Collaboration and a sense of community make a profound difference for everyone affected by glaucoma: patients, families and caregivers, doctors, scientists, vision industry leaders. To experience it yourself, attend one of Glaucoma Research Foundation’s annual events, which celebrate progress, possibilities, insight, and hope.
Glaucoma 360, our signature event, has become a destination for discovering the latest progress toward a cure. Each year, nationally and internationally respected pioneers in the fields of vision research, business, and medical innovation come together to share insights, spark new ideas, and accelerate advances in glaucoma science and treatment. Specialists in diagnosis and care offer continuing education courses for their colleagues. Research pioneers report on their lab work and clinical trials. This exciting three-day event includes activities to celebrate, innovate and educate:
• An annual gala: Honoring outstanding leadership in ophthalmology, inspiring individuals who are living with glaucoma, and the transformative generosity of our supporters (many of them patients and their loved ones).
• New Horizons Forum: A full day of presentations, panels, and discussions dedicated to translating new ideas into better glaucoma therapy, for industry executives, CEOs from start-up companies, ophthalmic leaders, venture capitalists, and representatives from the Food and Drug Administration.
• Glaucoma Symposium CME: A gathering for practicing ophthalmologists, ophthalmology residents, and fellows, highlighting the latest advances in glaucoma management, medications, and surgical techniques.
• Optometric Glaucoma Symposium: A meeting for practicing optometrists highlighting the latest advances in glaucoma management.
When you face a complex illness that threatens your vision, knowledge is a powerful resource. Our annual Glaucoma Patient Summit is a live forum that shares the latest treatment options and practical insights. This popular event attracts a diverse community, from people born with glaucoma to the newly diagnosed to those who have lived with glaucoma for many years. Patients and caregivers connect and share their experiences, learn more about glaucoma, and hear about emerging pharmaceutical and surgical approaches.
Inder Paul Singh, MD: We’re going to have some time, maybe about 20 minutes or so, to have a nice group discussion and answer some questions from the audience out there. We’ve received a number of questions, which we’re going to try to get to. Again, if we don’t get to all the questions, I apologize, we’ll try to follow up on the back end as well.
But I just want to start out before we start answering questions, just to [mention], for me personally, about the incredible proliferation of technology that we’ve seen over the last decade. I’ve been out of fellowship now for 15 years, and just to see the incredible [advances], not only on the pharmaceutical side, but [also] the surgical side; and our ability to help maximize and balance compliance and patient quality of life. As well as being aggressive [when necessary], trying to get those [intraocular] pressures down at the same time. We didn’t have that opportunity 15 years ago when I came out of fellowship.
And now with a lot of the new molecules, even recently with netarsudil, which is called Rhopressa or Rocklatan which is a combination with latanoprost or latanoprostene bunod which is called Vyzulta. These are new molecules that actually work on the meshwork, the part of the eye that actually causes resistance. We can actually address the pathology, the area that’s causing the pressure to go up as well. Then all the new surgical options that Sahar [Bedrood] mentioned, [with] safety being higher. We can address compliance [when] patients are having a hard time with drops. We can get those pressures down nicely as well.
So, I just want to say it’s exciting for me as a provider to help offer these opportunities to patients, to maximize the safety, and compliance, as well as being aggressive [with treatment] early on. With that said, we do have a lot of questions and I want to ask the panelists here. The first question we see here, and I think I see this all the time, is dry eye. We hear a lot about dry eye. I think it’s become a new topic in ophthalmology and optometry in general, but how does it affect glaucoma? Sahar or Ranya [Habash], you talked about drops and surgery. What are your thoughts on how dry eye affects glaucoma and what can you do about it?
Sahar Bedrood, MD, PhD: Thanks, Paul. I think I’ll chime in here. Dry eye and glaucoma very much go hand in hand. A lot of the [glaucoma medication eye] drops that we start on our patients unfortunately cause significant redness and dry eyes. So we are in a battle of trying to treat that while also treating their glaucoma. I think most patients will still vote to get lower pressure. And so that’s why we keep them on these drops. But a lot of our discussions in the forums when we speak with the other doctors, is [about] ‘how do we optimize the ocular surface to reduce that dryness?’ Maybe it’s taking them off certain drops. Maybe it’s just one drop that’s a culprit. Maybe it’s all of them. And then it’s even more reason to go into a surgical situation for that patient, but it is certainly a chronic issue along with glaucoma. And I’m curious to see if Ranya has any other tips for this.
