EDITORIAL

Optimizing Glaucoma Care: A Holistic Approach

Tanuj Dada1, Nidhi Chauhan2

Journal of Current Glaucoma Practice (2023): 10.5005/jp-journals-10078-1416

Managing a glaucoma patient is like entering into a lifelong 1,2

partnership with a fellow human being. The treating doctor is Department of Ophthalmology, Dr Rajendra Prasad Centre for
Ophthalmic Sciences, All India Institute of Medical Sciences, New
dealing with not only ocular disease but various mental and
Delhi, India
physical health issues that impact the overall quality of life of
the patient, in addition to integrating the patient into a new Corresponding Author: Tanuj Dada, Department of Ophthalmology,
Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute
family and social dynamic as vision-related quality of life gets
of Medical Sciences, New Delhi, India, e-mail: [email protected]
hampered. There are also several unforeseen circumstances that
How to cite this article: Dada T, Chauhan N. Optimizing Glaucoma
may arise, like what we saw during the coronavirus disease 2019
Care: A Holistic Approach. J Curr Glaucoma Pract 2023;17(3):111–112.
pandemic, where many patients lost access to healthcare and
economic constraints caused by job cuts which pushed patients Source of support: Nil
into a situation where they could not afford topical medical Conflict of interest: None
therapy. It is time to expand the role of a glaucoma surgeon
beyond prescribing drops and performing lasers/surgery such
that they can positively impact the lives of glaucoma patients Holistic glaucoma management would entail a focus on all the
and their families. mechanisms that are implicated in apoptosis of retinal ganglion
Glaucoma is the leading cause of irreversible blindness cells (RGC), including barotrauma, 6,7 autonomic dysfunctions
worldwide.1 It’s been noted that blindness is considered to be with sympathetic overactivity leading to vasoconstriction and
one of the most feared medical conditions, and adults who lose ischemia/hypoxia, 8 reductions in neurotrophic factors like brain-
visual function are 90% more likely to experience depression derived neurotrophic factor,9 increase in inflammatory mediators
than people whose visual function is not compromised. 2 like transforming growth factor-β,10 increased cortisol levels,11
Giving the patient a diagnosis of glaucoma incites immediate mitochondrial and nitric oxide pathway dysfunction, and age-
anxiety with fearful and negative emotions. “Am i going blind?” related neurodegeneration which leads to progressive loss of
is a question often the glaucoma patients ask us with great RGC. Health education regarding the disease, appropriate use
apprehension about the future. They need to be spoken to with and application of eye drops, associated systemic disease and
care and compassion and made to understand the disease and its drug interaction with glaucoma medications, dietary and lifestyle
holistic management in a manner that instills hope for the future. modifications, vitamin supplements, physical exercise, breathing
Furthermore, as a patient follows up and notices the techniques for relaxation, yoga (without head down postures),
progression of disease with advancing visual field defects (this and meditation, eligibility for driving and risk of motor vehicle
may happen even with adequate intraocular pressure (IOP) control, accidents, cessation of smoking, etc., should be imparted to all
which becomes even more frustrating for both the patient and glaucoma patients. Appropriate referral to physicians for the
the treating doctor) and age-related deterioration, this creates a detection and management of systemic disease on a regular basis
condition of chronic stress (allostatic overload) which increases the is essential, and rehabilitation of visually impaired patients with
risk of other life-threatening diseases such as cardiovascular disease, assistive devices is required. The importance of family screening
diabetes, obesity, arthritis, and cancer and increases the risk of (especially for siblings) should be discussed with the patient,
mortality. Chronic stress leads to an increase in endogenous cortisol, and appropriate annual appointments should be fixed for family
which has the potential to raise IOP and worsen optic neuropathy, members.
while at the same time, high cortisol levels are detrimental to the In addition, psychological counseling of the patient and
hippocampal neurons and are implicated in cognitive decline and the family, along with an assessment of the caregiver burden, is
neurodegenerative disease. This can create a vicious cycle and lead essential, especially when dealing with visually impaired/blind
to further deterioration of the disease. An increase in stress can also glaucoma patients.
lead to a rise in catecholamines, which can compromise optic disc With glaucoma patients, we are not just treating the disease at
perfusion.3,4 Increasing evidence from human to animal studies has one point of interaction but are following up with them for the rest
shown that glaucoma shares some common neurodegenerative of their lives. How we can support them in this long journey is the
pathways with Alzheimer’s disease and other tauopathies, such as goal of effective management. Assessing their existing support
chronic traumatic encephalopathy and frontotemporal dementia.5 group, evaluating their financial burden, and titrating therapy
Alleviating chronic stress and reducing allostatic load and other accordingly with generic/branded medications or low-cost
strategies to target neurodegeneration can be additional goals in microinvasive glaucoma surgery or even a primary trabeculectomy
the management of glaucoma patients, which are often overlooked where medications are not available/affordable is essential.
in routine clinical care. Providing them with access to the required psychological, social,

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 Optimizing Glaucoma Care

thrive and flourish and live happily even with a sight-threatening

disease, and that should be the matrix for our measurement of a
successful outcome.
The four pillars of glaucoma management are summarized in
Figure 1.

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112 Journal of Current Glaucoma Practice, Volume 17 Issue 3 (July–September 2023)