Lifestyle Changes for Glaucoma Patients

Yvonne Ou, MDAssociate Professor of OphthalmologyCo-Director, Glaucoma ServiceVice Chair for Postgraduate EducationDepartment of Ophthalmology, UCSF

Disclosures: None

““Doctor, what else can I do to help my glaucoma?”

Where are we on the pyramid?

Avoid overtreating hypertension

Sleep habits

Eat your veggies

Start exercising

Don’t overcaffeinate

Keep yoga upright

Lifestyle modifications in glaucoma

141 patients, avg age 65, 57% female

Mean baseline MD -6.6 dB

Average of 6.7 days of physical activity measurement, average of 5613 steps per day, 148 min/day of nonsedentaryactivity, 11 min/day of moderate-to-vigorous physical activity

Ophthalmology 2019;126:958-964.

““Each incremental increase of 1000 steps per day was associated with less sensitivity loss over time (+0.007 dB/year, P < 0.001). Each additional 30 minutes of nonsedentary activity and each 10 minutes of moderate to vigorous activity also associated with less VF sensitivity loss over time.”

Ophthalmology 2019;126:958-964.

Patients with greater VF loss perform less physical activity

Ramulu PY et al. Ophthalmology 2012;Jun;119(6): 1159-1166.

JAMA. 2018;320(19):2020-2028

““Adults should do at least 150 minutes to 300 minutes a week of moderate-intensity, or 75 minutes to 150 minutes a week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity. They should also do muscle-strengtheningactivities on 2 or more days a week. Older adults should do multicomponent physical activity that includes balance training as well as aerobic and muscle-strengthening activities.”

““Recommendations emphasize that moving more and sitting less will benefit nearly everyone. Individuals performing the least physical activity benefit most by even modest increases in moderate-to-vigorous physical activity.”

Fact or Fiction?Glaucoma patients should avoid yoga

Jasien JV et al. PLoS ONE 2015; Dec; 10(12): e0144505

Downward dog results in the largest IOP increase in healthy and glaucoma patients

Jasien JV et al. PLoS ONE 2015; Dec; 10(12):e0144505.

Fact or Fiction?Sleeping with the head of the bed elevated lowers IOP

AJO November 2015, 160(5):929-936.

Lateral decubitus body position results in higher IOP in dependent eyes

Optom Vis Sci 2016, 93(9):1163-1170.

2 mmHg lower

2 mmHg higher

2 mmHg higher

Don’t overcaffeinate

Lifestyle modifications in glaucoma

Prospective, double-masked, crossover, RCT with 106 subjects

Subjects ingested 237 ml of caffeinated or decaffeinated coffee

IOP and BP were measured; OPP calculated

“Consuming one cup of caffeinated coffee (182 mg caffeine) statistically increases, but likely does not clinically impact, IOP and ocular perfusion pressure in those with or at risk for POAG.”

Eat your veggies

Lifestyle modifications in glaucoma

Greater intake of dietary nitrate (green leafy vegetables), an exogenous source of NO, was associated with a 20-30% lower POAG risk

The effect was greatest (40-50% lower risk) for POAG with early paracentral VF loss at diagnosis, to which vascular dysregulation has been associated

JAMA Ophthalmol. Mar 2016;134(3):294-303.

AJO October 2012, 154(4):635-644.

AJO June 2008, 145(6):1081-1089.

Avoid overtreating hypertension

Lifestyle modifications in glaucoma

What does the SPRINT trial mean for our glaucoma patients?

The SPRINT Research Group.N Engl J Med 2015; 373:2103-2116.

Systolic BP in the standard vs. intensive treatment groups

The SPRINT Research Group.N Engl J Med 2015; 373:2103-2116.

Intensive treatment group had a 25% lower relative risk for primary outcome

The SPRINT Research Group.N Engl J Med 2015; 373:2103-2116.

JAMA. 2016;315(24):2673-2682. doi:10.1001/jama.2016.7050

Treatment goal for SBP of less than 120 mm Hg reduced incident cardiovascular disease by 33% and total mortality by 32%.

The mean diastolic BP in the intensive group was 62 mmHg, 5 mmHg lower than in the standard group.

Ophthalmology 2007, 114(11):1965-72.

Ophthalmology 2014, 121:2004-12.

The duration and magnitude of decrease in nocturnal blood pressure below the daytime MAP, especially pressures that are 10 mmHg lower than daytime MAP, predict NTG progression.

Low nocturnal blood pressure, whether occurring spontaneously or as a result of medications, may lead to worsening of VF defects.

Work with internist & avoid nocturnal

hypotension

Head of bed elevation

Eat green leafy veggies

Start exercising, esp. if you aren’t already

Don’t overcaffeinate

Keep yoga upright, as inverted poses

transiently increase IOP

What I tell my patients about lifestyle changes

Thank you!

What I tell my patients about lifestyle modifications

Get moving, especially if you aren’t already Inverted head poses transiently increase IOP, but how this truly affects

glaucoma progression is unknown Consider sleeping with the head of the bed elevated Eat a variety of fruits and vegetables, especially green, leafy

vegetables Drink your daily cup of coffee, but don’t binge (or switch to decaf) What other risk factors for CV disease do you have? If not many, and/or

if glaucoma is progressing despite good IOP control, ensure patient is not being over-treated for hypertension

Caffeine inhibits ganglion cell loss in experimental glaucoma

Madeira MH et al. Sci Rep. 2016 6:27532.