Cannabis as a Treatment for Glaucoma - Part 2

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

(00:24):
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

(02:37):
program. Please share post and taga friend on Facebook to have them join
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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.
So, doctor Sishall, I havea question for you. So what I'm
hearing is if someone has glaucoma plusother medical qualifying conditions, right, they

(03:22):
really need to talk with a qualifiedcannabis physician to determine how to treat the
other stuff with cannabis. Medical cannabisis not the recreation of but medical but
then also be mindful of the impactto the glaucoma. Is that what you're
is how I interpret what you justdone. Yeah, I think that's fair.
The glaucoma really, as I see, it doesn't really play into the

(03:44):
discussion that much. So that isthen should tell you they have glaucoma.
Oh absolutely, you know, knowingthe full background is absolutely important. But
the glaucoma isn't going to tip mydecision made or the recommendations for treatment for
their back pain one way or theother. Now, there is an exception

(04:05):
to that which we touched on,and I think this might be a good
moment to bring it up. Andthat's CBD. Right. So, you
know, CBD has become very verypopular. It's now sort of freely available
at the grocery store and the gasstation. And the problem is that CBD
actually increases like intraocular pressure, right, So for glaucoma, it's exactly the

(04:29):
wrong thing. It turns out thatCBD is not proven to be of significant
benefit in any adult human condition.But you can easily imagine that there are
people out there thinking, well,if cannabis is good for glaucoma, it
isn't. But if they think thatthen CBD must be good for glaucoma too,
and let me go down to thestore and get some, And that's

(04:50):
exactly the wrong idea. I thinkthe final point should be just for point
of clarification so no one gets confused. One of the doctor Tishler is making
here is that CBD cannabis is notgood. You should not use it as
a primary form to treat your glockhma. So it's not a good treatment for

(05:11):
glockoma. That's the final point Ithink that everyone should know and understand.
Yeah, so, doctor Hill,that's a great segue into my follow up
question, So what is your recommendationfor patients who are diagnosed with glaucoma and
they're using cannabis now to manage thesymptoms. What is your recommendation? Well,
first of all, you shouldn't beusing cannabis to try to treat your

(05:32):
glaucoma. And I've had folks comein from with all kinds of the stories
about what they're doing to treat theglaucoma, from cannabis to eating raw pig
guys, to what okay say thatagain, Yeah that's a new one,
to eating raw pig guys. Allkanaza stories. I've had patients come in

(05:56):
and say, oh, I goto this dockyard and I get raw pig.
As you know, you all kindsof different story scenarios. But bottom
line is if you go to thedoctor and uh, he says you someone
says you've got glock hoomer, then, first of all, if you're patient
and you're told that you have blockhome on, your next question should be,
well, doctor, what type ofblockhoma do I have? Okay,

(06:19):
because one of the most common mistakesthat I see is that glockoma is shotgun
therapy for folks, Oh, yougot glockhoma, takes it to take this
drop outa da da dat. Butthere are many different different types of block
homa. So if somebody tells youyou have glockoma, then your next question
would be, well, doctor,what type of blockhomo do I have?

(06:40):
Because there's specific treatments for specific typesof block homa. Of course, the
most common type is primary opening andblock hooma or chronic open glocoma opening and
block homa. But if you havea diagnosis of block homer then you need
to be seen and have diagnostic testsdone to determine this specific type of blockhomer
you have and then have a specifictype of treatment that's specific for that type

(07:03):
of glockoma. So you want snipertherapy that's going to hit the bullseye rather
than shotgun therapy. If you haveglockomer, Yeah, can you tell us,
can us what the types of blahomaare. There are many different types
of blockhoma. The most common type, the most common garden variety type,
is primary opening of blockhoma, whichis seen in most of the general population.

