Early Detection Poses Challenge

Glaucoma may strike individuals of any age, but it is most prevalent in people over the age of 60. For Black Americans, the rate of prevalence ticks up much earlier, at about 40 years of age, and people with diabetes or a family history of the condition are also more susceptible. Because glaucoma is asymptomatic in initial stages, early diagnosis is challenging.

The disease occurs when the optic nerve and the retinal ganglion cells — which relay visual inputs to the central nervous system — are damaged; elevated pressure in the eye, or intraocular pressure, is the main culprit. When fluid accumulates in the eye, such as from overproduction or improper drainage, it increases intraocular pressure and also the risk of developing glaucoma. Symptoms appear slowly, with changes in peripheral vision occurring before forward-facing vision becomes compromised.

Comprehensive eye exams can catch glaucoma in earlier stages, as these screenings involve optic nerve examination, intraocular pressure measurement, visual field testing and risk factor assessment. Patients must be proactive about regular screenings because once vision is lost, it cannot be repaired or restored. Available therapies can stop glaucoma’s progression and generally focus on alleviating intraocular pressure, but early diagnosis remains key.

Building on Existing Diagnostic Tools

Advances in diagnostic tools can give clinicians more and better information for treating glaucoma. Optical coherence tomography (OCT), for instance, uses light-wave imaging to help assess the optic nerve’s structural integrity. More recently, OCT angiography (OCTA) has been adopted to consider the optic nerve’s support system, such as blood supply. Functional imaging may be the next wave, as it should enable clinicians to identify cells under oxidative stress and take corrective action before irreversible damage is done.

Understanding a patient’s visual field is critical to identifying ocular diseases, and virtual reality goggles are emerging as a user-friendly, portable device. Doheny Eye Institute, dedicated to vision science, is investigating VR to enhance existing field vision testing and foresees future assessments that could bypass patient response. With its predictive powers, AI should also have a diagnostic role; AI may identify factors that clinicians could overlook when determining the risk of disease, progression, and aggressiveness so that patients can be treated early and accordingly.

Treatment Options Keep Evolving

Patients have various treatment options for glaucoma and generally take one of three paths: medication, laser or surgery. In the past five years, two new medications have surfaced, each with a novel mechanism of action that is additive to clinicians’ arsenals. The rho kinase inhibitor works to lower intraocular pressure, while a nitric oxide medication has dual action, reducing pressure and improving blood flow and oxygen to the optic nerve head. Research organizations like Doheny Eye Institute are also investing in the drug delivery arena, seeking ways to reduce patient error in medication administration and improve outcomes.

Laser treatment is nothing new in treating glaucoma, but techniques and instruments are constantly being refined. Laser trabeculoplasty has gained more acceptance, and as a minimally invasive procedure, it provides relief by reducing intraocular pressure. A more recent introduction, micropulse transscleral laser therapy also relieves intraocular pressure but by delivering energy in short pulses, which appears to minimize collateral tissue damage.

Should patients be beyond medication or non-invasive procedures, incisional surgery remains an option to improve natural drainage of the eye or insert an implant to create an accessory drainage pathway. Advances in surgical procedures, implants and devices continue to be sought after in research circles.

The Future Lies in Neuroprotection

Glaucoma research is a dynamic field, and an emergent focus is neuroprotection, where treatment extends beyond decreasing intraocular pressure to intervention in the chemical pathways that lead to the death of retinal ganglion cells. This exciting area considers protective effects, such as a drug therapy that could prevent cells from dying. It also explores how cells could be resuscitated, or what interventions could return damaged cells to their full functionality. Ultimately, this field of study is working toward neuro regeneration, where neural pathways may be fully restored so that lost vision may be regained.

With continued advances in glaucoma-related research and development across the board — from diagnostics and devices to pharmaceuticals and drug delivery to laser and surgical procedures — the future for patients is looking brighter. Maintaining momentum will be key for researchers to achieve the ultimate goal and find a cure for existing and future glaucoma patients.

