Mindfulness-based stress reduction can be an adjunct to anti-glaucoma drops

Glaucoma and stress have a negative two-way relationship, with the presence of each condition worsening the other. Recent research shows prescribing mindfulness-based stress reduction to our glaucoma patients may be worth considering.

Here, I expand on this negative two-way relationship, and I explain mindfulness-based stress reduction.

NEGATIVE TWO-WAY RELATIONSHIP

Glaucoma, although commonly viewed primarily as an IOP-dependent/mechanical disease (barotrauma), may also develop from additional factors, such as decreased optic nerve perfusion and hypoxia (vascular dysregulation), increased mitochondrial dysfunction and oxidative stress with associated decreased nitric oxide levels (biochemical), and increased serum cortisol levels.^1-4 For these reasons, and with this context, it was suggested several years ago that, “…glaucomatous damage may be a specific organ manifestation of global vascular insufficiency and dysfunction rather than a separate disease process isolated only to the eye and its immediate vasculature.”⁵

Interestingly, stress — common reactions to anxiety and depression — is common among glaucoma patients^6-7 and worsens several of the above causative factors for the condition. More specifically, and directly related to these causative factors, psychological stress:

• Increases endogenous serum cortisol levels, which can increase IOP levels.^2,3
• Increases oxidative stress within the optic nerve and the trabecular meshwork (TM).
• Increases the sympathetic pathway (while downregulating the parasympathetic pathway), resulting in episodic (or sustained) vascular dysregulation.²

Such combinations may increase the risk of developing glaucoma among glaucoma suspect patients (an underappreciated-risk factor?),⁸ and may hasten retinal nerve fiber loss among glaucoma patients,⁹ thus, affecting these patients from diagnosis to prognosis.¹⁰

The Top Three Mindfulness Apps

THE TOP THREE APPS FOR YOGA AND MEDITATION IN 2020 BY NUMBER OF DOWNLOADS:

1

 

 

CALM (5.26 MILLION)calm.com

2

 

 

HEADSPACE (2.08 MILLION)headspace.com

3

 

 

MEDIOTOPIA (1.89 MILLION)meditopia.com

Source: Statista

MINDFULNESS-BASED STRESS REDUCTION

Mindfulness-based stress reduction (MBSR) is a low-cost, high-safety profile, ever-accessible treatment for glaucoma suspects or glaucoma patients. An example of MBSR is meditation. (Several meditation apps are available.)

So, how does MBSR help? The answer is that, as an adjuvant therapy with anti-glaucoma drugs, it can “augment optic nerve head perfusion and reduce IOP, which may positively impact the progression of glaucomatous optic neuropathy.”¹¹ Additionally, MBSR is a treatment that can be practiced by elderly or bedridden glaucoma patients.²

Further, if practiced regularly and properly, MBSR is associated with:

• Decreased serum cortisol levels (with secondary lower IOP levels).
• Downregulation of proinflammatory gene expression.
• Decreased oxidative stress.
• Improved mitochondrial function.
• Improved quality of life for both patients and caregivers.
• Improved ocular perfusion via decreased sympathetic/increased parasympathetic activity.^2-4,11
• Improved trabecular meshwork outflow gene expression.¹²
• Improved general systemic and ocular health.¹³

A FINAL NOTE

“The ability to positively impact the disease and improve health-related quality of life with mind-body interventions is an emerging therapy, whose full potential is yet to be realized.”⁴ OM

REFERENCES

1. Dada T, Verma S, Gagrani M, et al. Ocular and Systemic Factors Associated with Glaucoma. J Curr Glaucoma Pract. 2022;16(3):179-191. doi: 10.5005/jp-journals-10078-1383.
2. Dada T, Gagrani M. Mindfulness Meditation Can Benefit Glaucoma Patients. J Curr Glaucoma Pract. 2019;13(1):1-2. doi: 10.5005/jp-journals-10078-1239. Note: See Reference for helpful flowchart.
3. Dada T, Mittal D, Mohanty K, et al. Mindfulness Meditation Reduces Intraocular Pressure, Lowers Stress Biomarkers and Modulates Gene Expression in Glaucoma: A Randomized Controlled Trial. J Glaucoma. 2018;(12):1061-1067. doi: 10.1097/IJG.0000000000001088.
4. Dada T, Mondal S, Midha N, Mahalingam K, Sihota R, Gupta S, Angmo D, Yadav RK. Effect of Mindfulness-Based Stress Reduction on Intraocular Pressure in Patients With Ocular Hypertension: A Randomized Control Trial. Am J Ophthalmol. 2022;239:66-73. doi: 10.1016/j.ajo.2022.01.017.
5. Harris A, Siesky B, Wirostko B. Cerebral blood flow in glaucoma patients. J Glaucoma. 2013;22 Suppl 5(0 5):S46-8. doi: 10.1097/IJG.0b013e3182934b6b.
6. Abe RY, Silva LNP, Silva DM, Vasconcellos JPC, Costa VP. Prevalence of depressive and anxiety disorders in patients with glaucoma: a cross-sectional study. Arq Bras Oftalmol. 2021;84(1):31-36. doi: 10.5935/0004-2749.20210006.
7. Groff ML, Choi B, Lin T, Mcllraith I, Hutnik C, Malvankar-Mehta MS. Anxiety, depression, and sleep-related outcomes of glaucoma patients: systematic review and meta-analysis. Can J Ophthalmol. 2022:S0008-4182(22)00055-2. doi: 10.1016/j.jcjo.2022.02.010.
8. Berchuck S, Jammal A, Mukherjee S, Somers T, Medeiros FA. Impact of anxiety and depression on progression to glaucoma among glaucoma suspects. Br J Ophthalmol. 2021;105(9):1244-1249. doi: 10.1136/bjophthalmol-2020-316617.
9. Shin DY, Jung KI, Park HYL, Park CK. The effect of anxiety and depression on progression of glaucoma. Sci Rep. 2021;11(1):1769. doi: 10.1038/s41598-021-81512-0.
10. Liu J, Cao L, Yang G, Zhou R. Effects of non-pharmacological interventions on anxiety, depression, and sleep quality in patients with postoperative glaucoma: A protocol for systematic review and network meta-analysis. Medicine (Baltimore). 2021;100(35):e27090. doi: 10.1097/MD.0000000000027090.
11. Dada T, Lahri B, Mahalingam K, et al. Beneficial effect of mindfulness based stress reduction on optic disc perfusion in primary open angle glaucoma: A randomized controlled trial. J Tradit Complement Med. 2021;11(6):581-586. doi: 10.1016/j.jtcme.2021.06.006. Note: See graphical abstract for excellent summary.
12. Dada T, Bhai N, Midha N, et al. Effect of Mindfulness Meditation on Intraocular Pressure and Trabecular Meshwork Gene Expression: A Randomized Controlled Trial. Am J Ophthalmol. 2021;223:308-321. doi: 10.1016/j.ajo.2020.10.012.
13. Kumar A, Ou Y. From bench to behaviour: the role of lifestyle factors on intraocular pressure, neuroprotection, and disease progression in glaucoma. Clin Exp Ophthalmol. 2023. doi: 10.1111/ceo.14218.

DR. LIFFERTH is clinical editor of Optometric Management. He practices at Center for Sight, is a member of the Optometric Glaucoma Society, and a Glaucoma Diplomate of the American Academy of Optometry. For additional glaucoma cases, you can also follow Dr. Lifferth on his Instagram account: glaucomaqd. Email him at glaucomaqd@yahoo.com.