Eyeworld

SUMMER 2025 | EYEWORLD | 65 G CHANGING MINDSETS by Liz Hillman Editorial Co-Director About the physicians Qi Cui, MD, PhD Associate Professor of Ophthalmology University of Pennsylvania Philadelphia, Pennsylvania Monica Ertel, MD Assistant Professor of Ophthalmology University of Colorado Anschutz Medical Campus Denver, Colorado Shan Lin, MD Glaucoma Center of San Francisco San Francisco, California Kaweh Mansouri, MD Adjoint Professor Department of Ophthalmology University of Colorado Anschutz Medical Campus Denver, Colorado Grace Richter, MD, MPH Partner Southern California Permanente Medical Group Kaiser Permanente Los Angeles Medical Center Los Angeles, California interventions can slow glaucomatous progres- sion and optimize optic nerve health among those who already have glaucoma," she said. Anecdotally, Dr. Richter mentioned a pa- tient she began seeing several years ago who was 49 years old. Early on, this patient admit- ted to having poor diet and lifestyle habits, but her diagnosis with glaucoma motivated her to make changes to both. "She started eating a healthy Mediterra- nean diet and exercising, and she was very adamant about not starting glaucoma treatment until she spent a few months with her new diet. Because her disease was relatively early stage, we agreed on this plan," Dr. Richter said. "Surprisingly, her visual field defect went away for the next several visual field tests and her in- traocular pressure modestly improved. Though her diagnosis was still 'preperimetric glaucoma,' she was ecstatic that this had happened. I love learning from my patients, and she opened up my mind to the impact that lifestyle may have on glaucoma." Even though nutrition is important for over- all health, Dr. Richter said currently the only proven treatment for slowing glaucoma is IOP reduction with drops and/or procedures. Dr. Richter said she describes nutrition as a "sup- plemental way to optimize optic nerve health, based on newer evidence." Exercise First and foremost, Shan Lin, MD, said that lowering IOP is the only proven way to pre- vent glaucoma progression, but he said when patients ask what else they could do, he men- tions that exercise is an overall positive for their health. "Aerobic exercise is shown to be bene- ficial in terms of helping to lower intraocular pressure a small amount," Dr. Lin said. The mechanisms of action for this include decreased aqueous production, dehydration of the globe, increased outflow, and decreased episcleral venous pressure. There are some caveats for exercise when a patient has glaucoma, however. Weight training or weight-bearing exercises and certain yoga positions where the head is below the heart tend to increase eye pressure, Dr. Lin said. W hile the treatment mainstays for lowering and/or maintaining a target IOP are achieved with sur- gery, laser, or pharmaceuticals, patients often ask what else they can do. Several physicians spoke to EyeWorld about lifestyle changes that they recommend as an addition to traditional glaucoma therapies. Nutrition When it comes to nutrition, Grace Richter, MD, MPH, said there is evidence that positive nutritional habits can help reduce risk of devel- oping glaucoma, though there isn't data yet on whether this can slow existing disease. "That doesn't stop me from discussing nutrition with my severe glaucoma patients, who are on the brink of blindness with very delicate remaining retinal ganglion cells and who have the most at stake," she said. Dr. Richter said Level 1 evidence suggests patients should increase dietary nitrates, such as green leafy vegetables and beets, adopt a Medi- terranean diet, avoid ultra-processed food, and reduce carbohydrate intake. Level 2 evidence suggests patients increase fat and protein from vegetable sources, replacing carbohydrates, increase fruit and vegetable intake, increase dietary niacin, and avoid a very low fat diet. "This is a lot of information, and it can be overwhelming to some patients, so I start with an easy and obtainable goal to eat a salad every day," Dr. Richter said. "For those who are more interested and ready to optimize their diet, I dive into more details." Dr. Richter said the Level 1 studies support- ing that dietary interventions can reduce risk of developing glaucoma are largely epidemiology based, following participants over many years and understanding dietary habits with detailed food questionnaires. Though there are no studies to date that look at the effects of dietary interventions on slowing glaucoma progression, Dr. Richter said there are well-studied biological mechanisms showing that certain dietary interventions can reduce oxidative and inflammatory damage and enhance mitochondrial function of retinal ganglion cells. "I think it's just a matter of time before we have data proving that dietary Impact of lifestyle modifications on glaucoma continued on page 66

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