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Glaucoma is a group of optic nerve-damaging eye conditions. The optic nerve transmits visual information from your eye to the brain. Optic nerve damage is often associated with high pressure in the eye (as is often the case with glaucoma). Still, glaucoma can occur even if you have normal eye pressure.

While glaucoma can occur at any age, it is more common among older adults. The disease is a leading cause of blindness for people over age 60.

Today we explore a United Kingdom study that explores the relationship between insufficient sleep and glaucoma risk.

Glaucoma basics

Glaucoma worsens over time and tends to run in families. Glaucoma can lead to permanent vision loss or blindness within a few years if the damage worsens.

Most individuals have no early symptoms (such as pain or visual loss). By regularly visiting your eye doctor, you are more likely to diagnose and manage glaucoma before you have a long-term visual loss.

Once the vision is lost, you cannot recover it. However, lowering eye pressure may help you keep the vision you have. Fortunately, most individuals with glaucoma who are diligent about regular eye examinations and follow their treatment plan will retain their vision.

Glaucoma causes

Normally, our eye’s fluid (or aqueous humor) flows out of the eye through a mesh-like channel. The fluid can build up if the channel is blocked (or if the eye produces too much fluid). Unfortunately, we don’t know the cause of the blockage, but one can inherit risk.

Less common causes of glaucoma include:

• Eye injury (such as from a chemical or blunt trauma; uncommonly from eye surgery for another condition)
• Eye infection, severe
• Blood vessel blockage in the eye
• Inflammatory conditions
• Steroid medicines

Glaucoma typically affects both eyes but may be worse in one than the other.

Glaucoma types

According to WebMD, there are two main forms of the condition: open-angle and angle-closure glaucoma. Open-angle (wide-angle) glaucoma is the most common type. The eye’s drain structure (trabecular meshwork) looks normal, but the fluid doesn’t flow out as it should.

With acute or chronic angle-closure (narrow-angle) glaucoma, the eye doesn’t drain properly because the drainage space between your iris and cornea is too narrow. The result? A sudden buildup of pressure within the eye. Angle-closure glaucoma is associated with cataracts and farsightedness.

Less common types include normal-tension glaucoma, a condition with visual blind spots. Alternatively, the optic nerve is damaged, even though the intraocular pressure is normal. Some view it as a form of open-angle glaucoma.

Finally, pigmentary glaucoma involves very small pigment pieces from your iris (the colored portion of your eye) getting into the eye fluid and clogging the drainage canals.

Glaucoma risk factors

While glaucoma most commonly affects adults over 40, one can suffer from the disease at any age. African-Americans are more likely to suffer from the condition at a younger age and with more vision loss.

After cataracts, glaucoma is the leading cause of blindness in African Americans. The Glaucoma Research Foundation explains that many people are unaware that:

Glaucoma strikes earlier and progresses faster in African Americans. The glaucoma risk is 1.2-times higher if the condition runs in the family. Other factors putting African Americans at even greater risk include age over 40, extreme nearsightedness, high blood pressure, diabetes, and prolonged steroid use.

Glaucoma is five times more common among African Americans. Glaucoma-related blindness is roughly six times more common. Glaucoma often occurs at an earlier age in African Americans — on average, about ten years earlier than in other ethnic populations.

We don’t know why African Americans have a higher risk, but inherited genetics plays a role.

Other glaucoma risk factors include:

• African American, Russian, Irish, Japanese, Hispanic, Scandanavian, or Inuit ancestry
• Age over 40
• A family history of glaucoma
• You are nearsighted or farsighted.
• Poor vision
• Diabetes
• Steroid medications such as prednisone
• Certain bladder control or seizure drugs. Select over-the-counter cold medicines may raise the risk.
• Eye injury
• Corneas that are thinner than usual
• Hypertension, heart disease, diabetes, or sickle cell anemia
• High eye pressure

Glaucoma symptoms and diagnosis

Symptoms

Most individuals who have open-angle glaucoma do not have symptoms (unless the disease is late in its progression). The primary symptom is a loss of peripheral (side) vision.