(07:26):
You also have different types of angleclosure block homa. You have different
types of anatomical type of block homersthat can be caused by congenital defects.
You have different types of traumatic typeof blockoma. So there are many different
types. But if you have glockoma, you need to see someone who basically
is glock Hoomer. Specialists figure outwhat type you have and then prescribe a

(07:49):
specific type of treatment for that specifictype. And I thank god that I
was at Harvard at the time thatdoctor Morton Grant, who was considered the
father of glackcoma, that worked atthe Massachusetts I here, and I thank
god that I had the privilege towork with him and to train under him,

(08:11):
and he's basically responsible for me beinga blockhoma especialist today. And he
was a tremendous man. He was. I considered him as a genius.
He was the smartest person I evermet. But he also was the most
humblest person that I ever met.Just a beautiful personality, a beautiful person,

(08:31):
and I really cherished the time thatI spent with him training at the
mass Iron Air. So. Yeah, many different types of blockhoma. And
one of the things that he toldme and I still use that philosophy today
is that glockcoma is none forgiving.And he would always tell me, Charles,

(08:52):
if you're going to treat a glockomapatient and if there's something you're not
sure about, error on the sideof overtreatment versus undertreatment, because it's none
forgiving and whatever an optic nerve thatone may encounter, severe damage is permanent
and irreversible. Yeah, can youtalk about what potential treatments are. I

(09:13):
know, before the show, whenwe were talking back and forth, you
were in surgery all day treating patients. So can you talk a little bit
about what some of the treatments arefor glaucoma The first line of treatment that
we like to start, of course, is drops. We was trying to
and there are many different types ofdrops that work different mechanism of actions to

(09:33):
either increase the outflow facility the lordof pressure or prevent the production of aquius,
which is the fluid inside the eye. And let me just say,
the eye is not a bony structure. It's a fluid field organ structure,
and it maintains its shape by theproduction of aquious humor inside the eye.

(09:54):
So fluid is constantly being produced insidethe eye to maintain the shape the Uh.
Now, what happens is if thatfluid is not draining out of the
eye at the same rate that isbeing produced, you get an increase in
the intra ocular pressure. An increasein the intra ocular pressure essentially chokes off
the circulation to the nerve in theback of the eye, leading to neurmal

(10:16):
damaged nerve damage, and when youhave nerve damage, then of course that's
gonna affect your vision. So manydifferent types of glockcoma here. Again,
the most common type is primary openingof GLOCKMA, and we've actually isolated the
gene that causes that. The geneis more common uh and uh in the

(10:37):
black population, higher incidents in thepopulation from the Caribbean area as well.
So wow, So for those whoare listening, how often should they go
to their doctor? I mean,what's what should we do? I mean
right now, I'm thinking what's mynext best step right now to prevent I
mean, because my family from theCaribbean American. I'm over fifty, right,

(11:00):
so what should I do right nowto make sure that I don't get
glacoma? And the age limit isthirty. If you're over thirty, glaucoma
will usually start around the mid thirtiesor so, So fifty is kind of
pushing in well not really, hopefullynot. But yeah, if you have
those risk factors, then you needto see an opt themologist to be evaluated

(11:22):
to make sure that you're okay,okay, all right, and if you
have here again, the things toremember if you have a family history of
it, if you're black, Hispanic, or Asian, and then you need
to be seen on a regular basis, because you can be seen today and
then three six months or later youmay have the disease. So it just

(11:45):
depends on when the gene is goingto express itself. But here again,
if it's genetically driven and you havea family history of it, it will
usually express itself into mid thirties orso. Wow. So here again,
if you have a family history,you're in your thirties, you're black,
Hispanic, then you need to beseen on a regular basis. Remember,
we have to be proactive. That'sthe key because once you encounter nerve damage,

(12:09):
visual feel loss, then it's permanentand irreversible. So you really got
to be proactive with this stuff.Thank you. Hell, if I might
ask a question, if you haveall of those particulars but no family history,
are you still particularly at risk?Particulars such as well, again black
and from the Caribbean and over thirty, but no family history, we don't

(12:35):
worry. Yes, yes, youknow you still have to worry because it's
like one of my friends was tellingme, she said, well, you
know, if you're Jewish, itdepends on who your mother is because your
father could be anyone. So yeah, so if you have those those things,
yeah absolutely. If you're if you'reblack, you really don't know what

(12:58):
your heritage is. But if youdon't, they may have had it.
And doctor tips. That's the excellentpoint because so many people die from with
glaucoma and don't realize they had it. So they have had it and not
realized it. Because here again,you can have twenty twenty vision, pinhold
twenty twenty vision. And this iswhat I see a lot of a lot

