Cannabis as a Treatment for Glaucoma - Part 1

Episode Transcript

(00:01):
From the WA and M Studio onthe campus of Florida A and M University.
This is Mary Forum Radio, aweekly conversation on the education and research
of the medical marijuana being conducted atthe BMW. HI. I'm Heidi Otway,
your host for this conversations on Cannabisvirtual form, brought to you by
the Medical Marijuana Education and Research Initiativeat Florida and M University. In this

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conversation, we're talking about cannabis asa treatment for glaucoma. So let's talk
and learn about this subject with ourguests. Doctor Charles Hill is a Distinguished
Fellowship trained glaucoma specialist with more thanthirty five years of experience in private practice.
In addition to being an HBCU graduate, Doctor Hill hons his skills in

(00:44):
ophthalmology at Harvard Medical School. DoctorHill, Welcome to the Forum. Tell
us more about yourself. Thank you. My name is Charles Hill, and
I graduated from Alabama State University undergradschool, Medical School, University of Iowa,
Internship at Michigan, pre registering Fellowshipat WashU and Saint Louis Residency at

(01:08):
Harvard Post Registering Fellowship in Glock.Homer at Emory and been in private practice
here in the metro Atlanta area forabout thirty nine going on forty years.
So thanks for having me. I'mhappy to be here. Well, we're
glad to have you. Our othermedical expert is doctor Jordan Tishler, a

(01:29):
pioneering CANNABINOIT specialist who has extensive andextensive medical background. Doctor Tishler is a
distinguished faculty member at Harvard Medical Schooland serves on numerous boards. Doctor Tishler,
Welcome to the forum. Tell usmore about yourself. Thank you for
having me. You know, giventhe nature of my practice, I often

(01:49):
start to say, you know,my background is pretty conventional. I went
to Harvard College, I went toHarvard Medical School, and I trained in
internal medicine at one of the Harvardhospitals. I also often say, look,
if you go through Harvard, thatmany times we call ourselves preparation age.
Then I practiced an emergency medicine forabout twenty some odd years, and

(02:14):
that sort of led me into thisinterest in cannabinoid medicine. And I've now
spent about fifteen years practicing this kindof medicine exclusively, with a real focus
on treating patients in sort of avery conventional fashion with this unconventional medication.
All right, well, thank youboth to everyone joining us on this line

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(03:00):
Facebook. After the live program,your name will be entered into a drawing
on February eighth, twenty twenty fourto win a one hundred dollars gift card
provided by one of Mary's partners.Now, let's start this conversation on cannabis,
doctor Hill. I'm going to startwith you. Tell our listeners and
viewers what is glaucoma. Glaucoma isan optic neuropathy. Back in the old

(03:24):
days, we used to think ofglaucoma as just being secondary to increase intra
ocular pressure that destroys the optic nervein the back of the eyes. But
since that time and over the years, throughout the years, we've come to
think of glaucoma as being more ofan optic neuropathy, where the main risk

(03:45):
factor is increased intra ocular pressure,but you can also have vascular insufficiencies that
can cause damage to the optic nerveas well as other immunological processes. So
the thinking has changed throughout the years, where the interracular pressure increase indrocta pressures
the main risk factors, but youcan also have other vascally insufficiencies and other

(04:10):
immunological processes that can damage the nerveas well. And also we've actually isolated
the gene that causes glockoma as well, So it's a genetically driven disease.
That's about ten percent occurrence in thegeneral population, but in the population,

(04:31):
in the black population, specifically folksfrom the Caribbean area, the incidents can
be as high as twenties or twentyfive percent because the genetic mixing in those
populations were not as prevalent as asit is in folks who don't live in
those isolated environments. So if you'reblack, and then if you're thirty older,

(04:57):
you have a family history of glockoma, then you at increased risk and
you need to be seen by specialistswho knows what's going on, because we
see far too many folks who goblind and necessarily simply because they don't get
to the right people at the righttime. It's thought of as being more
of an optic neuropathy this stage,and it's the prevalence is fore more common

(05:19):
in Blacks, Hispanics, and Asians, and there are different types of glockoma
as well that can affect those differentpopulations. Black folks hispanic we most commonly
see primary opening glackoma, and Hispanicswe see angle closure because the anatomical structure
of the eyes that are different.So yeah, it's thought of as more

(05:42):
of an optic neuropathy. Now thatcauses damage to the optic nerve in the
back of the eye. That leadsto nerve damage, visual feel loss,
loss of sight. So it's avery slow, insidious process. You can
have severe nerve damage and not beaware of it. You can lose up
to like ninety ninety five percent ofyour nerve function before you have signs or

