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SEPTEMBER 2024 NEWSLETTERTHE GROWING CALL FOR PRESERVATIVE-FREE EYEDROPSPROGRESS IN OPTIC NERVE REGENERATION PROBLEMS WITH CONTRAST SENSITIVITY?GLAUCOMA AND YOUR LIFESTYLEPHYSICIANS’ PERSPECTIVE ON LIVING WITH GLAUCOMA Message
Newsletter September, 2024Message from the PresidentDear Readers, As summer nears its end, we are busy planning another season of our already impressive educational programming – aimed both at our growing interested public and the medical community.In this issue, you’ll read about last week’s fascinating webinar featuring Dr. Thomas V. Johnson and the exciting progress in his lab’s work on vision-restoring therapy at Johns Hopkins Wilmer Eye Institute. This was a follow-up to a webinar one year ago that is the most-watched webinar ever on our website, with over 70,000 viewers. Dr. Johnson has received partial funding for this important project from the Foundation via several named grants.Our next webinar, coming up on Thursday, September 12, features Dr. Janey L. Wiggs of Harvard Medical School and the Massachusetts Eye and Ear Inrmary. Physician-scientist Dr. Wiggs is a pioneer and international leader in ocular genetics. She will speak on The Role of Genetics in Glaucoma Diagnosis & Prevention. Looking further into the future, I am delighted to announce that Dr. Michael Chiang, Director of the National Eye Institute (NEI), will be speaking at TGF’s International Think Tank next summer.We so appreciate and thank you for your interest and your support. It gives encouragement and meaning to the work that we do on behalf of patients, scientists, and physicians.. With gratitude,Elena Sturman
Living with Glaucoma - Doctors’ PerspectivesPrevious “Living with Glaucoma” columns have focused on the lives and experiences of glaucoma patients. For this issue, we have turned the tables to focus instead on three doctors in a busy glaucoma practice. While they do not have glaucoma, they live with glaucoma as they care for patients every day.Drs. Jonah Bergman, Alexandra Cleminson, and Amy Lee are three optometrists who work in the high-volume practice of glaucoma and cataract specialist, ophthalmologist Gregory Harmon in New York City. They see newly-diagnosed as well as longtime patients as the rst stop for patients in the oce before seeing Dr. Harmon.“With newly-diagnosed patients,” Dr. Lee says, “we go over what glaucoma is, discuss the dierent ways we assess risk and treat the disease. We stress why adherence is so important, and explain why we have the many tests we do. And, we answer any questions patients might have so they can take better ownership of their care.”optometrist in his oce“Our relationship with our patients is a very important bond and trust is critical,” says Dr. Bergman. “It’s especially important because we see our patients regularly – every 3 or 6 months over a very long period of time, even a lifetime, as glaucoma is a chronic disease.” All three doctors agree that the most frequently asked question by newly-diagnosed patients is about vision loss, “Will I go blind?” “How will glaucoma aect my vision?”Dr. Cleminson says that while eye disease is scary, the doctors talk to new patients about the fact that glaucoma is generally a very treatable condition if diagnosed early, with an array of treatments, and that vision is usually controllable. “We try to comfort and provide reassurance to our patients.” “We also suggest some lifestyle changes – like exercising three times a week, avoiding steroids, drinking less caeine.”New patients represent dierent age groups. For some in their 50s, says Dr. Lee, we are asking them to do so much for their eyes. It seems like a lot, especially when there are no visual or physical symptoms.“It’s not unusual that some have never had an eye exam – they might be coming in because their reading glasses don’t work anymore. Part of our job is to say – this is why glaucoma is called ‘the sneak thief of sight.’”Some of the older patients may be more accustomed to spending time in a doctor’s oce. But they may not have support at home and some people have diculty putting eye drops into their eyes. “I try to help patients be compliant, to make the routine easier,” says Dr. Cleminson. “For example, if the patient is on several drops, I’ve made a diagram, with tables for when to take dierent drops, which color bottle to take when.”