(13:18):
of times patients come to me andthey said, well, doctor Sorson said,
I got twenty twenty vision. Yeah, you can have twenty twenty vision
pinhole vision. It's still twenty twenty, but all your peripheral nerve function is
gone and your vision is constricted downto maybe a five degree central island.
Absolutely, yes, and so Idon't think what you said. Yes,

(13:39):
Absolutely, get screened. Get screened. That's the key. Get screened.
So, doctor Tishla, you know, we talked a lot about that.
You know, cannabis is not theideal treatment for glaucoma, So what is
cannabis good for treating qualifying conditions?Let's talk about that. Well, well,

(14:00):
you know, let's back up fora moment in that question and leave
the qualifying conditions aside, because thoseare often less based on science than we
would like them to be. Solet's just sort of talk more from a
medical point of view of what wecan actually accomplish. And you know,
the number one complaint in the UnitedStates two primary care is pain, and

(14:28):
as I'm sure you and the listenersare aware, our ability to treat pain
is somewhat limited at this point,right. I mean, we've got things
like tail and all and the variousmotrin type things, right, and sometimes
those work and sometimes they don't.Sometimes people can't take them for one reason
or another. So you know,those things are great, but then the

(14:50):
question is after that, what,right, Well, we've started to use
things like gabapentin, which can workfor some people, but pretty quickly we
run out of options. And nowwe're talking about opioids right now. Don't
get me wrong, I have hada career of being a stingy bastard when
it comes to opioids, but Ido believe that they do have value,

(15:15):
but that maybe we over use themand it would be great to have other
things that worked as well. Andthat's where cannabis comes in. So if
you pit cannabis against opioids for sortof which one is better in terms of
pain management, neither is great.They're okay, But if you're pitting them

(15:35):
against each other in terms of whichis safer. Cannabis clearly wins. So
I would say, look, youknow, if you have somebody with pain
and you've tried the first line agentsbefore you get to the opioids, which
are sort of the last line agents, this is where cannabis belongs. And
while it isn't perfect, and itcomes with side effects like any other medicine,

(15:58):
those side effects can be managed againby going to somebody like myself who
knows how to do that, andwe can achieve benefit and pain reduction and
higher quality of life. And thereare studies that show that it doesn't mean
that you won't need any opioid.Sometimes you need a little of both.

(16:18):
But what's also interesting is the studiesshow that if you start with cannabis and
you do need some opioids, youneed a lot less and that makes it
safer. So that's sort of onearea that cannabis can contribute to. Another
area, the second most common complaintto primary care is insomnia, right whether

(16:41):
people have trouble getting to sleep orstaying asleep, where unfortunately some people have
all of the above. This isagain the number two complaint, and it's
again an area where you know conventionalmedications leave something to be desired. And
I think, frankly speaking, thatthe treatment of insomnia is a thing that

(17:02):
cannabis does best of all, Sovery low doses that can be used,
and they can be extraordinarily effective,and people wake up the next morning feeling
we're freshed and invigorated. And theway we approach the insomnia depends on what
type of insomnia they have. Andwe are talking about medical cannabis, not

(17:22):
the recreational street cannabis. Well,how do can I just regress for a
second here? Yes, I kindof got carried away when you're asked me
that question about the treatments for glaucoma, and all I mentioned was topical drops
being the first line. That isthe first line, and then we have
oral medications we can use. Then, of course, we have different type

(17:44):
of laser surgeries we can use,and then as a last reserve, last
resort, it's actual nice surgery surgicalprocedures that are performed. So I just
want to make that clear that up. Thank you. I appreciate that,
doctor Tiler. Did you want tofinish your thought? There? Are we
good? Yeah? I sort oflost my train of thought a little bit.
I'm sorry, we were talking about. You know, I wanted to

(18:06):
just make it clear that we're becausein Florida, recreation Oh, that's right,
recreational. You know, recreational isnot legal in Florida. Medical cannabis
is legal in Florida, So Iwant to make sure I had that balance
set. You know, we talked, we're talking about the medical grain.
Yeah, to to to answer yourquestion, there are now a whole bunch
of different ways we can look atthese sort of same substances. Right,

(18:29):
there's illegal cannabis, which has alot of risks. A lot of them
are legal risks, but also haverisks from contamination and improper testing and mold
and all sorts of things that canbe in it, so we'd like to
avoid that. And now we've gotthese hemp derived chemicals which can be converted

(18:51):
into intoxicating substances, and that presentsits own big problem because they're unregulated and
may have byproducts of that conversion processin them as well as other contaminants.
So those are things that, despitethe fact that they're now legal and don't
present legal risk, present health risksand we should avoid that. And then
you've got this idea of recreational versusmedical kind of the state regulated stuff.

