Glaucoma: Anti-Glaucoma Regimen; Emphasizing Non-Pharmacologic Therapy and Lifestyle Changes; Part 3 of a 3-Part Series

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Glaucoma: Anti-Glaucoma Regimen; Emphasizing Non-Pharmacologic Therapy and Lifestyle Changes; Part 3 Of a 3-Part Series

Part I of this paper discussed the failure of conventional glaucoma therapy. Part II discussed the epidemiology and etiology of glaucoma. Part III presents non-pharmacologic approaches to this blinding eye disorder. According to the medical literature a daily nonpharmacologic regimen to help control, prevent or eradicate glaucoma would include the following:

A. Shift the diet away from meats and dairy products towards a largely vegetarian diet that includes cold-water fish and eggs.

Rationale: The retinal blood vessels supply oxygen and other needed nutrients (antioxidants, B-vitamins, precursors for neurotransmitters) to the retinal ganglion nerve cells and their axons. The caliber of the retinal blood vessels among glaucoma subjects is much smaller than healthy individuals.( 1) Thus any antiatherosclerotic, anti-vasoconstriction measures that can maintain the diameter of these vessels is primary. Research conducted in 1949 at Duke University noted that all of the patients with ocular hypertension who were placed on a lowfat rice-based diet showed marked reduction in their intraocular pressure. The 2000 calorie diet consisted of only 5 grams of fat derived from rice, sugar, fruit and fruit juices and excluded foods like nuts, vegetable juices, and absolutely no salt. Patients were given nutritional supplements consisting of moderate doses of vitamins A, D, B1, B2, B3, pantothenic acid and calcium. Reductions of 5-7 mm Hg in eye fluid pressure were not uncommon over long periods of time, which is greater than can be accomplished with current medical therapy.( 2, 3) The responses were almost immediate. Within two days of employing the low-fat rice diet, systemic blood pressure and intraocular pressure fell dramatically. Yet today, few if any eye physicians suggest a change in diet to control intraocular pressure. A diet centered around vegetables reduces systemic hypertension( 4) and should reduce intraocular fluid pressure. Dietary control has application to the estimated 7 million American adults who have the pre-glaucoma condition called ocular hypertension. Weight control is also part of this regimen. Moderate egg consumption does not significantly increase total cholesterol and may increase HDL "good" cholesterol.( 5)

Adrenal hormones are involved in regulating intraocular pressure. Acetylcholine, an adrenal hormone, is involved in vaso-regulation among cardiomyopathic animals but not in normally healthy animals. LDL (lowdensity lipoproteins) inhibit the relaxation of the vascular endothelium to acetylcholine, serotonin arid aggregating platelets. This suggests that chronic hyperlipidemia inhibits the relaxation of smooth muscle that lines the retinal blood vessels.( 6) Thus a diet low in saturated fat that includes LDL-lowering foods (garlic, vitamin C-rich foods, almonds, onions, olive oil, fish oils, grape seed oil, avocados) is desirable.( 7) Because LDL cholesterol really does its damage once it hardens or becomes oxidized within the arterial wall, potent antioxidants, especially vitamin E and coenzyme Q10, have been recommended.( 8) Since LDL oxidation is dependent upon copper and iron, avoidance of these oxidants in food supplements is also advised.( 9)

B. Daily exercise, at least 30 minutes of brisk walking.

Rationale: Aerobic exercise training has been shown to decrease mean intraocular pressure by 4.6 mm Hg in previously sedentary glaucoma patients.( 10) Physically unfit glaucoma patients experience more of a benefit from an exercise program compared to those who participate in active exercise.( 11) The pressure-lowering effect of exercise is equal to (and additive to) that of topical beta blocker eye drops.( 12) The intensity of the exercise appears to increase the pressure-lowering effect.( 13) Because many glaucoma patients may be elderly and overweight, patients may not be amenable to strenuous exercise. However, a regimen of 40 minutes of brisk walking four times a week for three months has been shown to significantly reduce intraocular pressure.( 14) Few eye physicians suggest an exercise program for their glaucoma patients.

Aggressive physical exercise which produces profuse sweating may cause loss of important electrolyte minerals, such as zinc, potassium and magnesium. Replacement of lost electrolyte minerals may be required.

C. Avoid tobacco, as nicotine has been identified as an optic nerve toxin (tobacco amblyopia).

Rationale: Some studies indicate cigarette smoking has little or no effect on the incidence of glaucoma.( 15, 16) However, one study shows that active cigarette smokers have a 2.9 times increased risk of developing glaucoma.( 17)

The effect of cigarette smoking was compared among 70 glaucoma patients and 70 normal adults. Immediately following their last puff on a cigarette their eye fluid pressure was tested. The intraocular fluid pressure rose more than 5.0 mm Hg in 37% of the glaucoma subjects versus only 11% of the normals. The authors of this study concluded that cigarette smoking temporarily increases vasoconstriction.( 18)

Nicotine has been shown to decrease retinal blood flow by 9.6-16.4% among diabetics who have a high incidence of glaucoma.( 19) The internal diameter of blood vessels has been shown to decrease after smoking.( 20) Smoking has been shown to block normal vasodilation.( 21)

