“The insidious thief of vision”: glaucoma has begun to occur even in infants

Gadget users are at risk

“Nothing can be more terrible than losing your sight – this is an unspeakable insult, it takes away nine-tenths of the world from a person,” Maxim Gorky once said. Today in our country about 1.3 million people suffer from glaucoma. And at least another 500 thousand people also suffer from this disease, but do not even know it. Unfortunately, a decrease in visual acuity in glaucoma begins already in the advanced stages of the disease, and while there are no symptoms, many people delay visiting a doctor. With the development of glaucoma, the visual fields begin to fall out in fragments, and often the second eye compensates for that part of the “picture” that is no longer accessible to the affected eye.

No one is immune from the disease: glaucoma occurs even in infants, although in most cases it is a disease of old age. The reason for the development of glaucoma is still unknown to science. No one knows why at some point the optic nerve begins to atrophy, and the loss of thickness of the retinal nerve fiber layer during the glaucomatous process at the initial stage of the disease is 11 times greater than that during natural aging.

However, risk factors for developing the disease are known. First of all, older patients are at risk, but heredity also plays a role (if you have a family history of glaucoma, your risks are higher). Hereditary and familial forms account for at least 1/3 of all cases of open-angle glaucoma. At the same time, scientists have already identified more than 30 genetic loci for various forms of glaucoma, but the role of only three or four of them has been studied in detail.

In addition, high eye strain, the presence of vascular pathologies and high myopia are important for the development of the disease. That is, those at risk are those who regularly sit at the computer or look at gadgets, patients with arterial hypotension, atherosclerosis, migraines, Raynaud’s syndrome, sleep apnea syndrome, diabetes, in the end, just myopic people…

Professor Egorov says that previously, angle-closure glaucoma was more common (this type of disease is characterized by very rapid progression, resulting in rapid vision loss). But today, in 90% of cases, glaucoma has a long course (the primary open-angle form, or POAG, is diagnosed). For a long time it does not manifest itself with any symptoms, and often the patient comes to the doctor with an advanced disease.

And although both scientists and doctors continue to conduct research into the nature of glaucoma and are searching for means to completely cure it, unfortunately, the disease is still incurable – it is impossible to completely stop vision loss once a diagnosis has been established. However, everything possible can be done to slow down this process as much as possible – that is, delay the onset of darkness for years and even decades.

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Since 2008, doctors have noted a trend in the decrease in the number of visits to an ophthalmologist (in 2008 there were 65.7 million visits, and in 2020 – 41.5 million). The number of ophthalmology beds during this time decreased from 24 thousand to 13.6 thousand, and the provision of ophthalmologists – from 1 per hundred thousand population to 0.89.

News in diagnostics

Doctors remind that you should visit an ophthalmologist, even in the absence of symptoms and eye diseases, once a year. After 40 years, you need to measure your intraocular pressure (IOP) level annually. Thanks to the efforts of specialists from the Russian Geographical Society, diagnostics of IOP level, that is, one of the criteria on the basis of which glaucoma can be suspected, was included in clinical observation, and was performed for Russians starting from the age of 40, while at the age of 18 to 39 years such a study must be completed every three years .

By the way, very soon it will be possible to measure the IOP level even at home: portable devices for this purpose have already appeared (patients can measure pressure by simply placing the device on their eyelid). However, Dr. Egorov emphasizes that home control, of course, is not enough: visits to an ophthalmologist are mandatory. After all, although rare, there are still patients in whom glaucoma develops against the background of a normal level of ophthalmotonus. In addition, there are people with individual—higher or, conversely, lower—indicators of normal IOP, and only a specialist will be able to understand in which cases a diagnosis can be made. “About 60 years ago, ophthalmologists took it as an axiom that glaucoma and increased intraocular pressure are synonymous,” says Professor Egorov. — So, in 1958, patients with an IOP level above 21 mm Hg. began to diagnose glaucoma, regardless of the presence of any signs of glaucomatous damage. They were prescribed IOP-lowering eye drops and told to use the drops three to four times a day or they would go blind. Patients with a blood pressure of 20 mm Hg. they said that they did not have glaucoma, and no treatment was prescribed.”

But today everything has changed dramatically. There is a group of patients with individual low normal values ​​(16–18 mm Hg), approximately 21.3%. And there are also patients with individual high normal levels – 23–26 mm Hg, and their number is 6.5%. The average IOP in healthy individuals is in the range of 19–22 mmHg.

According to the head of the department, ophthalmologist at the Regional Ophthalmological Clinical Hospital (Kursk), Andrei Brezhnev, today high-tech diagnostic methods are being introduced into the routine practice of doctors: static automated perimetry (SAP) and optical coherence tomography (OCT), so there is a range of possibilities for early diagnosis of the initial stages of glaucoma is expanding. A search is also underway for molecular biomarkers of glaucoma that could predict its development and course, as well as the nature of its progression. However, so far there has been no significant progress in this direction. Scientists are considering markers of oxidative stress, the complement system and growth factors as promising candidates, and biological media, in addition to the usual blood and urine, can include sweat, the vitreous body of the eye, tear film, and saliva. “Yet the molecular mechanisms of glaucoma are not fully understood, and the data obtained are often contradictory. In addition, antiglaucoma drugs can also influence the expression of biomarkers,” says Dr. Brezhnev.

