Article revised on 1/24/2024 with corrected information on Flammer syndrome.

Help patients decrease these lifestyle-associated risk factors

Modifiable risk factors related to lifestyle may mitigate the course and prognosis of glaucoma. Here, I discuss these risk factors.

SMOKING…

Smoking causes episcleral vasoconstriction, decreased optic nerve perfusion, irregular blood flow, and elevated vasospasms due to increased blood viscosity.¹ Additionally, smoking increases the oxidative load within the eye (even on a histological level within the trabecular meshwork), and decreases circulating antioxidants.¹ Such an environment, especially among those who have genetic risk factors for glaucoma, and among men, may increase the risk of developing the silent thief of sight.^1,2 What’s more, this risk increases proportionately among heavy smokers.³ Further, it has been suggested that smoking intensity in glaucoma patients is associated with faster rates of retinal nerve fiber layer thinning³ and higher IOP levels vs. those who have never smoked.⁴

Action step: Consider recommending one of the many free smoking-cessation apps available, as well as directing patients to credible and comprehensive online resources such as, How to Quit | Smoking & Tobacco Use | CDC.

STRESS…

Stress may be a significant causative factor of glaucoma (not just associated with the diagnosis) for the following reasons:

• “…chronic stress can trigger “psychosomatic” organ dysfunctions anywhere in the body. Why should the organ ‘eye’ be an exception?”⁵
• “…acute and chronic stress increases IOP…”⁵
• People who have Flammer syndrome (FS) react very differently and usually more intensely to emotional stress than people without FS. Stress also intensifies the symptoms of FS and can, thus, contribute to the occurrence or progression of FS-related diseases, such as normal tension glaucoma,” according to Josef Flammer, the ophthalmologist whose work led to the term “Flammer syndrome.”
• Blood pressure (specifically high and low blood pressure) may be associated with an increased risk of developing primary open-angle glaucoma, and increasing evidence shows nocturnal hypotension, specifically, may further negatively affect such progression.^6-14

Action step: To stop stress, Sabel et al suggest “…stress reduction through relaxation techniques (e.g., meditation) and positive vs. negative (e.g., “You will go blind”) patient communication.⁵

STIMULANTS…

A large biobank review reveals that patients within the highest 25^th percentile of genetic predisposition to higher IOP were more likely to have higher IOP after caffeine intake vs. those who had a lower polygenic risk score (PRS). As a result, the researchers concluded that, “…genomic data may be needed to make recommendations regarding caffeine consumption and glaucoma risk.”¹⁵

In a similar large genetic biobank study, those patients within the highest PRS quintiles who ingested alcohol had, “…0.15 mmHg (95% CI, 0.07 to 0.24) higher IOP…thus implicating alcohol consumption as a potentially modifiable risk factor for glaucoma”¹⁶ too.

Action step: For patients who may have a higher PRS profile, optometrists can recommend moderation with caffeine intake with a gradual reduction over several weeks. Regarding alcohol, to change behavior, many times we need to change our environment. With that context, also consider these helpful tips, “11 ways to curb your drinking,” from the “Harvard Health Publishing” website.

GO FOR GOOD…

Looking beyond IOP levels as the greatest modifiable risk factor, and considering at least these three S’s, where applicable, may help us make a beneficial impact on our patients’ glaucoma prognosis. OM

Clarification

In a later conversation with Josef Flammer, the ophthalmologist whose work led to the term “Flammer syndrome" (FS), Dr. Flammer clarified that FS is, in fact, inborn instead of being the result of stress. "But people with FS react very differently and usually more intensely to emotional stress than people without FS. Stress also intensifies the symptoms of FS and can, thus, contribute to the occurrence or progression of FS-related diseases, such as normal tension glaucoma,” according to Dr. Flammer. Dr. Lifferth thanks Dr. Flammer for this clarification.