Tobacco has another route whereby it may promote glaucoma. Tobacco amblyopia has been shown to occur without malnutrition, accompanying alcoholism, or a deficient vitamin B12 status.( 22) Smoking may promote the lack of hydrochloric acid upon which various optic nerve nutrients, particularly vitamin B12, depend upon for absorption.( 23) In two cases smokers experienced bilateral optic neuropathy without malnutrition, alcoholism or abnormal vitamin B12 levels. Administration of intramuscular vitamin B12 resulted in complete recovery of vision even though the patients continued to smoke.( 24)

All smokers and alcohol users, whether they have detectable glaucoma or not, should be prophylactically placed on a daily nutritional supplement regimen that includes 1500-3000 micrograms of oral vitamin B12, the glutathione precursor cysteine and 600 mg. of vitamin E (both shown to detoxify cyanide induced optic nerve disease),( 25) and 1 milligram of folic acid (which has been shown to increase visual acuity among smokers with optic neuropathy -mean visual acuity improvement of five lines on the Snellen eye chart in 2 months).( 26) I.H. Leopold recommends a combination of 300 milligrams of thiamine (vitamin B1) weekly and 1000 micrograms of intramuscular vitamin B12 (hydroxocobalamin) weekly for three months in severe cases of tobacco amblyopia.( 27) Low blood thiamine levels have been reported among patients with common glaucoma which has often been associated with malabsorption due to a lack of digestive enzymes.( 28)

D. Reduce free-radical induced inflammation and oxidation by:

Wearing ultraviolet-protective eyewear.
Increase intake of fresh fruits and vegetables to five servings a day.
Supplement with antioxidant nutrients. Various experts and organizations have stepped out to recommend antioxidant supplements for the population at large. The following are believed to be safe dosages of nutrients.
G.E. Bunce, eye researcher, Department of Biochemistry and Nutrition, VPI and State University:( 29) Vitamin E: 200-400 IU, Vitamin C: 100250 Mg, Beta carotene: 25 Mg

Alliance for Aging Research:( 30) Vitamin E: 100-400 IU, Vitamin C: 250-1000 Mg, Beta carotene:10-30 Mg

University of California at Berkeley Wellness Letter:( 31) Vitamin E: 200-800 IU, Vitamin C: 250-500 Mg, Beta carotene: 6-15 Mg

Rationale: In 1993 David L. Epstein, professor and chair of ophthalmology at Duke University, said "what we need is a trabecular diuretic"( 32) -- drano for the eyes. Just such a drain cleaner may be found in antioxidants. Ironically, a decade earlier, Professor Epstein participated in an animal study that showed that glutathione, a potent endogenous antioxidant whose synthesis can be dietarily enhanced by the amino add cysteine, was effective in protecting the fluid drain of animal eyes from hydrogen peroxide-induced damage. The fluid outflow through the drain was suppressed only when the protective antioxidant/glutathione system was inactivated.( 33) Why oral antioxidants are being ignored as therapy for glaucoma patients is unexplained.

F.M. Flores notes that oxygen free radicals and hydrogen peroxide in the aqueous humor are involved in the biochemistry of the fluid drain of the eye. Oxidation of methionine residues of collagen in the trabecular meshwork has been documented in eyes from patient with common glaucoma.( 34) Lipid peroxidation is involved in the dystrophy and destruction of cells in the fluid drain of the eyes.( 35)

A laboratory study shows that a steroid (dexamethasone) or other oxidative stress decreases the phagocytic (garbage-removing) properties of the cells in the fluid drain of the eye.( 36) This gives credence to the idea of supplementation with oral antioxidants.

There are sparse but encouraging reports on the use of antioxidants to treat glaucoma. S.C Evans used large doses of antioxidants, 180,000 IU of vitamin A, 200 mg. of vitamin E and 3000 mg. of vitamin C to bring glaucoma under control within a one week period of time among malnourished West Africans.( 37) Researchers in India theorize that vitamin A works to maintain an open drain within the eye by sustaining the dehydrated state of collagen. Should hydration of the collagen meshwork in the fluid drain of the eye occur then openings in the drain swell which leads to the buildup of abnormally high fluid pressure. Glaucoma subjects have been found to have lower serum carotenoid (vitamin A precursor) levels than glaucoma-free individuals.( 38)

Antioxidants also protect the optic nerve in two other important ways. One is to block oxygen-free radical induced vasoconstriction that leads to ischemia of the nerve cells. Schumer and Podos recently suggested the use of antioxidants such as ginkgo biloba and vitamin E in the control of glaucoma.( 39) Second, the optic nerve sheath may come under attack from free radicals induced during a viral infection or other systemic disease. Antioxidants may thus protect from inflammatory demyelination of the nerve sheath. Glutathione peroxidase (endogenous antioxidant derived from cysteine, selenium and vitamin E), catalase and superoxide dismutase (zinccopper dependent endogenous antioxidants), have been shown to detoxify hydrogen peroxide induced demyelination of the optic nerve.( 40-42)

It is interesting to note that the extinction of xanthophyll carotenoids from the papillo-macular area of the retina, as detected by non-invasive spectrophotometry, is the first detectable sign of optic nerve fiber loss among patients with glaucoma.( 43) Carotenoid pigments derived from green leafy vegetables (xanthophylls as obtained from spinach, collard and mustard greens and kale) are potent antioxidants and have recently found to be beneficial in prevention of macular degeneration.( 44)

High-dose vitamin C has been used to control the intraocular pressure through an osmotic effect. Oral doses of vitamin C, 0.5 grams/kilogram of body weight (34 grams for a 150 pound person), have been shown to reduce eye fluid pressure.( 45) By dividing daily dosages into 3-4 daily administrations and starting with single-daily doses and slowly working up to bowel tolerance, the side effects of diarrhea and nausea are avoided. However, such high doses of vitamin C are not practical for everyday control of glaucoma.

