 Hi everyone. For those who don't know me, I'm Mulu. I'm one of the current glaucoma fellows at the Moran. And I have the pleasure of giving the last garden rounds of this academic year. I was initially pretty excited that I got assigned such a late date because I love to procrastinate. But as the date approached and I was struggling to find a topic, I realized all the topics I were of interest had already been talked about. So this was sort of in the back of my head and I was doing clinic and this patient asked me a question that I think we get actually quite often. And the patient who was very complying with her eye drops wanted to know there was anything else she could do to help control her glaucoma. And so I sifted through a lot of patient testimonials and anecdotal evidence and I came up with there were four things that as physicians that we should be aware of when looking at a glaucoma patient and this is looking past drops, lasers, and surgery. And I'll go through each one of these. So the first is acupuncture or acupressure. According to traditional Chinese medicine, there are two opposing forces, noesim and yang, and the imbalance of these two forces caused a blockage of the vital energy, also noeschi. So chi flows along pathways in the body known as meridians in a passive with certain points which can be stimulated known as acupoints. And it is believed that disease can be prevented or treated by stimulation of relevant acupressure points. The mechanism of action of acupressure is not really known. We do know it has something to do with stimulation of the autonomic nervous system. More specifically acupressure to intraocular pressure in a rabbit model, Chu and Potter found that acupressure in certain points can reduce aqueous humor production. And there has been other studies showing increasing coriorentinal circulation. So Chinese medicine believes that weakness in the eye or eye disease is due to weakness in the liver or kidney. And so if you have eye issues, the liver and kidney acupoints are really stimulated and those are shown here in the supine and prone poses. There's also something known as auricular acupressure. There's a homunculus in your ear and stimulation of the corresponding point on the ear can help balance the corresponding organ. And so as you can see the acupoint for the eye is down here on the ear lobe. So the literature does have a few reports of patients with glaucoma or ocular hypertension that's shown a decrease in intraocular pressure after acupressure treatment and also one showing a lower variation in diurnal IOP 24 hours after treatment. The Cochrane group attempted to do a review in 2007 to help establish acupuncture as a therapeutic modality for glaucoma. However, they found the studies that were available were of poor quality, no randomized controlled trials and they were not able to establish the effective acupuncture. This is a study that was published in 2010. It's a prospective randomized controlled trial done by a group in Taiwan. They studied the effective acupressure on patients that had been diagnosed with glaucoma or ocular hypertension for at least a year who had not undergone any laser tuberculoplasty or glaucoma surgery. They split these patients up into two groups, the control group and the treatment group. In the treatment group the patients received simulation of the acupoints for the eye, liver and kidney for three minutes twice a day for four weeks. Whereas the control group received acupoint tapping for, they assumed unrelated acupoints for the jaw, wrist and shoulder. They did actually find a significant decrease in IOP in the control group versus the sham group as soon as ten minutes after treatment and lasting all the way till four weeks. After four weeks acupoint treatment was stopped and so at the eight week follow-up there was no difference between the two groups in their intraocular pressure. They also did show a decrease in IOP in the control group. They did not mention whether this decrease in intraocular pressure, whether that was statistically significant to baseline, but their theory as to this was because all the meridians are connected and so stimulation of the wrist or the shoulder could have had an effect downstream on the eye acupoint. Now let's talk about exercise and glaucoma. Dynamic exercise such as walking, running, cycling, it's widely accepted in literature to have a decreased effect in intraocular pressure. The three main theories as to why this occurs is either decrease in blood pH perhaps due to elevated blood lactate or elevated plasma osmolarity. This is a very busy table. It was compiled by Riesner at all in 2009. It just shows all the studies that show that dynamic exercise have an effect on IOP. I did highlight a couple of studies here. All the arrows for IOP effect are pointing down except for the arrow which has the blue arrow and their exercise rather than biking, jogging, walking was actually bench presses and so the authors explained that their increase in IOP was likely due to the valsalva maneuver during the bench press. Koreshi is circled here. It's something I want to talk about in a couple of slides. So yes, exercise does have a decreasing effect on IOP, but what about intensity of exercise? Do you get the same reduction in IOP whether you're walking versus doing more intense exercise? And that's what Koreshi studied. He looked at