Newsletter September, 2024 What can patients do? Be compliant with medications and not miss appointments. Learn about their family history and encourage family members who may be at risk to get their eyes checked.Access to information has been a real game changer, says Dr. Bergman. Patients can educate themselves about the disease process via the internet, which generally is a good thing. But as the doctors point out, some of the extreme cases found online can sometimes increase anxiety. “That’s why we’re here too – to help patients understand what’s important and what’s not so much,” says Dr. Lee.“Our practice is team work,” says Dr. Cleminson. Everyone contributes in dierent ways. At the end of a visit, the patient should feel fully satised that everything has been addressed.”Taking Lifestyle into AccountAt the June TGF Symposium, a presentation on the genetics of glaucoma was followed by a talk by Pradeep Ramulu, MD, PhD on “Taking Lifestyle into Account.” Dr. Ramulu is chief of glaucoma at the Wilmer Eye Institute at Johns Hopkins in Baltimore.He asked: “If glaucoma is the third most heritable disease, is there reason to focus on behaviors? We know there is some variability. Are there behaviors that could greatly lower the risks? Could we do better? Dr. Ramulu described three levels of glaucoma risk. Individuals at very high risk are going to get the disease, he said. People who are sort of in between may or may not get it. And then there is a third group – it doesn’t matter what they do, they are not going to get glaucoma. He compared this group to individuals who eat a cheeseburger every day but don’t get heart disease.Citing various past studies, Dr. Ramulu looked at whether certain lifestyle behaviors make a dierence, using IOP as a measure. He suggested future studies focus on the middle risk group to see if you can change the outcome.For example, one caeine study found that while caeine causes a rise in IOP among people in the higher risk group, it didn’t really seem to matter if you had a low predisposition.Marijuana use is the lifestyle issue that doctors get asked about all the time, said Dr. Ramulu. The simple answer, he said, is that marijuana use creates a very transient treatment, lasting only around 4 hours.While that may not convince some to abstain, he cited lots of other reasons. Dosing is not standardized. It’s THC – the primary psychoactive compound in marijuana, that actually lowers the eye pressures, and the actual amount of that you would get in a joint can vary widely.
The dosing you need to lower the IOP is actually the dosing that causes changes, including lowering of blood pressure and psychotropic eects. In other words, he said, you have to be high to lower your pressure. woman meditating in a quiet parkWhen people talk about marijuana today, they’re talking about many dierent forms. A lot of people want to use CBD oil as a substitute but CBD oil, Dr. Ramulu pointed out, has no eect on lowering IOP.On the other hand, Dr. Ramulu said studies on meditation have been pretty incredible -- there is strong evidence for IOP lowering with meditation in glaucoma eyes. When IOP was measured a few hours later, patients had a nice decrease in IOP.Exercise works too, but you have to keep on doing it to lower IOP. Several studies have pointed to positive systemic changes which is why exercise has been called the polypill. Risks for many diseases go down with exercise.One study put normal adults through a circuit training program. Using weights that increased their heart rates, they did nd that there were changes in perfusion blood ow.There is also strong evidence that exercise can benet mitochondrial function in addition to other benecial changes. Among people with glaucoma, more active people do progress slower, although the eect is rather mild. There is evidence that in animals, exercise really is protective for glaucoma.Dr. Ramulu thinks it would be helpful if we looked at lifestyle in connection with genetic risks – he thinks we could learn a lot more that way. Research Progress in Vision-Restoring Therapy The Johnson Laboratory at the Johns Hopkins Wilmer Eye Institute has spent the past ve years working to develop stem cell therapies capable of regenerating the optic nerve and restoring vision for patients suering from glaucoma.This is a challenging goal since it requires the replacement of lost nerve cells in the eye and the building of new connections between these stem cell-derived neurons and the patient’s own cells in the retina and the brain.Following up on Dr. Thomas V. Johnson’s popular TGF webinar last year, Dr. Johnson presented new developments from his research in an August 28th webinar, showing that TGF neurons are able to form new connections with the recipient retina after being transplanted into the eye. This advance represents a major step forward towards eventually developing new treatments for reversing blindness in patients with glaucoma.
