looking for someone, the American Glaucoma Society or ags, we maintain a list of of fellowship trained glaucoma specialists in the United States and patients can go on that site and search by zip code to look for a fellowship trained glaucoma specialist.

A (27:07)

Fantastic. And we'll have all of those resources in our show Notes. I want to thank you both so much for spending a little time with us today. I'm so glad and I am very appreciative of the information that you've shared.

B (27:21)

Well, you're welcome. It was a pleasure.

C (27:22)

It's been my pleasure. Ricky and Ed, thank you so much.

A (27:26)

Thanks so much for listening. And now stay tuned for a short episode from our sister podcast, Insights and Sound Bites. And remember, if you want to hear more like this, you can visit the Insights and Sound Bites podcast page on our website, where you'll find lots more stories like Angela's, plus, you'll be able to submit one of your own. All right, let's hear from Angela as she shares her story of living with glaucoma and what has helped her to cope and adjust.

D (27:55)

Hello, my name is Angela Delgado. I live in New York City. I worked in the hospital for a long time, and I always on the computer a lot, and I noticed that I started to see floaters in my eyes. And overall, I just realized that my side view was going. And when I went to the doctor, they told me that I have symptoms of glaucoma. And I'm like, glaucoma? What is that? You know, I heard of it, but I just didn't know anybody that had that. They said, eventually, you're going to wind up losing your vision more and more over time. And they said that there's no cure for glaucoma. And I'm like, what do you mean there's no cure? You can't fix this. I want this fix now. But overall, I started to lose most of the vision in the right eye, so now I'm using the left eye. So I'm off balance when I'm walking because I have no peripheral. They told me, oh, well, you should sign up for commission for the blind. I said, commission for the blind? I said, what are you saying? I'm not like those people. You know, my situation is different. They gave me the cane. I had the mobility training, the rehab, and it came out to where I live. I can't legally drive anymore, so they declared me legally blind and visually impaired. I had the cane inside my rain boots in the closet. I was like, well, I still got a little bit of vision left, so I'm going to use what I got. I don't want people to know my business, I said, because it's my secret. So the secret was killing me. The secret was putting me in dangerous situations. I called so many times, I bumped my head so many times. You know, I was taking a train and buses and people coming left, right, all different directions in the city. And I was like, oh, excuse me. They said, watch out, lady. This is what's wrong with you. My daughter came by to see me. She said, mommy, why don't you take your cane with you? And when she said that, it was a light bulb went off in my head, and here I am. It's not like I don't have a kid. We're going to the mall. And I remember the last time we went to the mall, I ran into a pole. I had a big old knot on my head, almost split my head open. And I was afraid of that. But I didn't say anything. I just wanted to make them happy. I'm a brand new king that's in the closet in my rain boots. And I haven't even been wearing the rain boots because the cane was in it. So I felt like it was contaminated with the king. She said this would help you so much. And all I could do is. And then I started crying. I started crying because I'm crying now, but I started crying because it made me realize that the only person that was embarrassed of my vision loss was me. And I didn't want to burden nobody else. And they was more worried about me not using the cane, you know, And I didn't know that. And I thought that they didn't want to be around me or when they was around me. I wanted to be like them. I want to go and act like I still see as good. But when we went to the mall, I had the cane out and every. It just fit me. The cane was moving without me. Put it that way. It was guiding me without my permission, if that makes any sense. Everything just happened so naturally. That was the best thing I ever did.

A (31:29)

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