E. Rule out toxic effects to the Optic nerve from drugs, especially steroids.

Various pharmacological preparations are known to be toxic to the optic nerve, including ibuprofen, aspirin, tranquilizers and antidepressants (lithium, monoamine oxidase inhibitors), antidiabetic drugs, and antibiotics (chloramphenicol, isoniazide, ethambutol). Maria Teresa Dorigo and Romeo Altafini write: "While adverse drug reactions do not greatly affect the optic nerve...many of these side effects may be overlooked....Visual defects due to toxic neuropathy are...usually attributed to another cause."( 46) Irving Leopold notes that drugs such as ethambutol, diodohydroxyquin and iodochlorhydroxyquin are metal chelators that have been linked to optic nerve atrophy. Thus zinc supplements should be considered when suspected pharmacological agents are being used.( 47)

The widespread use of corticosteroids, and the known fluid-pressure rise of steroids makes this prescribed hormone the primary iatrogenic cause of glaucoma. For some time now investigators have been aware of an unknown factor that produces a variable fluid pressure response to topical steroid preparations, whether studied along individual or genetic lines. There is ample evidence that vitamin C may be this unknown factor that normalizes fluid pressure with the use of steroids.

While serum vitamin C levels can become saturated at less than 200 mg. daily intake, extracellular fluids such as the aqueous exhibit 20-30 times greater concentration than blood. This is believed to be a protective mechanism against solar-induced oxidation and inflammation.( 48) Even among individuals whose average dietary intake of vitamin C is 148 mg./day (two times the Recommended Daily Allowance), supplementation.with 2,000 milligrams of vitamin C increases aqueous ascorbic acid levels by 32%.( 49)

In 1974 researchers from Italy found that steroid eyedrops dramatically reduce the levels of vitamin C from the aqueous, vitreous and lens of rabbit eyes. Topical steroids also cause the aqueous fluid to gradually become alkaline which is directly related to a 5.5 mm Hg average rise in intraocular pressure after 30 days of instillation.

These researchers concluded, when corticosteroids are used, that "convenient doses of vitamin C should be administered both by systemic and possibly by topical route, in order to maintain ocular physiological levels."( 50) Vitamin C regenerates type I collagen, laminin and fibronectin growth factors in the coils of the fluid drain (trabecular meshwork).( 51) Uncounted thousands of adults who use steroid preparations come down with avoidable glaucoma annually, a malady that could be prevented by avoiding the use of steroids altogether (which only mask symptoms of inflammation), or by administering vitamin C in therapeutic dosages during steroid therapy.

F. Supplement with smooth-muscle relaxants and natural-calcium channel blockers:

Magnesium: 400 mg. daily

Rationale: Vasoconstriction may occur at any site in blood vessels where there is a concentration of free-radicals and eventual release of thromboxane. Vasoconstriction has been noted to be a problem among glaucoma patients earlier in this paper, especially among low-pressure glaucoma patients.

Smooth muscle which surrounds blood vessels constricts with the buildup of intracellular calcium. Calcium-channel blockers have been utilized successfully to treat low-pressure glaucoma, but their side effects are of concern.( 52, 53)

The role of magnesium in glaucoma therapy is intriguing. Magnesium is known as "nature's calcium-channel blocker." The western diet is rich in calcium, a mineral that has been widely linked with arterial disease.( 54) Western diets are abundant in calcium-rich dairy products and weak in magnesium due to the depletion of this mineral from soil with the use of artificial fertilizers.( 55) Magnesium deficiency is associated with systemic hypertension, a factor associated with glaucoma.( 56) A regimen of 365 mg. of magnesium divided into three daily doses has been shown to reduce blood pressure among patients taking oral beta blockers.( 57) A low magnesium/high calcium ratio favors blood coagulation and increases the release of adrenal hormones that are involved in intraocular pressure regulation.( 58) Adrenal hormones stimulate the decomposition of fat (lipolysis) which can intensify magnesium deficiencies as magnesium forms a complex with liberated fatty acids.

As previously noted in this paper, silent heart attacks have been found to be more prevalent among low-pressure glaucoma patients. Magnesium has been shown to reverse atrial fibrillation,( 59) a problem also noted among low-pressure glaucoma patients. Low dietary magnesium has been positively linked with sudden cardiac death.( 60) Patients with Raynaud's disease (cold hands and feet) do not respond to magnesium supplementation as well as do healthy adults.( 61) Raynaud's has been positively linked with the low-pressure variety of glaucoma. The use of 750 mg. of daily oral magnesium has been shown to improve retinal circulation in cases of hypertensive retinopathy.( 62) A daily regimen of 243 mg. of magnesium has been shown to improve circulation and visual fields among glaucoma patients with vasospasm.( 63)

Physical or emotional stress increases the need for magnesium. As noted previously, a stressed-out, anxious personality has been observed among many glaucoma patients.( 64)

The low daily intake of magnesium, less than the Recommended Daily Allowance,( 65) suggests that physicians would be wise to recommend daily magnesium supplements for their glaucoma patients, if not their entire patient population. The prevalent recommendation of a 2:1 ratio of calcium to magnesium to enhance bone strength should be questioned as a possible contributor to vasoconstrictive disease. A 1:1 calcium/magnesium ratio would be more desirable.