seven POAC patients versus seven healthy normal subjects all between the years of 40 and 50 years old. All the subjects were put to three different levels of intensity of exercise. Walking for an hour, jogging for an hour were running as fast as possible until quote unquote volitional exhaustion which is exact quote from their paper. IOP was measured at baseline at 520, 40 and 60 minutes and also after cessation of exercise every 10 minutes until IOP returned to baseline. So yes, like the other studies they found that there was a decrease in IOP with exercise, but interestingly they found that the more strenuous or higher intensity of exercise like running, the greater decrease in IOP. So that's the ovals versus the rectangles. And furthermore they found that running had a longer period of IOP decrease after cessation exercise than a lower intensity exercise such as walking. We'll talk about yoga because that's actually becoming very popular in America. This is the Sharshasana pose and its modifications. The Yoga Journal published a survey in 2012 that reported 8.7% of US adults practice yoga. That is a 30% increase since 2008. And of course non-practitioners almost half Americans call them aspirational yogis meaning that they wanted to get into yoga forecasting a likely increase in yoga practice in the near future. So it's very likely that many of our patients participate in yoga. Which is why I want to talk about this study that was published in Ophthalmology in 2006 discussing the pose that I had just shown, the Sharshasana or headstand posture and its effect on intraocular pressure. So they recruited 75 yoga practitioners and measured their IOP sitting at rest and also well in the head pose. And they found a two fold increase in intraocular pressure while the patient was in the headstand posture and that was maintained throughout the time the patient was maintaining the posture. But luckily came down back to baseline after resuming a normal sitting position. They theorized the increase in IOP was likely due to increase in episcopal venous pressure while the patients are in that headstands. They did not find an increase in incidence of ocular hypertension or glaucoma in this cohort of yoga practitioners though the average age was in the 30s and that would be rather young for glaucoma. But they did advise that glaucoma patients be cautioned against long times in the Sharshasana pose. Occupation, this is not really a treatment but it's something that we should be asking our patients, especially those who look like normal glaucoma patients well controlled IOP in the office but still with visual field progression. There were a few case reports about brass instrument players who had exactly that and that sort of ended up in this study like this by Schumann et al. a group from Tufts. They looked at the effect of intraocular pressure high resistance wind instrument on intraocular pressure so they recruited 46 professional musicians from the Boston area and split them into three groups. High resistance wind instrument players which you know is your oboe, bassoon, phantron, trumpet the low resistance group included flu, clarinet, saxophone, tuba and trombone and then the no resistance which are the non-wind instrument players and they performed baseline exams on all of these patients including intraocular pressure, hungry visual field and they found that there's no significant difference in the optic nerve head appearance among the three groups of musicians though no OCT, RNFL was performed but they did find that three out of the nine high resistance wind instrument players had abnormal visual fields though they did not mention or describe the type of defect this is a pose to one out of 11 for low resistance and two out of 23 for the non-wind players who had abnormal visual fields and the abnormal visual field was directly correlated to the number of life hours the musician had spent playing that high resistance wind instrument player wind instrument. They also this looks fun doesn't it? They also measured IOP while the musicians were playing their instruments and this is a new metronometry tracing of IOP while an oboeist was playing. You can see when he or she started playing baseline IOP maybe about 15 once the musicians started playing it went up five points to about 20 and then when the musician was asked to increase volume and pitch the IOP went up to as far high as 40. This is a slide showing a single musician playing three different instruments so on the left tracing A and B is the musician playing the clarinet and saxophone respectively which are low resistance instruments. Baseline IOP about 10 and as he starts playing he's asked to increase the pitch to as high as possible and the volume to as high as possible and the IOP peaks at just above 20 and on the right is the trumpet which is a high resistance instrument so baseline IOP that's where the red line is about 10 and he peaks to just above 30 when asked to play a high pitch at a high volume. So they theorized that Valsalma Maneuver is the reason why for these increased intracular pressure it's needed to play these high resistance wind instruments. It causes a rise in intracerative pressure which compresses the vena cava impeding the drainage of the vortex mains increasing the episcular venous pressure and also increasing the UVO volume. So they concluded that high resistance wind