Angle-closure glaucoma symptoms typically come on more rapidly and are more apparent. Because damage can quickly occur, if you have any of the following symptoms, please seek medical care: Visual loss; seeing halos around lights; eye redness; eye pain; an upset stomach or vomiting; a hazy-appearing eye (especially in infants).

Glaucoma diagnosis

Many have glaucoma and don’t know it. Regular eye exams are critical to catching glaucoma or other eye problems. Clinicians may perform a dilated eye exam to widen pupils and view the optic nerve at the back of the eyes.

Genioscopy involves an examination of the angle where the cornea and the iris meet. An ocular pressure test (tonometry) measures eye pressure, while optical coherence tomography (OCT) searches for changes in the optic nerve.

Other approaches include pachymetry to measure corneal thickness and a visual acuity test (eye chart) to look for vision loss. A slit lamp exam examines the inside of your eye with a special microscope known as a slit lamp. Finally, a visual field test (perimetry) looks for peripheral vision changes.

Sleep insufficiency and glaucoma

A new research study illustrates an association between poor sleep and glaucoma. The study drew on a database of over 400,000 individuals (in the UK Biobank) to explore links between sleep and vision loss.

The study looked at sleep behavior, including too much, too little, insomnia, daytime sleepiness, snoring, and being a “morning lark” or “night owl.” The study defined normal sleep duration as seven to nine hours. After tracking the health and lifespan of the participants until the first diagnosis of glaucoma, death, emigration, or end of monitoring in 2021, researchers identified 8,690 glaucoma cases.

Here are the results:

Frequent daytime sleepiness was associated with a 1.2-fold higher risk for glaucoma. The risk rose 1.12-times with insomnia and 1.08-times with short or long sleep duration. Snoring was associated with a 1.04-fold higher risk.

Compared with those without glaucoma, participants with the condition tended to be male and older, and have high blood pressure, diabetes, or smoking history.

The risk increases associated with insufficient sleep appear to be relatively small. In addition, the researchers do not establish causality.

The researchers note that glaucoma might influence sleep patterns rather than vice versa. They also offer some possible biological explanations for the association. The internal pressure of the eye rises when we lie down or when sleep hormones are off (as happens with insomnia).

Furthermore, anxiety and depression (sometimes associated with insomnia) may increase eye pressure, possibly due to dysregulated cortisol stress hormone production.

Alternatively, repeated episodes of low oxygen secondary to sleep apnea may also damage the optic nerve.

I want to use this new research as a springboard to talking about glaucoma. Here are some steps from the Mayo Clinic that may allow you to detect and manage glaucoma early, hopefully preventing visual loss (or slowing its pace).

• Get regular eye examinations. Generally, the American Academy of Ophthalmology suggests an eye exam every five to 10 years if you are under age 40; every two to four years if you are 40 to 54; every one to three years if you are 55 to 64, and every year or two if you’re older than 65.
• You’ll need more frequent screening if you have a higher risk of glaucoma. Ask your healthcare provider to guide you to an appropriate screening program.
• Know your family’s eye health history. Glaucoma tends to run in families.
• Wear eye protection. Serious eye injuries can cause glaucoma. Please wear appropriate eye protection when you play sports or use power tools.
• Take prescribed eye drops regularly, as directed (even if you have no symptoms).

Other tips

Finally, don’t smoke, and watch your caffeine intake. The latter can increase your eye pressure. Elevate your head when you sleep, for example, with a wedge pillow to lower eye pressure.

Learn more here about glaucoma:

Glaucoma

Glaucoma is a condition that damages your eye’s optic nerve. It gets worse over time. It’s often linked to a buildup of…

www.webmd.com.

Thank you for joining me today.

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