Other vasodilating agents may also be effective. The use of L-arginine has been shown to restore vascular endothelium vasodilation,( 66) which may have application for glaucoma subjects.

G. Use safe nutritional supplements that naturally reduce secretion of aqueous humor.

Coleus: 200-400 mg. daily

Rationale: Coleus is the herbal equivalent to pressure-reducing eye drops.

Coleus is a variety of mint plant used by ancient Hindu practitioners as a remedy for a variety of disorders including asthma, heart disease and high blood pressure. Forskolin is the name for the herbal extract of coleus used in experimental eye drops to control glaucoma. Like magnesium, forskolin/coleus relaxes smooth muscle and thus enhances vasodilation. Coleus is available in capsule form in health food stores for oral intake under the ayurvedic Indian medicinal name forskohlii.

Coleus is related to magnesium through the intracellular messenger called cyclic AMP. Magnesium inhibits cellular calcium influx and accentuates cyclic AMP.( 67) Increased cyclic AMP levels are associated with suppression of platelet aggregation and relaxation of vascular smooth muscle.( 68) Cyclic AMP is produced by the non-pigmented epithelial cells of the ciliary body or aqueous secreting gland of the eye. Cyclic AMP is a key intermediate in the regulation of aqueous humor,( 69) the fluid that fills the front of the eye and which carries nutrients (primarily glutathione and vitamin C) to the lens and cornea. Eye drops containing one percent forskolin/coleus lower the eye fluid pressure for up to five hours by reducing the flow of aqueous fluid within the eye by 40%.( 70) Just one drop of forskolin reduced intraocular pressure by 34% in humans.( 71) Various other drugs have been designed to stimulate cyclic AMP, the cellular messenger that controls aqueous flow in the eye. These in clude calcium channel blockers (Verpamil, Nifedepine), prostaglandins and melatonin.( 72) The use of coleus appears to pre-date these drugs by several centuries. Coleus is also known to have antihistamine properties and thus may reduce allergically controlled elevation in eye fluid pressure.( 73)

The experimental use of forskolin eye drops was abandoned because it is an opaque substance (patients can't see through it) and it didn't penetrate into the cornea very well. The non-patentable oral route of administration provided no economic incentive for pharmaceutical companies to bring such a product to market.

More forskolin/coleus is required in darkly pigmented eyes because of its attachment to the melanin pigment of the iris.( 74) Coleus has a long history of safety. Suggested daily dosage is 200-400 mg.

Since omega-6 fatty acids produce a two-fold increase in intracellular cyclic AMP, and a three-fold increase in cyclic AMP when combined with coleus/forskohlin, this polyunsaturated fat should accompany the use of coleus.( 75)

Moreover, the use of coleus is traditionally used to treat cases of asthma, while beta-blocker eye drops used to treat glaucoma patients are contraindicated in cases of asthma or any history of upper respiratory distress. Coleus also has anti-hypertensive properties, a problem that often accompanies glaucoma.

H. Protect the optic nerve sheath by supplementing with vitamin B12 (anti-demyelinating protocol):

Vitamin B12: 1500 mcg. daily

Rationale: The successful long-term ( 5-year) use of 1500 micrograms of vitamin B12 to stop progression of peripheral vision loss among glaucoma patients, without lowering intraocular fluid pressure, was reported in 1992.( 76) Vitamin B12 deficiency is known to cause myelin sheath degeneration which is the insulation surrounding the optic nerve fibers. Better than half of the animals deprived of dietary vitamin B12 first develop lesions in the papillomacular area of the optic nerve. Thus the lack of vitamin B12 may cause optic atrophy which is the end-stage appearance of glaucoma.( 77)

In humans the first sign of vitamin B12 and folic acid deficiency are hematologic (anemia). Over 1 million senior Americans are believed to have pernicious anemia due to lack of this essential vitamin in foodstuffs and lack of gastric absorption with advancing age.( 78)

The optic atrophy associated with B12 deficiency is clinically indistinguishable from tobacco or alcohol amblyopia. A test to measure the secretion of gastric acid (Schilling test) is not always reliable among smokers since it has been shown that gastric acid secretion and absorption of vitamin B12 is only impaired while the subject is smoking.( 79) In 1944 Caroll noted that patients with visual disorders who continued to smoke and consume alcohol experienced complete recovery of their visual disorders when they took B12 supplements.( 80) Clinicians should inquire about alcohol and tobacco use among their glaucoma patients.

The fact that an estimated 50% of older adults have atrophic gastritis and lack secretion of gastric acid sets the stage for decreased vitamin B12 levels.( 81) This in turn can result in memory problems, confusion, dementia, depression or psychosis typically seen in elderly patients.( 82) So it is no wonder that glaucoma patients are often noncompliant when given daily medications.

