Douglas J. Rhee

Complementary and alternative medicine for glaucoma

Given the recent interest in complementary and alternative medicine (CAM), some patients may seek such treatments to supplement their traditional glaucoma management. The prevalence of CAM use for glaucoma is approximately 5%. We reviewed the literature to determine the potential benefit of various alternative treatments. Aside from a temporary osmotic effect from high dose intravenous ascorbic acid, there is no evidence that megavitamin supplementation has a beneficial effect on glaucoma. During exercise, autoregulation in healthy eyes seems to maintain a consistent blood flow rate to the optic nerve despite fluctuations in intraocular pressure (IOP). In a glaucomatous eye, the very modest IOP-lowering that follows exercise may be offset by the initial elevation in IOP that occurs when one first initiates exercise. At this time, there is no evidence to encourage or discourage the use of special diets, acupuncture, relaxation techniques, or therapeutic touch specifically for the treatment of glaucoma. Very little research has been done on the majority of herbal remedies with regard to their treatment of glaucoma. Marijuana can cause a profound lowering of IOP, but the high nonresponse rate, short half life, and significant toxicity are strong indicators that it is not an appropriate therapeutic agent. Ginkgo biloba and some other Chinese herbal remedies do not affect IOP, but may improve blood flow to the optic nerve and, as such, may have a beneficial effect on glaucoma. These agents have recognized toxicities. Although there are some well-designed studies of alternative treatments, many of the recommendations for using alternative treatments are currently unsupported by the data provided.

Prevalence of the use of complementary and alternative medicine for glaucoma

OBJECTIVESnTo estimate the prevalence of complementary and alternative medicine (CAM) for glaucoma, explore possible demographic and disease-related associations, and inquire about the perceived benefit of these treatments.nnnDESIGNnCross-sectional study.nnnSETTING AND PARTICIPANTSnOne thousand twenty-seven consecutive patients from two urban, referral glaucoma practices.nnnMAIN OUTCOME MEASUREnUse of CAM specifically for glaucoma.nnnRESULTSnThe response rate was 97.4%. The percentage of people reporting use of CAM for glaucoma was 5.4% (54 of 1000 subjects) with 32 of these 54 (59%) having used more than one type. The percentages of those using the various types of nontraditional medicine were: megavitamin therapy (62.9%), herbal therapy (57.4%), exercise (24.0%), diet modification (22.2%), meditation, (1.8%), acupuncture (1.8%), faith healing (1.8%), and homeopathic remedies (1.8%). Patients who used CAM were more likely to be educated beyond high school (P = 0.0014) and less likely to be retired (P = 0.0053). Use of nontraditional therapy was not strongly associated with race (P = 0.044), age (P = 0.062), gender (P = 0.24), length of diagnosis (P = 0.91), or number of glaucoma medications (P = 0.58). Of those using nontraditional therapy, 52% believed that it was helpful, 39% were unsure, and 9% considered it not helpful; 72% discussed their use with an ophthalmologist. Seventy percent discovered it from sources other than providers of either traditional or nontraditional care.nnnCONCLUSIONSnThe prevalence of CAM use for glaucoma was 5.4% (95% confidence interval, 4.0%--6.4%). Most glaucoma patients currently cared for by ophthalmologists do not use nontraditional medicine.

Charles Bonnet Syndrome and glaucoma.

Dear Editor: Approximately one third of patients referred for vision rehabilitation report experiencing recurrent visual hallucinations, the Charles Bonnet Syndrome (CBS). Four elements are required to define CBS; formed visual hallucinations, insight into the unreal nature of the positive phenomena when it is explained to the patient, some degree of vision loss, and no other psychiatric or neurological diagnosis to explain the hallucinations. Most CBS subjects studied have had a diagnosis of age-related macular degeneration. Glaucoma is a leading cause of irreversible visual impairment and blindness in the developed world, however, little is known about the prevalence of CBS in these patients. A previous study found a 12.3% prevalence of CBS in patients with glaucoma, but excluded patients with greater than 20/80 acuity and included subjects with glaucoma and other ocular disease. A case series reported CBS in 4 patients with glaucoma who had visual acuity better than 6/12. We undertook this study to evaluate the prevalence of CBS in patients with glaucoma referred for vision rehabilitation. We retrospectively reviewed the patients seen at the Massachusetts Eye and Ear Infirmary Vision Rehabilitation Clinic from March 2007 to August 2008. Each patient was asked a leading question to elicit the symptom of hallucinations. “Many patients who come to this Clinic tell us that they see things they know are not there. Some see patterns or shapes. Others see images of people or animals. Have you ever experienced this?” Our analysis considered 3 groups, the total cohort referred to vision rehabilitation, those with a diagnosis of glaucoma and other ocular diagnoses, and those with only a diagnosis of glaucoma. Charles Bonnet Syndrome cases were matched with controls without hallucinations of similar glaucoma status, age, acuity, and contrast sensitivity. Each variable was investigated by matching on the other variables with a one-to-many strategy in which controls were uniquely chosen randomly among eligible pairings. In our cohort of 698 patients, 23% (161/698) reported recurrent visual hallucinations. Twenty percent (141/689) of the overall group had a diagnosis of glaucoma and of these, 127 had other coexisting ophthalmic diagnosis. Twenty-one percent of those with any diagnosis of glaucoma (29/141) had hallucinations, while 29% percent of those with only a diagnosis of glaucoma (4/14) reported hallucinations (Figure 1 and Table 1, available at http://aaojournal.org). There was no significant difference between the report of hallucinations in the patients with glaucoma compared with those without glaucoma (P 0.497). There also was no significant difference between the report of hallucinations in those who only had a diagnosis of glaucoma compared with those with any other diagnosis (Fisher exact test P 0.41) (Table 2, available at http://aaojournal.org). One glaucoma patient with hallucinations had acuity of 0/25. Although visual field data was not available for all ubjects, patients who experienced CBS all had either seere field loss represented by a mean defect greater than -12 Severe Defect by Hodapp-Parrish-Anderson Glaucoma Seerity criteria), or narrative report on the medical record of advanced glaucoma.’ We have previously shown that reuced contrast sensitivity is a risk factor for CBS. This ame association is found in this vision rehabilitation cohort lthough not in the smaller subset of glaucoma-only subects. Age was a significant risk factor for CBS in glaucoma ubjects (T-test P 0.001) (Table 3, available at http:// aojournal.org). Further study with larger samples of glauoma patients would be required to draw conclusions about he level of visual field loss or contrast sensitivity loss at hich patients become at risk of experiencing hallucinaions. Although patients report a negative reaction to the onset f the hallucinations, most do not report hallucinations due o concern that their mental competence may be questioned. hose who do report their hallucinations are often met with uizzical looks, as not all physicians appreciate the nature of he syndrome. Many patients express relief and gratitude hen reassured that the hallucinations are not a symptom of ental incompetence, but rather a symptom of vision loss. ur findings indicate that patients with glaucoma referred or vision rehabilitation have the same chance of reporting BS than patients with other diagnoses. Physicians might nquire about CBS in patients with severe visual field loss in rder to provide assurance to glaucoma patients who may xperience this peculiar symptom. MARY LOU JACKSON, MD BRIAN DROHAN, PHD Boston, Massachusetts