Ranya Habash, MD: Yeah, I agree with everything you said. And one of the things I like my patients to know is, even if we’re maximizing treatment for one condition like glaucoma, it doesn’t mean we can’t maximize the vision in other ways. And so you’ll often see patient with a cataract too, that’s affecting their vision or dry eyes is a really good example. So, just like you, I try to optimize the ocular surface because even if they have this visual field defect, if you optimize the ocular surface, they can often get better vision without even having to do anything extra for the glaucoma. So I think that’s really important to keep in their minds that, sometimes they go to these other doctors and they’re being told, “Oh, there’s nothing else I can do for you.” Right? But there is always something else you can do. And it’s even something really simple, like optimizing the ocular surface and fixing dry eye conditions.
Inder Paul Singh, MD: I’m glad you guys brought that up because it is really important to realize that there are very few other conditions in the eye that have as many associated symptoms as dry eye, right? Think about it. Tearing, burning, fluctuating vision, pain, redness, all these symptoms. And so if you do have bad glaucoma, let’s say, and you have lost a lot of your field of vision. You want to maximize the light entering the eye. And that’s where we can try to address the surface as much as possible. Sometimes it’s a hard set, take you off some medications, give you a holiday and do some drug delivery, a of beam of light, SLT. And then put you back on drops if we have to. So again, I think we’re trying to maximize the surface as much as possible now. We have tools that we never had before that can allow us that opportunity. So, fantastic recommendations. Thank you, guys.
Another question we had here is a question on caffeine and does it affect pressures, and do we [patients] have to limit the amount of caffeine that we use? And so Alicia, what are your thoughts on caffeine and the ability for that to change [intraocular] pressures?
Alicia Donahue, OD: I had a couple of glaucoma patients that came into the low vision clinic and they said, “Hey, I stopped drinking all coffee, and now I have these terrible headaches, because I think that the caffeine could be causing my recent increased IOP spike.” And what I usually will tell these patients is… I’ll always talk with their glaucoma specialist as well. But if you’ve been having your one to two cups of coffee a day, the last 20 years, and now you stop them and it’s causing awful headaches, I don’t that those one to two cups of caffeine a day are going to cause your glaucoma to be significantly worse.
Now, excessive caffeine, for many reasons, not just glaucoma, is not ideal. So having eight to 10 cups of coffee a day, or, I had one patient that came in that was drinking a huge, extra-large coffee, four times a day, for many reasons in general health, as well as for eyes, I’d probably recommend cutting that back. But your standard one to two cups a day, if you’ve been doing it for years, I don’t always tell patients it needs to be stopped.
Inder Paul Singh, MD: There’s some studies that show caffeine, actually doesn’t in fact increase, it actually lowers pressures in some cases, but general health you’re right. I have ADD in general. I’m always hyper. So me drinking more caffeine is not a good thing. Trust me on that one. But tell me about computer screens. We just talked about dry eye, but are computer screens bad or good for you when you have glaucoma?
Alicia Donahue, OD: So, some patients with glaucoma can experience more glare or difficulty from computer screens in some small studies, but the computer screen is not making glaucoma worse. So that’s what I always tell my patients. Now with extended computer use, it can make dry eye worse because you tend to blink less often when you’re staring at a computer for hours and hours. So some things that I’ll recommend, because dry eye can be seen in up to 60% of glaucoma patients. So what I’ll tell patients is you can get these little timers downloaded from the internet for free. They remind you every 20 minutes, it’ll beep, just look 20 feet away for 20 seconds. Blink your eyes. Stop the eye spasm from looking at the computer for so long and keep up your good visual hygiene.
Other things, a lot of patients will ask you about blue light blocking glasses for computers. They are always an option. I will say that the current studies do not show a huge benefit from them. So when patients go out and spend hundreds and hundreds of dollars on blue blocking glasses, there’s no large scale study yet showing that that is definitely helping. But to patients that anecdotally are benefiting from them, there’s no harm in using them. And many other tints, sometimes I’ll try on a computer as well.