(06:04):
symptoms of it. And it's howto ask you, Yeah, what are
the signs and symptoms. I'm curiousabout that. That's that's why it's so
dangerous because you can it's such aslow insidious process. You can lose a
lot of your nerve function without havingany signs of a symptom. You can
lose up to like ninety ninety fivepercent or more before you have signs or
symptoms of it, And that makesit very very dangerous, a slow insidious

(06:28):
process that gradually slowly creeps up onyou. But once you encounter the nerve
damage is permanent and irreversible. Butthe most common signs block homa. If
you have an increase of a suddenincrease in the droctal pressure, you will
see halos around lights, gradually lossof peripheral vision, side vision. But
here again you have to be veryvery careful because you can you cannot have

(06:54):
any of those signs of symptoms.But it's such a slow insidious process.
It just gradually slowly creeps up onSo the main thing is that you have
to be proactive, and being proactiveyou have to realize who are the main
folks that are at risk, Andlike I said earlier, if you are
black, if you have a Hispanicor Asian if you have a family history

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of the disease, if you're thirtyor older, then you really need to
be seen by someone who knows what'sgoing on to be properly evaluated, because
you really have to be proactive becauseonce you lose vision suffer nerve damage,
it's permanent and irreversible. So it'sa disease process that if you have those
risk factors, you really need toaddress them before you encounter nerve damage.

(07:35):
It's permanent and irreversible. So thekey is to if you have those refactors,
get yourself checked on a regular basis. Yeah. Wow, that thank
you for that very thorough explanation.I'm thinking, do I have halos in
my eyes? I'm sorry to questionmyself because y'all I'm black, I'm over
thirty, So thank you for that. So, doctor Tishler, I want

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to talk to you about Let's talkabout can right, That's what our conversation
is about. And we know thatit is some states that allow medical cannabis
have it as a qualifying condition,So it's cannabis a good treatment for glackoma.
Well that's the main question and theanswer is very simple, unfortunately,

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and the answer is no. Thefact is that almost every state, as
you mentioned, has this is aqualifying condition. But that's not based on
science. And there's been a lotof effort made over the last you know,
thirty years to get cannabis to beavailable as a therapeutic and also as

(08:43):
a recreational substance. And there wassome early research in the nineteen seventies which
demonstrated that folks who smoked cannabis hada decrease in that intraocular pressure that doctor
Hill was taught looking amount. Andfrom there, you know, and that's
sort of where the evidence stops,right, is, Okay, if you

(09:07):
smoke cannabis, the pressure goes down. And then the various efforts to legitimize
and make available this substance for variousreasons picked up on that research and has
kind of run down the field withit. But there hasn't been the kind

(09:28):
of real studies that we would needto show that, in fact, this
cannabis not only lowers the pressure butactually stops the disease. Right. And
you know, one of the pointsthat I like to make very frequently is
that while the cannabis did lower thepressure, it only did it for two

(09:50):
hours, right, Right, whichwould mean that if you were doing this
seriously, you would need to smokeor otherwise ingest ca as every two hours
to keep pressure low, even duringthe middle of the night when you're supposed
to be sleeping. Right, Andas doctor Hill mentioned, this is a
disease you can't ignore because if youthink you're treating it but you're really not,

(10:13):
you're going to lose your vision,doctor Hill. And also there's a
diurnal variation that occurs in the intraocular pressure. The pressure doesn't stay the
same in a twenty four hour period, and if doctor Tesla just alluded to
there, the key is that wefound that the peak interraocular pressure occurs between

(10:33):
midnight and six am, where you'rein the bed, so you're sleeping,
and you're not going to be smokingthe pot every two hours when you're sleeping
hours, but that's when you're atthe highest risk, between midnight and six
am. So you need to havesomething on board to prevent that spike that's
going to occur between midnight and sixam, because that's when you're going to

(10:54):
have the peak interocular pressure. Ithink the blood pressure follows the same pattern
most people. I'm sure everybody's heardsay, oh, so and so died
and their sleep well they died orsomething, and it's usually from their blood
pressure spiking between midnight and six am. Most people in the world usually died
during that time period. The drocularpressure follows the same pattern, is gonna

(11:15):
peak between midnight and six am,and if you don't have anything on board
to prevent that peak, then you'regonna get increased pressure. It's going to
kill the circulations of the off thenerve in the back of the eye,
lead to nerve damage and blindness.So the point that he made is excellent
that you got a smoke pot everytwo hours or so to keep the pressure
down. No one's gonna do that. That's not practical. Not when you

(11:37):
have a drop. You can puta drop in before you go to bed
at night and it's gonna last ina twenty four hour period or depending on
the drop that you usual at leasttwelve hours, which is going to prevent
that spike from a current that causesall the nerve damage. So, DoD
do you have talked a little bitmore about the drops. I don't think
we've referenced that tell us that isthat a MODEUBT A mode of getting cannabis

