for optometrists and eye care professionals with Professors Charles McGhee & Dipika Patel Series Editors Should glaucoma patients avoid caffeine? BY DR JINNY YOON AND PROFESSOR HELEN DANESH-MEYER* Caffeine is a popular psychostimulant that acts as an adenosine receptor antagonist at physiological concentrations. It is the most widely used drug in history, consumed daily by more than 70% of New Zealanders in the form of coffee, tea, chocolate and caffeinated soft drinks. It has been estimated that adults aged between 20 and 64 years are exposed to an average of 3.5mg of caffeine/kg body weight/day 1 . Historical studies suggest some ophthalmologists have long expressed concerns about the effect of caffeine on intraocular pressure (IOP) in glaucoma patients 2,3 . To date, IOP remains the only treatable risk factor in primary open angle glaucoma (POAG), the most common type of glaucoma. Thus, establishing the link between caffeine and IOP is of great importance for improving the management of POAG. Effect of caffeine on IOP A number of clinical trials have investigated the immediate effect of caffeine on IOP. The effect of caffeine has been regarded as controversial due to inconsistencies amongst study findings. These inconsistencies can be attributed to variable study protocols, such as sources and doses of caffeine, methods of tonometry and time points of IOP measurement. Additionally, participant characteristics and severity of glaucoma were often not clearly documented in some studies. Nonetheless, a careful review of the literature reveals a common trend. In young and healthy volunteers without history of ocular diseases, no significant changes in IOP were detected up to four hours following ingestion of caffeine capsules 4,5 . One study, however, demonstrated a post-caffeine increase in IOP of 2-3 mmHg in healthy volunteers aged between 20 and 29 and this increase was maintained for three hours 6 . However, the volunteers drank a litre of coffee in this study and the authors did not delineate the effects of volume overload and high dose caffeine. Several randomised controlled trials and subsequent meta-analysis of those studies reported IOP changes in patients with POAG or ocular hypertension following caffeine ingestion. There was a statistically significant increase in IOP when the patients were exposed to 180mg of caffeine in coffee, equivalent to approximately one double-shot espresso 7,9 (see Table 1). The metaanalysis showed the weighted mean IOP differences before and after coffee consumption in patients with glaucoma or ocular hypertension: 0.347 at 30 minutes, 2.395 at 60 minutes and 1.998 at 90 minutes (95% confidence interval 0.078-0.616, 1.741-3.049, 1.522-2.474, respectively) 7 . A major shortcoming of this meta-analysis is the lack of age-matched controls, leaving the effect of aging unknown. The healthy controls were mostly in their 20s. The age range of glaucoma patients were not stated in the papers but were expected to be in a much older age group. Furthermore, the authors did not differentiate high tension POAG from ocular hypertension, or normo-tension POAG, when they could represent distinct disease entities. Despite these weaknesses, the consensus is that caffeine, at least transiently, induces a small increase in IOP in glaucomatous eyes, but not in young healthy eyes. What is the pathophysiological significance of the IOP change? Two large-scale epidemiologic studies addressed the question whether caffeine consumption is associated with the development or progression 22 NEW ZEALAND OPTICS April 2018 of glaucoma. The Blue Mountains Eye Study, a cross-sectional study conducted in Australia, investigated correlation between IOP and regular daily caffeine intake in POAG patients 10 . The participants completed questionnaires on their pattern of coffee consumption and underwent comprehensive glaucoma assessment. The study demonstrated a positive association between daily coffee drinking and high IOP, only in people with POAG. POAG patients who drank coffee daily had higher mean IOP (19.6mmHg) than those who did not (16.8mmHg). This result reached statistical significance after adjusting for age, sex, systolic blood pressure, myopia, current smoking and diabetes. A large-scale prospective study of health professionals in the USA showed an association between coffee consumption and development of POAG in people with a family history of glaucoma¹¹. A large number of health professionals over 40 years of age and without a history of POAG were followed up for 18 years in this study. Daily caffeine intake of up to 600mg per day (approximately four doubleshot espresso coffees or five cups of brewed coffee) was not associated with increased risk of developing POAG as shown by relative risks of around 1. With over 600mg of daily caffeine intake, the relative risk increased slightly to 1.61. Notably, in people with a family history of glaucoma, high caffeine intake of more than 600mg per day increased the relative risk from 0.94 to 2.01. In other words, people with a family history were twice as likely to develop POAG as those without, if they were heavy coffee drinkers (>600mg per day). Taken together, there is still insufficient evidence to support caffeine as an