What confounds clinicians is the absence of anemia even though other neurologic signs are present. This may be a primary reason for the mystery and confusion surrounding glaucoma therapy. Frequently neurologic manifestations of B12 deficiency, such as optic atrophy and visual impairment, are reported prior to the detection of anemia.( 83)

The linkage between low dietary vitamin B 12 levels and multiple sclerosis, a demyelinating nerve disease, is of further interest.( 84, 85) Supplementation with vitamin B12 has led to an almost complete recovery of visual field defects among MS patients.( 86)

Clinicians should make their patients aware of factors that interfere with B vitamin absorption, such as coffee, aspirin, and lack of dietary zinc required for the production of gastric juice. Digestive enzymes may be helpful to some patients. Some readers will critique the suggestion of a vegetarian diet for glaucoma patients since it is low in vitamin B12, as meats are the primary dietary source of B12. However, normal dietary intake of vitamin B12 (the mean B12 intake of U.S. adults is around 5 micrograms) never approaches the therapeutic 1500 mcg. level which was shown in a clinical study to protect the optic nerve sheath and prevent peripheral vision loss.

One study notes that visual improvement did not occur among patients with tobacco amblyopia until they were switched from cyanocobalamin to hydroxycobalamin.( 87) Cyanocobalamin is chemically related to cyanide produced from tobacco smoke. So hydroxycobalamin is the preferred variety of vitamin B12.

Researchers have long searched for a regenerative factor for the optic nerve. vitamin B12 may be such a restorative agent as it has been shown to be involved in the myelination of nerves.( 88) Other remyelinating nutrients are arginine, sadenosyl-methionine and polyamines.( 89)

I. Supplement with chromium complex when taking beta-blocker eye drops.

Chromium: 200-600 mcg. daily

Rationale: Both oral and topical beta blockers have been shown to adversely alter plasma lipid profiles.( 90) Timolol, the eye drop commonly used to control glaucoma pressure, has been shown to increase triglycerides by 12%, reduce HDL "good" cholesterol by 9% and increase the risk of coronary artery disease by 21%.( 91)

The undesirable lipid profiles that accompany use of topical beta blockers can be overcome with nutritional supplements. Chromium is a mineral that has lipid-lowering properties.( 92) In men taking oral beta blockers, 600 mcg. of chromium taken three times daily increased HDL levels by 16%, and another similar study improved HDL levels by 38%. Thus a decrease in the risk for coronary heart disease of 12-17% can be achieved among glaucoma patients taking beta blockers by supplementing with chromium.( 93) To this writer's knowledge, no eye physician presently prescribes supplemental chromium for glaucoma subjects who take topical beta blockers even though this topic is covered in current medical literature.

For those patients who are on topical miotics to reduce eye fluid pressure, miotics are known to increase the permeability of the blood-aqueous barrier. The use of bioflavonoids (such as rutin, bilberry, ginkgo biloba, etc.) has been shown to further reduce intraocular pressure when taken with miotics.( 94)

J. Increase intake of omega-3 fatty acids through dietary consumption of fresh-water fish (cod, salmon, tuna, sardines) and omega-3 supplements.

Omega-3 fish oils or flax seed oil: 1000 mg. daily

Rationale: Epidemiological studies show a very low rate of common open-angle glaucoma among Eskimos who consume fish rich in omega-3 oils. The use of fish oil supplements has been shown to effectively improve cases of Raynaud's disease and should thus be effective in cases of low-pressure glaucoma if not the common form of openangle glaucoma.( 95, 96) Rabbits given intramuscular injections of omega-3 oil experienced a significant reduction in eye fluid pressure.( 97)

Furthermore, the increased incidence of glaucoma among diabetic subjects may be partially explained by abnormal metabolism of omega-6 fatty acids which enhances nerve demyelination.( 98) Thus omega-3 (flax seed oil, cod liver oil) and omega-6 (borage or evening primrose oil) combinations may be desired.

K. Minimize the volume of large proteins that can be trapped within the fluid drain inside the eyes:

Lens exfoliation: sun protection
Pigment loss: fatty acids
Histamine release: natural antihistamines, quercetin
Inflammatory matter (polymorphonuclear leukocytes) Example: following a viral attack (herpes)
Large proteins can clog the fluid drain (trabecular meshwork) of the eyes.( 99) These proteins emanate from inflammatory reactions, from histamine release, from melanin pigment lost from the iris or from cellular material which flakes off the crystalline lens, and other sources. The buildup of these proteins within the drain is progressive with age.( 100)

Aging changes in the eyelids of exfoliation patients can be observed upon biopsy.( 101) Solar radiation has been shown to damage the elastic connective tissues.( 102) The fact that exfoliation syndrome occurs more frequently among outdoor workers and in sunnier environments suggests that ocular protection from sunlight may significantly reduce the risk of this syndrome.( 103) Solar ultraviolet-B radiation (280-320nanometers) initiates damage to the lens epithelial cells which comprise the fibers that flake off in the exfoliation syndrome.( 104) Antioxidants have been shown to protect the lens epithelium from solar damage.( 106) Thus the link between solar radiation and exfoliation syndrome provides further evidence to advise populations to habitually utilize UVprotective eyewear in order to minimize the risk of exfoliative glaucoma.