(11:58):
through the eyes to help with that. Actually, when I was doing my
residency at Harvard at the Mass NineerInfirmary, uh my, one of my
colleagues, Claudia Eric, and thisis during the time when everybody was talking
about cannabis, smoking cannabis and treatingit for glock homa. Well, she
actually isolated the THAC out of themarijuana plant, put it in a drop

(12:22):
form, and did clinical trial studieson it, and it didn't prove to
be effective in treating glockhma. Sothat's the main study that I know of,
and I've been searching trying to findother studies, but I haven't been
able to find anything on that.But she she did extensive clinical trial on
it and didn't prove to be effectivein treating clock homa. So as I

(12:43):
know, I don't think there's anydrop form of THAC that you can use
to treat clock hooma because it's reallynot practical because the other medications it's just
so good and so much better.I think that's the treat point too,
you know, is that you know, when we think about treatments, the
question is is this new treatment inthis case some form of cannabis equal to

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or better than what we already have, right, And the answer is very
clearly know that if you can puta drop in your eye every twelve hours
and sort of end of discussion,right, that's much more practical and effective
and safe than this idea of usingcannabis, which really isn't practical or some
doctor tisl Also, can you addressthe side effix that the someone smoking mirijuana

(13:35):
every two hours, the systemic sideeffect that that may cause. Well,
yeah, I mean that's the otherpoint is that if you put those drops
in your eyes, you know,very rarely might be a little stinging.
Maybe in very extreme cases you mightfeel a little lightheaded briefly. But comparing
that with cannabis, where if you'resmoking a reasonable amount or I you know,

(13:58):
smoking is only one approach, butif you're using cannabis on a regular
basis, the major side effect isintoxication. Right, And in some cases
that can be useful or enjoyable,but doing it every two hours really means
you spend the rest of your lifestoned. Right, that's not very practical.

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The other thing is that we knowfrom other research not related to eyes,
is that if you're stoned all thetime. It is not good for
things like you're performance at school orwork, and it can actually exacerbate underlying
conditions like depression and anxiety. Andso if patients come to me for treatment
of depression and anxiety, very commonlythey've heard sort of out in the community

(14:41):
that they should be smoking weed allday and that turns out to be exactly
wrong, and it will actually makethings worse. Yes, we can use
cannabis for treatment of anxiety and depression, but the treatment is not sort of
what is the conventional wisdom. It'sreally very low dose is typically given kind
of right around bedtime, which havea positive effect compared to sort of that

(15:05):
you know, all day long smoking. And then there are other side effects
having to do with blood pressure andheart rate and those sorts of things.
Again, in the right patient,with the right approach, there's definitely value
in using cannabis as a medicine,but it's at lower doses than people are

(15:28):
used to doing. Is it's selectivetimes compared to sort of willy nilly,
and frankly speaking, there's always atrade off, right, and it has
to therefore be worth it. Say, if you're talking about back pain.
You know, that person's back painhas to be bad enough that a small
amount of round the clock intoxication isbetter than if they had nothing, right,

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So do stishall? I have afollow up question for you. So
what I'm hearing is if someone hasglaucoma plus other medical qualifying conditions, right,
they really need to talk with aqualified cannabis physician to determine how to
treat the other stuff with cannabis.Medical cannabis is not the recreation of but

(16:11):
medical. But then also be mindfulof the impact to the glaucoma. Is
that what you're is that how Iinterpret what you just done? Yeah,
I think that's fair. The glaucomareally, as I see it doesn't really
play into the discussion that much.So that is then should tell you they
have glacoma. Oh absolutely, youknow, knowing the full background is absolutely

(16:33):
important. But the glaucoma isn't goingto tip my my decision making or the
recommendations for treatment for their back painone way or the other. Now,
there is an exception to that whichwe touched on, and I think this
might be a good moment to bringit up. And that's CBD, right.

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Yeah, So you know, CBDhas become very very popular. It's
now sort of freely available at thegrocery store and the gas station. And
the problem is that CBD actually increaseslike intraocular pressure, right, So for
glaucoma, it's exactly the wrong thing. It turns out that CBD is not

(17:15):
proven to be of significant benefit inany adult human condition and so and can
do things like worse than glaucoma potentiallyand interact with common conventional medicines. So
CBD, while it's an important partof the way cannabis works as its own

(17:37):
medication, it's not something that Irecommended this time. But you can easily
imagine that there are people out therethinking, well, if cannabis is good
for glaucoma, it isn't. Butif they think that, then CBD must
be good for glaucoma too, andlet me go down to the store and
get some. And that's exactly thewrong idea. And similarly, if they're
coming in for their back pain,they may go to this or and get

(18:00):
told, oh, CBD or aone to one which is half THHD and
half CBD, And again that's thewrong idea. So we need to be
aware of all of the health conditionsthat are on the table, as well
as the fact that not all ofthese cannabinoids that are available are actually good
for you. Doctor think the finalpoint should be just for point of clarification

(18:26):
so no one gets confused. Thepoint that doctor Tishler is making here is
that CBD cannabis is not good.You should not use it as a primary
form of treat your blockhoma. Soit's not a good treatment for blockhoma.
That's the final point I think thateveryone should know and understand. Yeah,
so, doctor Hill, that's agreat segue into my follow up question.