REFERENCES

1. Law SM, Lu X, Yu F, Tseng V, Law SK, Coleman AL. Cigarette smoking and glaucoma in the United States population. Eye (Lond). (Lond). 2018;32(4):716-725. doi: 10.1038/eye.2017.292.
2. McMonnies CW. Glaucoma history and risk factors. J Optom. 2017;10(2):71-78. doi: 10.1016/j.optom.2016.02.003.
3. Jain V, Jain M, Abdull MM, Bastawrous A. The association between cigarette smoking and primary open-angle glaucoma: a systematic review. Int Ophthalmol. 2017;37(1):291-301. doi: 10.1007/s10792-016-0245-0.
4. Nishida T, Mahmoudinezhad G, Weinreb RN, et al. Smoking and progressive retinal nerve fibre layer thinning in glaucoma. Br J Ophthalmol. 2022;bjophthalmol-2022-321237. doi: 10.1136/bjo-2022-321237.
5. Lee CS, Owen JP, Yanagihara RT, et al. Smoking Is Associated with Higher Intraocular Pressure Regardless of Glaucoma: A Retrospective Study of 12.5 Million Patients Using the Intelligent Research in Sight (IRIS) Registry. Ophthalmol Glaucoma. 2020;3(4):253-261.doi: 10.1016/j.ogla.2020.03.008.
6. Sabel BA, Lehnigk L. Is Mental Stress the Primary Cause of Glaucoma? Klin Monbl Augenheilkd. 2021;238(2):132-145.doi: 10.1055/a-1303-8025.
7. Leeman M, Kestelyn P. Glaucoma and Blood Pressure. Hypertension. 2019;73(5):944-950. doi: 10.1161/HYPERTENSIONAHA.118.11507.
8. Zhao D, Cho J, Kim MH, Guallar E. The association of blood pressure and primary open-angle glaucoma: a meta-analysis. Am J Ophthalmol. 2014 Sep;158(3):615-27.e9. doi: 10.1016/j.ajo.2014.05.029.
9. Kim H, Choi B. Nonlinear Relationship Between Blood Pressure and Glaucoma in US Adults. Am J Hypertens. 2019;32(3):308-316. doi: 10.1093/ajh/hpy186.
10. Leske MC, Wu SY, Hennis A., Honkanen R., Nemesure B. Barbados Eye Study Group Risk factors for incident open-angle glaucoma: the Barbados Eye Studies. Ophthalmology. 2008;115(1):85-93. doi: 10.1016/j.ophtha.2007.03.017.
11. Costa VP, Harris A, Anderson D, et al. Ocular perfusion pressure in glaucoma. Acta Ophthalmol. 2014;92(4):e252-66. doi: 10.1111/aos.12298.
12. Bowe A, Grünig M, Schubert J, et al. Circadian Variation in Arterial Blood Pressure and Glaucomatous Optic Neuropathy—A Systematic Review and Meta-Analysis. Am J Hypertens. 2015;28(9):1077-82. doi: 10.1093/ajh/hpv016.
13. Topouzis F, Coleman AL, Harris A, et al. Association of blood pressure status with the optic disk structure in non-glaucoma subjects: the Thessaloniki Eye Study. Am J Ophthalmol. 2006;142(1):60-67. doi: 10.1016/j.ajo.2006.02.055.
14. Bonomi L., Marchini G, Marraffa, et al. Vascular risk factors for primary open-angle glaucoma: the Egna-Neumarkt Study. Ophthalmology. 2000;107(7):1287-93. doi: 10.1016/s0161-6420(00)00138-x.
15. Macri C, Wong CX, Tu SJ, et al. Blood Pressure Measures and Incident Primary Open-Angle Glaucoma. Invest Ophthalmol Vis Sci. 2022;63(13):3. doi: 10.1167/iovs.63.13.3.
16. Kim J, Aschard H, Kang JH, Lentjes MAH, Do R, Wiggs JL, Khawaja AP, Pasquale LR. Modifiable Risk Factors for Glaucoma Collaboration. Intraocular Pressure, Glaucoma, and Dietary Caffeine Consumption: A Gene-Diet Interaction Study from the UK Biobank. Ophthalmology. 2021;128(6):866-876.

DR. LIFFERTH practices at Center for Sight. He 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. Disclosures: None. Email him at glaucomaqd@yahoo.com.