L. Control allergy and histamine release.

Quercetin: 500 mg. Daily

Rationale: The link between allergy and intraocular pressure was described by Sjogren in 1938.( 106) Certain forms of glaucoma have also been associated with autoimmune disorders as evidenced by antigens.( 107) Histamine may produce glaucoma (elevated fluid pressure). In 1947 Berens, Girard and Cummings documented cases of otherwise uncontrolled glaucoma that resolved when an allergen-free diet was prescribed.( 108) Histamine has been found in the aqueous fluid of glaucoma patients. In 1964 L.F. Raymond documented successful antihistamine treatment of 113 cases of common glaucoma which did not respond to conventional miotic eye drops. All of these patients exhibited allergies.( 109) Raymond noted that some glaucoma subjects who slept with their eye against a feather pillow often exhibited uniocular glaucoma. It has been shown that histamine in trabecular meshwork cells increases influx of intracellular calcium,( 110) which may in turn have detrimental effects upon circulation and smooth muscle relaxation. Bioflavonoids, particularly quercetin, inhibit histamine release.( 111) Quercetin relaxes vascular smooth muscle and has been shown to increase cyclic AMP.( 112) Quercetin also a strong affinity for iron, thus removing this oxidant from the body and reducing oxidative stress.( 113)

M. Treat the whole patient: employ stress reduction techniques.

Just the diagnosis of glaucoma increases the patient's anxiety and stress, beth of which have been identified as factors that exacerbate the problem. Emotional states of anxiety have been linked with glaucoma attacks and a rise in intraocular pressure as early as the year 1818,( 114) yet have gone largely unrecognized by modern practitioners who emphasize high-technology cures for the problem. Ripley and Wolff documented that emotional reactions of anger, anxiety, depression or a stressful life situation often coincide with elevated intraocular pressure. However, eye fluid pressure is never affected during feelings of happiness or tranquility.( 115) This causes medical investigators to ask the question: "Is the diagnosis of glaucoma a self-fulfilling prophecy?"

In 1940 Mark J. Schoenberg wrote that "in some glaucomatous patients there may be a definite relation between states of anxiety (worry, fear, fright, sorrow, disappointment, despondency)...and recurring crises of ocular hypertension."( 116)

Schoenberg notes that anxiety:

A. Increases the synthesis of epinephrine

B. Increases cardiac output

C. Shortens blood clotting time

D. Changes the blood pressure

E. Increases the number of red blood cells

F. Arrests digestion

G. Often results in hyperglycemia

H. Increases dry mouth and throat

I. Increases the size of the pupils

J. Increases bulging of the eyes

K. Causes the lacrimal glands to oversecrete

L. Promotes spasm of the retinal arteries in older patients

M. Decreases the focusing power of the eyes

Many glaucoma patients exhibit sleep disturbances, problems with digestion, loss of appetite and other symptoms consistent with chronic states of anxiety. Schoenberg writes that the autonomic nervous system is "out of balance in glaucomatous eyes." He indicates that affect the autonomic nervous system also have specific action in glaucomatous eyes. Schoenberg writes that "glaucomatous crises are therefore preventable by proper attention to the patient's emotional life." Schoenberg quotes Socrates: "Just as we cannot treat the eye without the head, and we cannot treat the head without the body, so we cannot treat the body without the soul."

In 1960 Maurice Croll and Leo J. Croll, linked attacks of acute glaucoma with emotional distress in adults who have anatomically short eyes (and narrow fluid drains).( 117)

Michael H. Rotberg writes that arousal of the autonomic nervous system may be involved in the onset of migraines and Raynaud's disease and that biofeedback, using digital skin temperature as a reflection of peripheral blood flow, can be used to train patients to control these disorders.( 118) us Biofeedback has possibilities for the control of low-pressure glaucoma and possibly the common form of glaucoma. Watching a Laurel and Hardy movie may do as much to control glaucoma as modern medical therapy.

N. There is currently no practical way of avoiding the preservatives in anti-glaucoma eye drops. The deleterious effects of preservatives in glaucoma eye drops were outlined in Part I of this paper. Merck, the maker of Timolol, lists a preservative-free beta blocker (OcuDose) in the Physicians Desk Reference, but it is not currently available in plentiful supply.

O. Avoid high volume intake of fluids within a short period of time.

Rationale: Caffeinated drinks like coffee have frequently been considered off-limits for glaucoma patients. Yet studies do not indicate caffeine intake elevates intraocular fluid pressure.( 119) Yet there is concern over high intake of fluids over a short period of time.( 120, 121) Limiting the intake of fluids to 8 ounces per hour for glaucoma patients has been suggested.( 122) While coffee doesn't elevate eye fluid pressure there is concern that it increases cholesterol which may impair circulation, but studies are inconclusive.( 123) Coffee boiled through a paper filter removes the hypercholesterolemic factor.( 124)

P. Increase the strength of the heart pump to improve vascular perfusion, particularly in cases of low-pressure glaucoma, with the use of coenzyme Q10 and ginger.

