The Relationship Between Glaucoma and Activities of Daily Living and Exercise

Educational Objectives

The goal of this program is to improve the management of glaucoma to optimize physical function. After hearing and assimilating this program, the clinician will be better able to:

1. Recognize the effects of glaucomatous vision loss on activities of daily living and overall health.

Summary

Loss of visual function in glaucoma: understanding functional consequences of visual impairment is increasingly important in the management of glaucoma; for a service to be approved by Medicare and other agencies, the clinician needs to demonstrate that the service provides a meaningful benefit to the patient; visual rehabilitation involves the reestablishment of visual function in patients with glaucoma; understanding how patients are affected allows clinicians to be better doctors and human beings; Jamil Zaki has discussed how empathy is a modifiable factor and changes over generations, changes within the same individual over time, and can be cultivated; Zaki states that empathy is best achieved by seeing the suffering of others; however, it can be difficult to comprehend the effects of vision loss on patients; vision loss affects patients in all aspects of daily life; appreciating their functional concerns allows the clinician to be a better advocate for patients and make better clinical decisions; glaucoma is a disease of peripheral and central vision with diffuse damage and areas of pronounced peripheral loss

Effect of glaucoma on reading: Salisbury Eye Evaluation evaluated spoken reading speed in patients with glaucoma; patients with advanced bilateral glaucoma had a decrease in speed of 30 words per minute; Ramulu et al (2013) found that glaucoma has a more significant effect on silent reading speed (in which sustained focus is required) compared with spoken reading; sustained silent reading requires the patient to operate close to their cognitive maximum; healthy individuals maintained reading speed over long periods; patients with glaucoma fatigued during long periods of silent reading, resulting in slower reading speeds

Driving: Salisbury Eye Evaluation found that the probability of driving cessation increases with greater damage in the visual field (VF) of the better eye; driving cessation leads to restriction of activities outside of the home; this restriction is associated with higher mortality, faster cognitive decline, higher risk of becoming frail, and overall negative effect on mental health; Ramulu et al (2014) used a cellular tracker and found that patients with glaucoma are twice as likely to remain at home on a given day, which may be related to the disease or medications; study analysis found that the strongest predictor was use of an α agonist; brimonidine is associated with increased fatigue; Owsley found that VF loss increases rate of vehicle crashes; visual acuity has not been shown to affect accident rate; older patients have a higher rate of car crashes per mile driven compared with middle-aged patients

Falls: falls are a significant public health issue because hospitalization and rehabilitation are costly and greatly affect the patient’s quality of life; the Falls in Glaucoma Study (Ramulu et al [2019]) found that the absolute number of falls per year was not higher in patients with glaucoma (due to less overall activity); however, patients with glaucoma had a higher rate of falls per step; a study found that glaucoma patients often do not adjust their homes to reduce risk for falls; fall hazards in the home and lighting conditions were similar among patients with mild, moderate, or advanced glaucoma; advise patients to be aware of lighting to reduce risk for falls

Physical activity: reduced frequency of exercise is associated with increased all-cause mortality; eliminating sedentary behavior reduces risk for all-cause mortality and various conditions by 5% to 10%; patients with glaucoma take fewer steps per day and engage in shorter bouts of activity (number of activity bouts was similar); exercise may offer protective effects; Williams et al (2009) found that a faster running pace and more frequent running were associated with lower self-reported rates of glaucoma in male runners; another study found that the amount of physical activity and level of fitness were protective against glaucoma; Chrysostomou et al (2014) found that exercise was protective of optic nerve damage in mice with induced elevated intraocular pressure (IOP); in humans, a single bout of exercise can induce a spike in brain derived neurotrophic factor (BDNF); advanced glaucoma may be associated with lower resting levels of BDNF; Passo et al (1991) found that exercise conditioning can lower IOP in patients with ocular hypertension; Lee et al (2019) found that rate of progression was 10% slower in patients treated for ocular hypertension who took ≈5000 extra steps per day; data from Bascom Palmer Eye Institute showed that circuit training improved tissue perfusion and retinal blood flow

Readings

Lee MJ, Wang J, Friedman DS, Boland MV, De Moraes CG, Ramulu PY. Greater physical activity is associated with slower visual field loss in glaucoma. Ophthalmology. 2019;126(7):958-964. doi:10.1016/j.ophtha.2018.10.012; Ramulu PY, Swenor BK, Jefferys JL, et al. Difficulty with out-loud and silent reading in glaucoma. Invest Ophthalmol Vis Sci. 2013;54(1):666-672. Published 2013 Jan 23. doi:10.1167/iovs.12-10618; Ramulu PY, West SK, Munoz B, et al. Driving cessation and driving limitation in glaucoma: the Salisbury Eye Evaluation Project. Ophthalmology. 2009;116(10):1846-1853. doi:10.1016/j.ophtha.2009.03.033; Ramulu PY, van Landingham SW, Massof RW, et al. Fear of falling and visual field loss from glaucoma. Ophthalmology. 2012;119(7):1352-1358. doi:10.1016/j.ophtha.2012.01.037; Ramulu PY, Hochberg C, Maul EA, et al. Glaucomatous visual field loss associated with less travel from home. Optom Vis Sci. 2014;91(2):187-193. doi:10.1097/OPX.0000000000000139; Ramulu PY, Mihailovic A, West SK, et al. Predictors of falls per step and falls per year at and away from home in glaucoma. Am J Ophthalmol. 2019;200:169-178. doi:10.1016/j.ajo.2018.12.021; Williams PT. Relationship of incident glaucoma versus physical activity and fitness in male runners. Med Sci Sports Exerc. 2009 Aug;41(8):1566-1572.

Disclosures

For this program, the following relevant financial relationships were disclosed and mitigated to ensure that no commercial bias has been inserted into this content: Dr. Ramulu is a consultant for Ivantis, Janssen Pharmaceuticals, Roche, and W.L. Gore & Associates, and receives grant/research support from the National Eye Institute and Perfuse Therapeutics. Members of the planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Ramulu was recorded at the UCSF Glaucoma Update 2022 in the Napa Wine Country, held July 22-23, 2022, in Napa, CA, and presented by the University of California, San Francisco School of Medicine. For information about upcoming CME conferences from this presenter, please visit: cme.ucsf.edu. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

OP610702

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.