(soft music)
Welcome to "Hadley Presents".
I'm your host, Ricky Enger inviting you to sit back, relax,
and enjoy a conversation with the experts.
In this episode, we explore frequently asked questions
regarding glaucoma.
And our guests are glaucoma specialist, Dr. Jullia Rosdahl
of the Duke Eye Center, interviewed
by Hadley Chief Program Officer, Ed Haines.
Welcome to the show, both of you.
Thanks Ricky.
Thanks Ricky, I'm really excited to be here.
I'm excited to have you
because glaucoma is one of those things
that I actually don't know as much about as I should,
even though my fiance has glaucoma
and sometimes I ask him things
and he tells me what he knows.
But I think that I'm going
to learn a lot more from our conversation today.
Before we jump into that though, I want
to know a little about each of you.
Just tell the audience a bit
about who you are and what you do.
Let's start with you, Ed.
Well, I'm Ed Haines.
I'm the Chief program officer at Hadley.
I've been with Hadley about 15 years,
but I've spent the majority
of my career in the field working with older adults
with vision loss, so I've had a lot
of clients over the years with glaucoma, so I'm thrilled
to be able to talk to Dr. Al today.
Fantastic and Dr. Rosdahl,
how about you, tell us a bit about yourself,
and I'm always curious
about how people choose the careers that they do.
So just tell us a bit about you
and what made you decide to become a glaucoma specialist.
Well, thank you.
So as you noted in the intro,
I'm a glaucoma specialist at the Duke Eye Center
in Durham, North Carolina.
And in additions to seeing patients with glaucoma
and prescribing eyedrops and doing lasers
and surgery, I also teach medical students
and ophthalmology residents,
and I'm involved in some research as well.
I lead our wellness program at the Eye Center
and I serve on some national organizations,
including the National Eye Health Education Program,
also called NEHEP,
and that's part of the National Eye Institute.
And that's actually where I learned about Hadley
and the great work that you're doing
for people with vision loss.
So I think that's how I was able to connect
and be a part of this program today.
You also asked about why I chose glaucoma as a specialty,
and I really enjoy telling this story.
When I was in medical school, I did a combined program
where I earned both a PhD and an MD.
And yes, my parents did wonder if I
ever would finish school, but I eventually did.
And in my PhD I studied how the neurons in the eye,
the retinal ganglion cells, how they developed
and made connections in the brain.
And that led me to the specialty of ophthalmology.
And then the choice of glaucoma wasn't a choice at all at
that point because in glaucoma, the neurons that die
and cause vision loss, those are the retinal ganglion cells.
And so now every day as a glaucoma specialist,
my job is really to help people save their vision
by saving those retinal ganglion cells.
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.
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?
So 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.
So when the nerve dies off like that, people lose vision
and it usually affects their peripheral
or side vision first in 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,
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.
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?
So 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 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 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 disease is 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 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.
And that actually was gonna be my next question.
I was just gonna ask,
does you know glaucoma always result
in some vision loss or blindness?
Can people with the right kind
of treatment prevent having any vision loss at all?
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 those areas
of vision loss, but they are not noticing it.
And so those patients too, with treatments started,
they can really not have vision loss
that's affecting their quality of life.
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?
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 vision.
And what are normally the kinds of treatments
that you prescribe for folks with glaucoma?
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 eye drop 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.
And I know with eyedrops, I've worked with people
that are not necessarily as conscientious about compliances,
maybe they should be.
So how important is it that the person follow through
with your exact prescription
and your instructions for medication?
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 regimens 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 eye drop medications.
Some of them need to be dosed 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.
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, people are advised against those
kinds of activities.
Do you recommend lifestyle changes to go with medication
or is that dependent on the individual?
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 neck ties 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 kind 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 gonna 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 in really advanced 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.
Now if people are adhering to their treatment
and they're 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?
That is a really common question, Ed.
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.
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?
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 testings 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.
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?
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 eyedrops will make their eyes feel better
or help them to see better, but that really isn't the case.
Eyedrops 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.
And once folks start seeing you
as their glaucoma specialist, do they still need
to see their local optometrist
or their local ophthalmologist as well?
Or do you kind of handle their care,
their primary eye care from that point forward?
So 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, a need for contacts,
and those are things that the optometrist
or that comprehensive doctor is helping with.
And so they'll still see them for those reasons.
And some patients have to travel quite a distance to see me.
And so we will 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.
Oh, that makes perfect sense.
And 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
and 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 to patients like that?
So I often have patients
who have both macular degeneration and glaucoma,
and I partner with my retina colleagues
to care for those patients.
And 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.
Okay, great advice.
I know it's scary how common I've 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?
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, just in this past year, a new way
of delivering glaucoma medications was approved by the FDA,
and it's an implant
that we can inject right into 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 eyedrops.
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.
Well 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 eyedrops, 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?
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's 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.
Well, that's terrific information
'cause I know that is a concern.
So thanks very much and I'm glad I asked the question.
Yeah, that's a 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 wanna 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,
places that they can go just
to do some of their own research?
So the websites that I recommend
for learning about glaucoma include the American Academy
of Ophthalmology Patient Education website.
That is called eyesmart.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 gonna 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 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 specialists.
Fantastic and we'll have all
of those resources in our show notes.
I wanna 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.
Oh, you're welcome, it was a pleasure.
It's been my pleasure,
Ricky and Ed, thank you so much.
Thank you.
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