instrument playing can cause transient increases in chocolate pressure and for those patients who seem like normal tangent glaucoma patients this is something that is important for us to rule out. And I want to end on a hot topic the state of marijuana this is published in Los Angeles earlier this year and I'll soon be moving to the state of Washington which has legalized medical and recreational marijuana and I thought I should build up on the facts about cannabis and glaucoma. In the state of Utah we are surrounded by several states who does have legalized medical marijuana. Cannabis has more than 80 chemical constituents out of these only 66 are cannabinoids and those are compounds that contain only carbon, oxygen and hydrogen and the most infamous one is THC or Delta 9 tetrahydro cannabinoid. It is responsible for the main psychotropic effect of marijuana its synthetic analogs, dronabinol or marinal is actually currently used as appetite stimulation for AIDS patients and also treatment for nausea and vomiting in patients with chemotherapy. So the effect of cannabis on IOP has been well established since the early 1970s. Helper and Frank noted a 25 to 30% reduction in IOP after patients smoked marijuana. Ivy administration of THC and rabbits produced significant but short term reductions in IOP and in 1984 Cola Santi found a topical application of cannabinoids in cats showed a localized effect. Interestingly in the mid 1980s California did fund a cannabis therapeutic research program to study the viability of THC or cannabis as long term treatment for glaucoma. They enrolled nine patients all with very severe uncontrolled and stage poag who were on maximum medical therapy. They started the patient either on 2.5 or 5 milligrams of PO THC QID and adjusted the dose upward down depending on the effects and recite effects the patients experienced. So all the subjects experienced initial decrease in chocolate pressure five out of the nine later however showed some resistance because their IOP went up later in the treatment and four out of the nine patients had to self-terminate the study due to intolerable side effects such as distortion perception severe dizziness and confusion. Interestingly according to study protocol all the patients all four of these patients who were terminated were offered marijuana cigarettes to be smoked QID as a alternative to THC pills and they all declined. The reduction of cannabis and IOP is still under investigation. We do know that the body produces endocannabinoids and they act on two different types of receptors CB1 and CB2. We think it is the CB1 receptors that is responsible for the reduction in IOP because it has been localized in the human eye in the serobodies, trabecular mesh work in Schlem's canal. So what is the issue with cannabis and THC for glaucoma why is it currently not a really viable solution well number one is derivative action extremely short only about three to four hours and also most importantly is the systemic and psychotropic effects. So coupled together a patient would have to be essentially high 24 seven to have a nice reduction in IOP. And that's why there's been a lot of interest in topical cannabinoids because they reduce the amount of systemic side effects while localizing its IOP reducing effect. The issue with this is that natural and synthetic forms of cannabinoids are extremely lipophilic so they have poor corneal penetration and also low aqueous solubility. Merit's group in 1981 instilled eye drop form THC and glaucoma patients they did find a significant reduction in IOP with minimal systemic effects however they had to mix the THC with mineral oil as vehicle which was extremely irritant to the human eye and Roth and Green in 1982 attempted using topical THC on rabbits without mixing it with an agent it was found that there was no effect on IOP but did cost a lot of eye irritation. So what is in the future there's currently a synthetic non-psychoactive kind of anoid known as hexanabinol or H2211 in rabbit studies it's shown to decrease IOP for as long as six hours with no change in blood pressure heart rate or pupil dilation. I couldn't find any reports of this drug in patients for glaucoma although I do know that it is currently under investigation treatment for traumatic brain injury and also solid tumors but until something more concrete comes out this is the AGS stands official stands on treatment glaucoma that was published in 2010 written by Harry Jim Pell. He says that although marijuana can lower the IOP its side effects and sure duration of action coupled with the lack of evidence that its use alters the course of glaucoma preclude recommending this drug in any form for the treatment glaucoma at the present time. So when a patient asks you if there's anything else he or she can do besides sticking with a drug regimen and coming to his or her follow ups it's a good time to take the opportunity to educate patients about his or her disease and there are few activities that should be avoided by the glaucoma patient prolonged head down position about salmoneuvers asking if he or she is a professional trumpet player aerobic exercise has been shown to have some benefit and should be used intensity depending on the general health of the patient and we should emphasize that alternative therapy cannot substitute the conventional treatment available currently thank you.