(19:17):
And interestingly enough, in most butnot all states, the regulation of recreational
cannabis is as good, if notbetter, than the regulation of medical cannabis.
And so the question of should peoplepurchase their state legal cannabis through a
recreational or a medical outlet is verymuch up for discussion. And my argument

(19:42):
is that in terms of safety there'sreally not any difference, but that in
Massachusetts where I am, one ofthe major benefits from going through the medical
system is that I, as theclinician, get some feedback through that system
that helps me take care of mypatience. I understand. In the end,

(20:03):
I think the most important message hereis if anyone out there has a
medical condition, it might be assimple as difficulty sleeping, you deserve the
input and guidance of somebody who knowswhat they're doing. And the people at
the dispensaries would love to guide you, but they don't know what they're doing,
and they also have a lot ofstuff they want to sell you.
So come find somebody like me whodoes nothing other than this kind of thing

(20:29):
for no purpose other than keeping peoplehealthy. That's my advice to people,
all right, thank you. SoI want to give you all a chance
to kind of give some closing thoughtsto our viewers and listeners about this topic.
Is whether you cannabis is a goodtreatment for glacoma. Doctor Tishlar,
what you said was wonderful, Socan you give us closing thoughts, And

(20:49):
then I'll close with doctor Hill,who is our glackoma specialist, to kind
of give some more context with closingthoughts of doctor Titular. Sure. I
mean, I think we've discussed it. Cannabis can be a very effective medication
for a range of problems. Glaucomajust isn't one of them, and that
the conventional medications and procedures that doctorHill has talked about are safe and effective

(21:12):
and protect your vision. And Ican't see why one would avoid those to
use cannabis with all of its downsides. So bottom line is for glaucoma,
this isn't the right medicine. DoctorHeal closing thoughts absolutely. What he just
said was absolutely the truth. AndI get in tremendous arguments with folks coming

(21:37):
in and want to argue about,oh I want to smoke marijuana a treatment
glockoma and it's just sometimes I justrun into mental blocks with these people and
I tell them cannabis marijuana is notan effective treatment for glockoma. If you
have glockoma, then you need tosee a glockoma specialist. You need to

(21:59):
be treated appropriately, and you cannotcount on smoking cannabis to treat your blockoma
because, as doctor Tisla said,you got to smoke every two hours and
it's not going to be effective duringyour sleeping hours. So, if you
have blockoma, and you need tofind out the type of block homa that
you have and then have a specifictype of treatment designed for that specific type.

(22:23):
And as I said earlier, westart out with topical drops, we
have oral medications, we have differenttypes of lasers that we can use to
treat blockhoma, and as a lastresort, a surgical intervention. So if
you have block homa, please don'tlisten to fairy tales what you see on
the internet. Here you're on theinternet of what your friend's telling you.

(22:47):
Glock homa needs to be treated medically, and marijuana cannabis is not an effective
treatment to treat glock homa. Ihave so many patients who come who are
pretty much legally blind who tried totreat themselves by smoking marijuana. It's not
an effective treatment for blockhoma. Soplease, please, please, if you
have blockhoma, seek appropriate medical attentionto be treated properly and appropriately. Do

(23:14):
not listen to folks fairy tales aboutcannabis marijuana being an effective treatment for block
coma. It is not, people, It is not an effective treatment,
and if you count on that,then you're really putting yourself at the risk
of going blind and whatever damage youhave is permanent and the irreversible. So
please don't do that. Wow.Thank you doctor Hill and doctor Tishla Tishlar,

(23:38):
and thank you for being guests onour Conversations on Cannabis virtual form brought
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(24:02):
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(24:27):
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