Low systemic blood pressure and poor tissue perfusion can lead to ischemic optic nerve disease, often found in cases of low-pressure glaucoma. Supplemental Coenzyme Q10 (100 mg./day), a non-vitamin nutrient that acts as a mitochondrial antioxidant, has been shown to significantly improve cases of heart failure.( 125) Ginger root supplements have also been shown to improve heart strength, equal to the effect of digitalis.( 126)

Q. There is a place for glaucoma surgery.

Rationale: Glaucoma patients often do not take the medications as prescribed. Studies show noncompliance rates range from 22-62% of patients.( 127) Another study shows that the mean number of days patients forgot to take their glaucoma medication in a year was 112.( 128) Glaucoma surgery when performed on a virgin eye (not already subjected to anti-glaucoma medications or laser treatment) may facilitate long-term pressure reduction and has advantages for patients who are unlikely to be compliant with any prescribed regimen, be it conventional medicines or a regimen as outlined in this paper. While the initial cost of glaucoma surgery may appear high, over the long-term surgery may oftentimes be more economical than medication.( 129)

Schumer and Podos have written an extensive review of the medical treatment of glaucoma. They note that in most cases anti-glaucoma medications reduce intraocular pressure, but the reduction in pressure while statistically significant may not be clinically significant, i.e. no change in the rate of progression of the disease. Many eye physicians are fooled by the fact that the medications are reducing fluid pressure but not arresting slow-progressive visual field loss. George Spaeth, a noted glaucoma researcher, indicates a fluid pressure reduction of 30% or more is required before reversal in the cupping of the optic disc can be observed.( 131)

Schumer and Podos go on to scrutinize laser treatment for glaucoma. They note that one year following laser treatment 23% of patients exhibit eye fluid pressure above 19 mm Hg or progressive loss of vision or need for more surgery. At 10 years following laser treatment the failure rate is 70%. The national Glaucoma Laser Trial study showed that more than half of the glaucoma patients who underwent laser treatment as their initial therapy (medication was withheld) still required medication within a 2-year period following laser treatment only. About 44% of patients who undergo laser-first treatment do not require medication after two years. Compare this with the fact that after two years only 30% of glaucoma patients receiving medication-first treatment are actually able to control their glaucoma without having to add another medicine to their daily regimen.

Schumer and Podos argue convincingly that glaucoma surgery avoids many of the drawbacks associated with laser and medical therapy, though they note that surgery does pose an increased risk to develop cataracts (the relative risk for glaucoma patients to develop cataracts is 2.9 vs. 14.3 for those glaucoma patients who undergo surgery).( 132) A drawback of medical therapy for glaucoma is that beta blockers result in an undisputed decrease in eye fluid pressure but no concomitant increase in the pulsatile ocular blood flow.( 133) However, one study shows that glaucoma surgery increases the pulsatile ocular blood flow by 29%, but surgery does not improve blood flow among glaucoma patients who have already begun medical therapy( 134) Medical therapy may reduce eye fluid pressure but not significantly affect the long-term progression of the disease. While surgery may become the treatment of first choice for eye physicians for common glaucoma, it has not been shown to be effective in sl owing the progression of vision loss among low-pressure glaucoma subjects.( 135)

R. Other alternative medicine approaches to glaucoma

Marijuana and Glaucoma

Rationale: A discussion of natural remedies for glaucoma cannot overlook marijuana. This herb, administered in the form of a cigarette, is without question the most potent pressure-reducing agent ever discovered. Eye fluid pressure is reduced by as much as 51% after smoking marijuana. Unlike beta blockers that cause bradycardia, marijuana increases the heart rate from 22-65%.( 136) Despite its proven effectiveness the American Academy of Ophthalmology "presently finds no scientifically verifiable evidence that the use of marijuana is safe and effective in the treatment of glaucoma."( 137) Marijuana is not without side effects. The euphoria associated with marijuana is offset by tachycardia, photophobia, blepharospasm, dry eyes, and short-term memory loss.( 138, 139) In March of 1992 the Federal government banned the use of marijuana for medical purposes.( 140) Yet today when eye surgeons are confronted with uncontrollable cases of glaucoma they privately recommend marijuana until the condition can be controlled through surgery or other means. Three points come to mind in the discussion of marijuana and glaucoma. One is that a natural herb is more potent in controlling glaucoma than any pharmacological formula. The second is that even herbs in some cases have undesirable side effects and need to be used judiciously. The third is that marijuana has stress relieving properties that have been overlooked in the control of glaucoma.

Acupuncture and Glaucoma

Rationale: Acupuncture has been successfully used to ameliorate various incurable eye disorders.( 141) It has been shown that enkephalin, one of the opiods stimulated by acupuncture, reduces eye fluid pressure.( 142) Various reports indicate acupuncture may be beneficial in some cases of optic atrophy( 143) and may further be helpful in cases where conventional medicines fail to stop progressive vision loss.( 144) Some patients with glaucoma have experienced reduction in the intraocular pressure following acupuncture. But acupuncturists are quick to note that deep nerve stimulus with needles is "not a substitute for conventional methods of treatment. But when every kind of routine treatment has been exhausted, acupuncture may offer some hope to patients."( 145)

At the XXIII International Congress of Ophthalmology in 1978, Hong Kong ophthalmologists Susan Wong and Renald Ching reported the successful use of acupuncture on 500 cases of incurable eye diseases including glaucoma, but noted that acupuncture did not reduce elevated intraocular pressure.( 146) Acupuncture has been combined with vitamin B12 therapy to control glaucoma in a dog.( 147) Electrical stimulation of the facial nerve root produces a marked increase in choroidal Mood flow which can also be duplicated by the topical application of capsaicin cream (an ingredient in cayenne pepper).( 148) Inasmuch as acupuncture improves circulation by encouraging vasodilation it may show positive benefits for individuals with glaucoma.