(18:47):
So what is your recommendation for patientswho are diagnosed with glaucoma and they're using
cannabis now to manage the symptoms.What is your recommendation. Well, first
of all, you should be usingcannabis to try to treat your glockoma.
And I've had folks come in withfrom with all kinds of the stories about
what they're doing to treat the glockoma, from cannabis to eating raw pig guys,

(19:11):
to what okay say that again,Yeah that's a new one, to
eating raw pig guys, all kindsof stories. I've had patient come in
and say, oh, I goto this dockyard and I get raw pig
as and I eat all kinds ofdifferent story scenarios, But the bottom line

(19:34):
is if you go to the doctorand uh, he says you someone says
you got glock hooma. The firstof all, if you're a patient and
you're told that you have block homa, your next question should be with doctor,
what type of blockhoma do I have? Okay, because one of the
most common mistakes that I see isthat uh, glockoma is shotgun therapy for

(19:56):
folks, Oh, you got glockhomatakes to take this drop out. But
there are many different different types ofblockma. So if somebody tells you you
have blockma, then your next questionwould be, well, doctor, what
type of blockma do I have?Because there are specific treatments for specific types
of blockoma. Of course, themost common type is primary openinging of block
hooma or chronic open clock cooma openingingin block homa. But if you have

(20:18):
a diagnosis of block homer then youneed to be seen and have diagnostic tests
done to determine this specific type ofglockoma you have, and then have a
specific type of treatment that's specific forthat type of glockoma. So you want
sniper therapy that's going to hit thebullseye rather than shotgun therapy. If you

(20:40):
have glockomer, yeah, can youtell us what? Can you tell us
what the types of blackoma are?There are many different types of block hooma.
The most common type, the mostcommon garden variety type is primary opening
of blockhoma, which is seen inmost of the general population. You also
have different types of angle closure blockoma. You have different types of anatomical type

(21:02):
of block homers that can be causedby congenital defects. You have different types
of traumatic type of glock hoomer.So there are many different types. But
if you have glockoma, you needto see someone who basically is a glock
homer. Specialists figure out what typeyou have and then prescribe a specific type
of treatment for that specific type.And I thank god that I was at

(21:25):
Harvard at the time that doctor MortonGrant, who was considered the father of
glockoma, that worked at the MassachusettsI'm here and I thank god that I
had the privilege to work with himand to train under him. And he's
basically responsible for me being a glockHomer specialist today. And he was a
tremendous man. I considered him asa genius. He was the smartest person

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I ever met, but he alsowas the most humblest person that I ever
met. Just a beautiful personality,a beautiful person, and I really cherished
the time that I spent with himtraining at the massign Are So. Yeah,
many different types of blockcoma and oneof the things that he told me

(22:11):
and I still use that philosophy todayis that glaucoma is none forgiving. And
he would always tell me, Charles, if you're going to treat glockoma patient
and if there's something you're not sureabout, error on the side of overtreatment
versus under treatment, because it's noneforgiving and whatever an optic nerve that one

(22:33):
may encounter. Severe damage is permanentand irreversible. Yeah, can you talk
about what potential treatments are. Iknow before the show, when we were
talking back and forth, you werein surgery all day treating patients. So
can you talk a little bit aboutwhat some of the treatments are for glaucoma.
The first line of treatment that we'dlike to start, of course as

(22:55):
drops. We was trying it,and there are many different types of drops
that work different mechanism actions to eitherincrease the outflow facility the lord of pressure
or prevent the production of aquius,which is the fluid inside the eye.
And let me just say, theeye is not a bony structure. It's
a fluid field organ structure, andit maintains its shape by the production of

(23:22):
aquious humor inside the eye. Sofluid is constantly being produced inside the eye
to maintain the shape of the eye. Now what happens is if that fluid
is not draining out of the eyeat the same rate that is being produced,
you get an increase in the intraocular pressure. An increase in the
intra ocular pressure essentially chokes off thecirculation to the nerve and the back of
the eye, leading to neuronal damagednerve damage, and when you have nerve

(23:48):
damage, then of course that's gonnaaffect your vision. Thank you doctor Hell
and doctor Tisula Tishular, and thankyou for being guests on our conversations on
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(24:55):
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