Newsletter September 2024Retinal ganglion cells (RGCs) are neurons in the retina that transmit visual information from the eye to the brain. They are also the cells that die in glaucoma. As Dr. Johnson explained: “We have successfully transplanted human stem cells derived from ganglion cells into eyes and we’ve achieved formation of synapses between these donor neurons and the recipient retina. So we know that when we transplant these RGCs into retinas, they are actually receiving communications that start with the rods and cones about light entering the eye.””There is still a lot of work ahead,” says Dr. Johnson. “We need to get RGC axons into the brain. Once they get there they need to form synapses, communication stations, and they need to achieve connectivity.”To learn more about this important research, how vision is lost in glaucoma, and the complex steps of Dr. Johnson’s ongoing research aimed at eventually restoring that vision, we urge readers who missed this presentation to view it on TGF’s website or YouTube channel! Having a Problem with Contrast Sensitivity? You are not alone. Loss of contrast sensitivity is an extremely common condition associated with aging – and a common problem for people with glaucoma. Contrast sensitivity is what allows us to detect things like dierent shades of the same color. It refers to the dierence in luminance or color that makes an object distinguishable. Loss of contrast sensitivity can hamper many daily activities. For example, patients may notice some signs when they have diculty with:Driving at night, or in foggy, rainy, or glare conditions, and accurately determining distances, the position of the lanes, and the presence of other cars. Reading a newspaper or magazine where the print contrast against the paper background is poor and tight line spacing may make reading dicult.Distinguishing objects when they are similar in color to their background, like nding a black wallet in a black purse; or pouring coee into a dark-colored mug.The threshold at which you see the target when taking a visual eld test is one indication of your threshold sensitivity. There is also a contrast sensitivity gradient that your doctor can administer to assess your level.You may be able to improve contrast sensitivity with the use of various tinted glasses, working with your doctor or low vision specialist. Also, when you can control it, use good lighting.
Doctor, I Have A Question I’ve been hearing more about the need for preservative-free glaucoma eye drops. Why is this need increasing?Question Answered by:Steven Zhang MD, PhDChief Medical Ocer, Thea Pharma, Inc.In the past decade, awareness has gradually increased regarding the high prevalence of ocular surface disease among glaucoma patients, particularly dry eye disease, which is linked to the preservatives in glaucoma drops.Currently, approximately 80% of glaucoma eye drops on the US market contain preservatives. The most commonly used preservative is benzalkonium chloride (BAK), found in concentrations ranging from 0.003%-0.02%. The eects of BAK have been well studied, and it is known to cause eye irritation and inammation, which could lead to the disruption of tear lm production, cell and tissue damage, and result in ocular surface disease such as dry eye. And ironically, many articial tears available for the treatment of dry eye disease in the US still contain preservatives. We acknowledge that preservatives are necessary to maintain the sterility of certain eye drops. However, for the treatment of chronic diseases like glaucoma, it’s preferable to avoid exposing patients’ eyes to preservatives, especially BAK. The longer and more frequently preservative-containing eye drops are used, or when multiple preserved eye drops are used, the more susceptible patients become to ocular surface disease. Over time, BAK harms the cells that help lubricate the surface of the eyes and the sensory nerves in ocular surface tissues.In Europe, the movement towards utilizing preservative-free glaucoma eye drops began earlier and it’s widely recognized. For example, in Denmark, it’s illegal to switch to a generic version of an eye drop containing BAK when a patient is prescribed a brand-name eye drop that does not contain BAK. Dierences in regulatory and pricing structures also exist resulting in more preservative-free glaucoma medications in Europe than in the U.S.While we lag behind Europe’s acceptance, we are now creating greater awareness and educating patients and doctors about the negative impact that all preservatives can have on the surface of the eye, as well as on a patient’s health and quality of life.Thea has a long legacy in developing preservative-free eye medication worldwide, including not just glaucoma drops but also articial tears. The Glaucoma Foundation is playing an important role in this eort as a founding member of the Preservative Freedom Coalition, which comprises stakeholders from patient advocacy groups, industry, and professional organizations who share a common goal of improving patient outcomes and ensuring access to safe and eective preservative-free treatment options.
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