Online glaucoma risk calculators are already being developed around the world. One of them, developed in Europe in 2004 based on research, allows you to calculate the probability of having glaucoma in almost 80% of cases. Yet the use of such calculators is still limited.

But modern devices for 24-hour IOP monitoring have already appeared, including in the form of touch contact lenses and intraocular implants. “The ultimate goal of glaucoma treatment is to preserve visual function and the associated quality of life. It is necessary to conduct large-scale clinical and epidemiological studies that expand the possibilities of forming “risk groups” for the development of glaucoma,” says Andrei Brezhnev.

Drop by drop

The risk of severe vision loss depends on the stage at which the disease is diagnosed, life expectancy, and the rate of vision deterioration. According to a member of the presidium of the Russian Geographical Society, head of the ophthalmology center, colonel of the medical service, doctor of medical sciences, professor of the Department of Ophthalmology. Academician A.P. Nesterov FGAU HE “RNIMU named after. N.I. Pirogova” of the Ministry of Health of Russia Alexander Kuroedov, today doctors have a large selection of drugs for each patient, so you can always choose adequate therapy for the patient: “The main thing is that the patient comes to us on time, and then shows responsibility and does not interrupt treatment. But, alas, more than half of patients are diagnosed at an advanced stage.”

Unfortunately, patients with glaucoma have low compliance—adherence to treatment. The share of low-compliance patients, according to doctors, is 20%, average compliance – 30% and high compliance – 50%. The share of low-compliance patients, according to the patients’ own responses, is 24.4%, average compliance – 74.4% and high compliance – 1.2% “However, low adherence to treatment is typical for patients who comply with recommendations for 20 days, average – 90 days, high – only 200 days,” explains Dr. Kuroyedov.

The problem is that glaucoma patients do not see a significant effect from the treatment. You need to put drops into your eyes every day, for many years in a row. In this case, the patient may not notice any improvement: after all, the goal of therapy is to slow down the onset of blindness. As a result, some patients decide that instilling drops is useless and simply stop doing it. As Professor Kuroyedov says, even the most responsible patients, on average, stay on therapy for only a year, after which they get bored, and they quit treatment and begin to miss visits to the doctor. As a result, sad consequences inevitably occur: the disease begins to gain momentum.

As Alexander Kuroedov says, the Russian Geographical Society teaches practicing doctors to conduct a constant dialogue with patients, express support for them, put them in a positive mood, but at the same time explain the consequences of refusing treatment: “And yet the patient himself must understand that the success of treatment depends not only from the doctor, but also from how carefully he follows the prescribed therapy.”

One of the reasons for refusing treatment in the past was side effects, which are often caused by eye drops with preservatives. However, today they are practically not used: preservative-free therapy is becoming the “gold” standard. Modern drugs can successfully slow down the onset of blindness in the vast majority of cases if the disease is detected at an early stage. When an advanced stage of the disease is diagnosed, the percentage of successful treatment is reduced to 2/3, and if the disease is caught at an advanced stage, alas, conservative treatment only helps in a third of cases. Nevertheless, such patients may be offered surgical techniques.

Cut without waiting for peritonitis?

Glaucoma surgery has also been increasingly developed in recent years. A well-known ophthalmic surgeon, vice-president of the Russian Geographical Society, Professor Valery Erichev said that the average age of detection of glaucoma in Russia, regardless of stage, is 61.5 years. The transition to surgical treatment of glaucoma is realized 6–7 years from the moment the disease is detected. Unfortunately, in every fifth patient, even with a normalized IOP level, visual function continues to deteriorate. In this case, patients are offered surgery.

Doctors call surgery the most reliable method of treatment, since “all non-operated glaucomatous eyes will eventually go blind, and among those who have been operated on there are many who do not manage to go blind before death.” However, since patients with glaucoma are most often elderly people, in most cases they also have other chronic diseases that can affect the outcome of surgical treatment. Professor Erichev cited data from one large multicenter study among 21,506 patients with glaucoma, according to which arterial hypertension was established in 52.7% of them, diabetes mellitus in 41.3%, coronary heart disease in 30.7%, chronic obstructive lung diseases – in 14.3%.

Valery Erichev says that the inevitability of progression in glaucoma is obvious and the most rational tactics for today: “early diagnosis – long-term therapy”, “late diagnosis – early surgery”.

…To stop the loss of vision among the population, the Russian Geographical Society developed the GlauBot telegram application. With its help, you can identify your individual risks of developing glaucoma. But for patients with an already established diagnosis, it will remind them to take medications or perform eye exercises.

The Russian Geographical Society considers the immediate tasks to be the creation of regional and interregional registries of patients with glaucoma, restoration of the system of medical examinations at enterprises, training of patients in methods of self-monitoring of indicators, full rehabilitation of the “polyclinic – glaucoma office – hospital” system and, of course, full-fledged training of medical specialists within the framework of postgraduate education.