Inder Paul Singh, MD: The 20-20-20 rule has helped me a lot because I’m on the Zooms all day long. And even now I’m like, “Oh my god, my eyes are getting dry. Oh no, I can’t see.” So thank you for that. I appreciate that. Just moving on. We have so many questions. I want to make sure I get to as many as possible. David, Sahar, and Ranya: Combined cataract and glaucoma, is that something that we’re doing mostly now? What are some of the options? I know you’ve mentioned some options, but can you combine cataract and glaucoma surgeries? Is that commonplace now?
David Richardson, MD: I think we’re doing that more than ever before. It’s interesting to see how things have changed in the last 20 years. When I graduated from residency, and now I’m aging myself, it was basically viewed that to combine the two meant one of them was going to fail, right? So either you’re going to have astigmatism at the time of cataract surgery from the trab [trabeculectomy] or the cataract surgery was going to increase the failure rate of the trab. And now with MIGS [minimally invasive glaucoma surgeries] and cataract surgery through corneal incision, and again, when I was in residency, we were actually doing superior scleral tunnel incisions. So yes, things have changed. And now if there’s somebody who’s even on a drop, one drop, for glaucoma and they’ve got cataracts, we should be thinking that this is an opportunity to treat this individual surgically with the safer minimally invasive glaucoma surgeries, as well as some of the bleb-related surgeries that are now available. And one of the reasons for that is, what you mentioned, is getting these patients off these drops can improve dry eye and improve the quality of their vision. So, that’s my view.
Inder Paul Singh, MD: Well, Sahar, you do a lot of the glaucoma surgeries and MIGS procedures as well. And so let me ask you, what is the value? This is someone on just one drop, they’re tolerating the drop okay, would you still do, let’s say a stent or something else at the time of cataract surgery to get them off that one medication? Is there a value, just getting them off of one med?
Sahar Bedrood, MD, PhD: Absolutely. I combine glaucoma surgery with cataracts [surgery] and it’s different for different patients. So if a patient is stable and on one drop, I will do a stent or some kind of angle surgery at the time of cataract surgery. Some of these MIGS devices really can only be done with cataract surgery. So I want to optimize that time in the OR and really do as much as I can, and with the lowest risk possible, to get this patient off drops, get lower pressure. It is all about improving their situation. So the stents or the angle surgeries are great in the more mild to moderate cases. In the advanced cases, you certainly can combine glaucoma [surgery] with a larger tube or a trab. I typically do those separately because I find that it has better success for me. However, in the more mild to moderate [cases], absolutely. I’m in there [performing cataract surgery], I am going to do something to lower their pressure.
Inder Paul Singh, MD: Ranya, let me hear your thoughts. Do you find yourself doing cataract surgery a little bit earlier than you used to? Obviously cataract surgery is safer now and the earlier we take out the cataract the quicker and safer it is for most patients, but do you find yourself now with glaucoma patients saying, “Let’s consider cataract surgery” earlier than you would have in the past?
Ranya Habash, MD: Yeah, absolutely. We’ve always known that just removing the cataract… always lowers the pressure by, in my experience, two to three points. (I don’t know what you guys think, but it would be good to hear your opinion too.) That in and of itself is already a help. And like we talked about before, sometimes the name of the game is to maximize the other stuff in the eye, even if you can’t treat one disease like glaucoma, as much as you have been. So, I think that’s really important, but then just like you guys were saying, you’re doing your patient a really big disservice, I think, if you don’t think about doing a glaucoma procedure at the same time as cataract surgery, because just like Sahar was saying, some of these devices are made to be used at the same time as cataract surgery. And it’s not even about the ocular surface at that point. It’s giving the patient a way so that they are always controlled by a way to control their [eye] pressure and it’s not dependent on them remembering to take their drops. So, compliance, as we know is an issue and this is a really nice safeguard that we can add at the same time as cataract surgery, relatively simply.
Inder Paul Singh, MD: I think, David, you mentioned astigmatism, I think now we’re actually treating astigmatism with cataract and glaucoma now. Before, because of trabeculectomy, you said “We’re not going to do so much. We’re not sure what our outcomes are going to be from a vision perspective.” Now, because these MIGS procedures, these angle-based surgeries are more predictable and less traumatic, I think we are able to offer things like a toric lens. Are you guys offering astigmatism correcting lenses at the same time as well?