Long-term complications of iris-claw phakic intraocular lens implantation in weill-marchesani syndrome

Purpose: This study was designed to report the long-term complications of iris-claw phakic intraocular lens implantation in a patient with Weill-Marchesani syndrome. Methods: Case report and literature review. Results: A 26-year-old man with a history of glaucoma had bilateral phakic lens implantation for high myopia 10 years previously. Two years later, the left implant dislocated and was repositioned. Slit-lamp examination of both eyes revealed phakic implants of the iris-claw variety. There were moderate iridocorneal adhesions in the areas in which the lens haptics pinched the iris in both eyes and moderate epithelial and stromal edema over the temporal one-third of the left cornea. The crystalline lenses were clear with 3+phacodonesis OU. Dilated fundus examinations revealed bilateral severe optic nerve cupping. Crystalline lens diameters were measured at 7.5mm in the right eye and 8 mm in the left. Anterior chamber depths were 2.63 mm OD and 2.40 mm OS. Specular microscopy revealed central endothelial cell counts of 1133 and 587 cells/mm2 OD and OS, respectively. Axial lengths were 23.3 mm OD and 25 mm OS. Gonioscopic examination revealed bilateral angle closure with marked peripheral anterior synechiae. Based on our findings of short stature, shortened and thickened fingers, relatively normal axial length, microspherophakia, high myopia, and glaucoma, we diagnosed the patient with Weill-Marchesani syndrome. Conclusion: Iris claw-lens phakic lenses may be an effective surgical alternative to correct high myopia in select patients; however, it may produce long-term complications in eyes with specific features.

A Schlemm Canal Microstent for Intraocular Pressure Reduction in Primary Open-Angle Glaucoma and Cataract: The HORIZON Study

OBJECTIVEnTo compare cataract surgery with implantation of a Schlemm canal microstent with cataract surgery alone for the reduction of intraocular pressure (IOP) and medication use after 24 months.nnnDESIGNnProspective, multicenter, single-masked, randomized controlled trial.nnnPARTICIPANTSnSubjects with concomitant primary open-angle glaucoma (POAG), visually significant cataract, and washed-out modified diurnal IOP (MDIOP) between 22 and 34 mmHg.nnnMETHODSnSubjects were randomized 2:1 to receive a single Hydrus Microstent (Ivantis, Inc, Irvine, CA) in the Schlemm canal or no stent after uncomplicated phacoemulsification. Comprehensive eye examinations were conducted 1 day, 1 week, and 1, 3, 6, 12, 18, and 24 months postoperatively. Medication washout and MDIOP measurement were repeated at 12 and 24 months.nnnMAIN OUTCOME MEASURESnThe primary and secondary effectiveness end points were the proportion of subjects demonstrating a 20% or greater reduction in unmedicated MDIOP and change in mean MDIOP from baseline at 24 months, respectively. Hypotensive medication use was tracked throughout the course of follow-up. Safety measures included the frequency of surgical complications and adverse events.nnnRESULTSnA total of 369 eyes were randomized after phacoemulsification to Hydrus Microstent (HMS) and 187 to no microstent (NMS). At 24 months, unmedicated MDIOP was reduced by ≥20% in 77.3% of HMS group eyes and in 57.8% of NMS group eyes (differencexa0= 19.5%, 95% confidence interval [CI] 11.2%-27.8%, P < 0.001). The mean reduction in 24-month unmedicated MDIOP was -7.6±4.1 mmHg (mean ± standard deviation) in the HMS group and -5.3±3.9 mmHg in the NMS group (differencexa0= -2.3 mmHg; 95% CI, -3.0 to -1.6; P < 0.001). The mean number of medications was reduced from 1.7±0.9 at baseline to 0.3±0.8 at 24 months in the HMS group and from 1.7±0.9 to 0.7±0.9 in the NMS group (difference = -0.4 medications; P < 0.001). There were no serious ocular adverse events related to the microstent, and no significant differences in safety parameters between the 2 groups.nnnCONCLUSIONSnThis 24-month multicenter randomized controlled trial demonstrated superior reduction in MDIOP and medication use among subjects with mild-to-moderate POAG who received a Schlemm canal microstent combined with phacoemulsification compared with phacoemulsification alone.