Conclusion

The concept of glaucoma as a disease separate from the rest of the body should be abandoned. An anti-glaucoma protocol should emphasize less costly methods of control. Anti-glaucoma therapy should blend with other nutritional and non-pharmacologic/non-surgical methods now recommended to prevent cardiovascular disease. A documentary report appearing in the Archives of Internal Medicine, emanating from the Cardiovascular Health Center at Harvard Medical School, says nonpharmacologic approaches to cardiovascular disease, rather than drugs and surgery, should be the first course of action employed by physicians.( 149) The same is true for glaucoma.

The eyes are not lacking in beta blockers, nor miotics, nor other synthetic drugs. They are often lacking nutrients that produce the hormones, enzymes and neurotransmitters that control human biochemistry, such as fluid balance, autoregulation of blood pressure and the visual process itself. Current medical practitioners have largely ignored less-costly and potentially more effective dietary, nutritional and life style regimens in favor of high-tech diagnostics, laser and surgical treatment. Eye physicians often find such simple approaches incompatible with their training and antagonistic to the barrage of advertising thrust at them by companies who sell diagnostic equipment or prescription drugs. Therefore, this writer believes glaucoma patients will have to find alternative approaches to glaucoma treatment outside of the conventional medical marketplace. Unfortunately the present emphasis in medicine is on treatment of disease rather than maintenance of health. Ironically, e ye physicians who prescribe unconventional nonpharmacologic therapy for glaucoma expose themselves to malpractice claims and censure by state medical boards. Yet unproven medical therapy requiring more drugs, then more laser treatment and more surgery, is never questioned by those who police medical care.

The current approach to eradicating glaucoma is so fraught with side effects that it is difficult to separate the treatment from the disease. Anti-glaucoma therapy should follow the dictum to "first do no harm."

Basic objectives of an anti-glaucoma regimen do not differ appreciably from those recommended for cardiovascular disease and maintenance of general health:

- Cease smoking

- Limit alcohol intake

- Control weight

- Exercise regularly

- Reduce oxidative stress on the eyes by wearing UV-blocking sunglasses

- Minimize saturated fats in the diet (meats, dairy)

- Eat five servings of fresh fruits and vegetables daily including green leafy vegetables rich in xanthophylls (spinach, kale, collard and mustard greens)

- Avoid optic nerve toxins such as steroids, tobacco, aspartame, certain drugs.

- Increase HDL cholesterol; reduce LDL cholesterol

- Utilize stress-reduction techniques

- Supplement with antioxidants, fatty acids, bioflavonoids, chromium, B-vitamins, etc.

- Consider digestive enzymes for smokers or where overt signs of indigestion exist (bloating/intestinal gas) or when pernicious anemia is detected. (Hydrochloric acid Supplements are not advised for patients with active gastric ulcers or hiatal hernia.)

- Utilize preservative-free anti-glaucoma eye drops if they become available

A dally anti-glaucoma nutritional supplement:

- Vitamin B12: 1500-2500 mcg. (IM injections if a smoker or hypochlorhydric/achlorhydric)

- Coleus/forskohlii: 200-400 mg.

- Magnesium: 400 mg.

- Vitamin C: 500-1000 mg. ( 2,000-3,000 mg. if a smoker)

- Vitamin E: 400 IU (800 IU if a smoker)

- Coenzyme Q10:30 mg. (100 mg. in cases of low-pressure glaucoma)

- Beta carotene: 25,000-40,000 IU

- Zinc: 15-25 mg.

- N-acetyl cysteine (glutathione precursor): 200-600 mg.

- Ginkgo biloba: 100-240 mg.

- Omega 3/omega-6 oils: 1000-3000 mg.

- Vitamin B6: 50 mg.

- Vitamin B1 (thiamine): 25-50 mg. (if a smoker, 300 mg. till vision resolves)

- Folic Acid: 400 mcg. (if a smoker, 1000 mcg.)

- Quercetin: 500 mg.

- Choline: 100 mg.

- Ginger: 100 mg.

Disclaimer: The accompanying article has been written for the benefit of the readers of the Townsend Letter for Doctors and Patients. I am a medical journalist and have written an opinion regarding the treatment of glaucoma in the accompanying paper. Clinicians should seek additional information from other sources before prescribing therapeutic regimens for their patients. Only a clinician is in the unique position to obtain a patient's medical history, allergies, use of prescription drugs, diet, and other factors that are necessary prior to development of a therapeutic regimen.

Financial Disclosure: I have written a book entitled Nutrition And The Eyes (Health Spectrum Publishers), which is designed for the lay reader. I am also financially involved in Eye Communications, a California company that manufactures sun goggles and distributes nutritional supplements.

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Townsend Letter for Doctors & Patients.

~~~~~~~~

By Bill Sardi

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