Ranya Habash, MD: Oh yeah, absolutely.
Inder Paul Singh, MD: So, Sahar, do you offer premium lenses like say, premium or an extended depth of focus lens for certain glaucoma patients?
Sahar Bedrood, MD, PhD: I do. If the patient is mild to moderate [case of glaucoma] and they don’t have any central vision loss, I will offer them that. If they’re advanced or if they have central vision loss or they have significant peripheral loss, I don’t think that they will benefit from a premium lens. However, in the early stages, absolutely, because there is a very high chance that that patient will never get significant vision loss from their glaucoma, and while I’m in there, I really want to help them with their presbyopia or their reading and their distance [vision]. And sometimes I have patients that say, “Even if I get 10 years out of this lens and somehow later on get glaucoma, at least I got really good 10 years.” And so I always do offer it in patients that qualify and I tell them all the risks, the good, the bad, the ugly, and I let the patient make the decision. But again, you have to be able to offer that to the patients.
Inder Paul Singh, MD: That’s exciting. We were finally able again, to improve quality of life for our glaucoma patients and we never had the opportunity before. So I think for me, it’s a philosophical difference now. And many years ago, I used to say, “Okay, I have a patient who has cataract who also has glaucoma.” So I’ll take care of the cataract and deal with glaucoma later. But now that we have these options, I think of my patient as a glaucoma patient who happens to have a cataract. So I’m going to do everything I can, [when] I’m in there for cataract surgery, [to] take care of the glaucoma at the same time and maximize both [treatments] as well.
So thank you for those insights. I’m going to move on to some other questions. I want to get James involved, sorry James. I was in surgery all day long here, but you had some great points earlier about how to cope with the psychology behind what our patients are going through. What about exercise? And you mentioned a bit about what you can do, but can you elaborate more on what exercises might be good for patients not only from a safety, but also just from a psychological perspective?
James Nole: Yeah, I think depending on the level of low vision, it will vary person to person. Obviously, if they can be mobile, definitely walking, and things like that. Definitely, I think weightlifting and working out in the gym. Doing stuff on machines [in the gym] can be really safe for people with low vision, just because everything’s there. And it’s not like other things where you might have to be moving your body more in a confined space, but finding an open space too, where you can kind of do whatever, doing different kind of exercise routines, whether it’s calisthenics, free weights, things like that. I think most of them can be safe for people with low vision. I don’t think there’s too many… At least in my experience, I don’t think there’s really any that would be off limits other than maybe… I wouldn’t recommend somebody run in a big city unless they’re going to a track or something like that. But they definitely want to be careful when it comes to traffic and crossing the streets and things like that.
Inder Paul Singh, MD: I think getting out there, getting active as much as possible. I think psychologically speaking, I think it seems like the more my patients are active and can continue some type of regimen, continue some type of activity that they can do every day, I think it just keeps them more stable and it feels like they’re integrated in society more than being isolated. And the psychology behind it and what you spoke about is so important, so thank you for all that as well. Quickly for the panel, anyone who can answer these questions here. Two of them. One of them is sleeping positions. There are certain studies that show glaucoma can be affected by pressure and blood flow. And do you find that there are sleeping positions that you tell patients not to [use], or to avoid?
David Richardson, MD: That’s a tough one because people tend to sleep a certain way and if you tell them to sleep a different way, it disrupts their sleep. And so which one is really the most important. If we don’t get good sleep, then that’s bad for our health. But in general, I will tell, especially my patients who have vascular dysregulation, low tension glaucoma, or say pressure-related issues other than in the eye, if they can sleep with their head elevated 20 to 30 degrees, that may be a benefit. If I have patients who have one eye that is significantly worse than the other, in terms of their glaucoma, I will tell them not to sleep on that side. So if their glaucoma is worse on the right, I’ll tell them to try to sleep on their left side. There may be some benefit there in terms of the pressure, but my experience in general is that people are so… they have a certain way that they sleep and it’s very difficult for them to get rest if they change that. Any other experience there?
Sahar Bedrood, MD, PhD: When I was in fellowship, we did a project, or I knew about the project we did at our institution where they put a contact lens that measured pressure. And they found that patients who were sleeping on their eyes, so the pillow pressing on their eye, was actually increasing the pressure and was causing some problems and some potential worsening of vision for some of the more advanced [glaucoma] patients. I’m not as worried in the mild patients, but in the advanced ones, we may want to consider educating them because people don’t know what they don’t know, right? So I would say yes. I would avoid sleeping on the side with pressure so that you’re not constantly pushing on the eye because that is in itself causing the pressure to go up for five or six hours.
We’re doing all this stuff to try lower the pressure and then physically pushing on it could actually cause that. It’s a small thing. Whether it may or may not affect them in the long term, we don’t actually know, but I certainly would recommend it. But I agree. It’s hard to change someone’s sleep patterns. If they like to sleep on their stomach, then they’re going to get pressure on their eyes, but it’s definitely worth letting them know about it.
Inder Paul Singh, MD: Those are great points. [What about SLT laser treatment?] Even as a primary therapy. Can you repeat SLT? And do you repeat SLT?
David Richardson, MD: That’s a really interesting question. We know it can be repeated, I think in general, we’ve taken the approach of performing SLT, and then when it fails, redoing it. There’s an interesting study going on in Italy right now in which they’re just repeating SLT on a regular basis with a really low energy level. I think that’s a really interesting option. We don’t know the answer yet, whether that’s the best way of doing it, but it’s such a low risk treatment, my view is that if I’ve got a patient who it’s wearing off on my first thought is to offer to repeat it.
Inder Paul Singh, MD: And another question I have real quick for everybody here, is there a maximum number of drops one can take a day? This could be anybody’s question. Do you have a max that you say, “Okay, I’m done with drops.” Or do you just kind of have a certain limit, then you add more? Or how does that work for you?
Sahar Bedrood, MD, PhD: Well, you can add up to four different, maybe even five different bottles and certainly there are patients that are on that if they need to be. I typically, once I start adding the third bottle to the patient, I am thinking about surgery because we have found that it’s not very useful after… You keep adding and adding, right, and it’s not very useful for pressure lowering after the third or fourth bottle that you put on there. In some patients, however, especially when ones who don’t want surgery or can’t have surgery, sure, absolutely. We put on as many as we can to get to the optimal target pressure for them.
Inder Paul Singh, MD: That’s great. Absolutely. Changing our paradigm, we’re not waiting and waiting until people have poor compliance and then we’ll do something. After two or three bottles it’s hard to keep stable. Real quick here, Storing your [eye drop] bottles, do you guys have any advice on storing them when they’re walking, hiking, traveling? Any thoughts? Are you okay to keep them out?
Ranya Habash, MD: I always tell patients just to keep everything in the fridge, just because it’s cooler when it hits the eye’s surface, it doesn’t burn as much. And then being out walking, or out and about, you don’t have a choice a lot of times, but yeah, whenever you can I tell them to cool them down in the fridge.
Inder Paul Singh, MD: And they can tell that it got in the eye too, which is kind of nice. You’re absolutely right. Alicia, any thoughts on what over-the-counter medications they should avoid in terms of pills or even drops?
Alicia: So normally what I tell patients is if they’re going to be taking an over-the-counter artificial tear or something, make sure it’s separated by seven to 10 minutes from your glaucoma drop. Because oftentimes if you’re putting in those over the counter drops and then your glaucoma medicine, not all of it gets in, some of it washes out, because it’s too much liquid going on the eye at a time. I also tell patients to be really careful about any hydrocortisone cream or steroid cream near the eye. They sell that over the counter now and patients will use it if they get an allergic reaction near the eyelid, but that can really spike your eye pressure and so I always tell patients to definitely avoid that.
Another thing I find is sometimes patients will start taking like PreserVision or Eye-Vite when they have glaucoma because they see it on TV or they see it as an eye vitamin at the pharmacy. Those over-the-counter eye vitamins can be useful in certain types of macular degeneration. But PreserVision for glaucoma isn’t necessarily well studied or indicated. So you might be spending a lot of money on a vitamin over the counter that may not benefit your glaucoma specifically.
Inder Paul Singh, MD: Thank you for that. Unfortunately, we have so many more questions, but not enough time, but we’re going to try to get to them in the next Q and A session. Thank you everybody for the panel. Thank you for great presentations and all the questions from the audience.
(The printed edition of the Gleams newsletter is only available if you live in the United States or Canada)