independent risk factor for the development of POAG, but people with POAG or with a family history of glaucoma (ie. genetic susceptibility) may be more vulnerable to the effects of caffeine. Mechanism of caffeine-induced IOP elevation The main mechanism of caffeine’s effect is via adenosine receptor antagonism and subsequent increase in sympathetic tone and a slight elevation of blood pressure¹². In young and healthy volunteers, 200mg of oral caffeine led to significant retinal vasoconstriction one hour post-ingestion 4 . This was negatively correlated with mean arterial pressure, suggesting an auto-regulatory response to increased blood pressure. Another study demonstrated that ingestion of 300mg of caffeine caused an increase in the resistive index of retrobulbar arteries in young and healthy volunteers¹³. Hypothetically, the increase in systemic blood pressure will increase pressure within the ciliary arteries, which in turn will increase ultrafiltration and aqueous production, thereby elevating IOP. Increased arterial pressure can also increase venous pressure and reduce aqueous clearance, thereby contributing to elevated IOP. Caffeineinduced vasoconstriction was however not associated with high IOP in the young and healthy, suggesting the presence of an unknown homeostatic mechanism to maintain the IOP. Table 1. Average IOP before and after caffeine ingestion in patients with normo-tension glaucoma and ocular hypertension 9 Coffee and glaucoma? Consequently, more questions arise as to why caffeine elevates IOP in only glaucoma patients. Several researchers postulate there may be an inherent susceptibility to the effect of caffeine in glaucomatous eyes. There is mounting evidence that vascular and autonomic dysfunction is a key pathologic process in glaucoma (for a comprehensive review, see reference 14). Doppler ultrasound imaging studies demonstrated that POAG patients failed to auto-regulate central retinal artery blood flow during postural change. Gene expression studies identified impairment of nitric oxidemediated smooth muscle cell relaxation and excessive plasma levels of endothelin, a potent vasoconstrictor, in response to physiological perturbations in POAG patients. Polymorphisms of nitric oxide synthase and caveolin, which lead to impaired vasodilation, have been associated with POAG. Genetic dysautonomic conditions such as familial dysautonomia and nail-patella syndrome are associated with subtypes of POAG. Moreover, examination of the nail bed capillary network revealed abnormal peripheral microvascular circulation in glaucoma patients. It is possible that caffeine produces a pathologic haemodynamic response and consequent IOP change in glaucoma patients with structurally and functionally impaired microvasculature. The debate continues… Based on the evidence accumulated to date, glaucoma patients may be advised to avoid caffeine intake for 90 minutes before IOP measurement, in order to obtain a more accurate IOP reading. However, there is no known clinical benefit of avoiding caffeine in the long-term management of POAG and without clear evidence we are more likely to cause unnecessary anxiety associated with caffeine consumption. A few crucial questions remain to be answered before clinicians can make evidence-based recommendations on caffeine consumption. l If caffeine transiently elevates IOP, does frequent coffee drinking lead to sustained elevation in IOP? What is the effect of repetitive caffeine intake? l Vasoconstriction was observed in healthy eyes following caffeine administration, but the haemodynamic response to caffeine is yet to be explored in glaucoma patients. l The link between chronic caffeine exposure and the severity of glaucoma has not been established. Is chronic caffeine exposure associated with more advanced POAG? Does withholding caffeine provide any long-term benefit in terms of POAG progression? These questions need to be addressed in future studies to establish evidence-based recommendations. In the meantime, it would be reasonable to advise patients to avoid excessive caffeine intake if IOP control is critical since even a small reduction in IOP has been shown to reduce the risk of glaucoma progression 15 . ▀ References 1. Ministry for Primary Industries. Caffeine. New Zealand: 2012 November. 2. Leydhecker W. Influence of coffee upon ocular tension in normal and in glaucomatous eyes. Am J Ophthalmol. 1955 May;39(5):700-5. 3. Davis RH. Does caffeine ingestion affect intraocular pressure?. Ophthalmology. 1989 Nov;96(11):1680-1. 4. Terai N, Spoerl E, Pillunat LE, Stodtmeister R. The effect of caffeine on retinal vessel diameter in young healthy subjects. Acta Ophthalmol (Oxf). 2012 Nov;90(7):524. 5. Adams BA, Brubaker RF. Caffeine has no clinically significant effect on aqueous humor flow in the normal human eye. Ophthalmology. 1990 Aug;97(8):1030-1. 6. Okimi PH, Sportsman S, Pickard MR, Fritsche MB. Effects of caffeinated coffee on intraocular pressure. Appl Nurs Res. 1991 May;4(2):72-6. 7. Li M, Wang M, Guo W, Wang J, Sun X. The effect of caffeine on intraocular pressure: a systematic review and meta-analysis. Graefes Arch Clin Exp Ophthalmol. 2011 Mar;249(3):435-42. 8. Higginbotham EJ, Kilimanjaro HA, Wilensky JT, Batenhorst RL, Hermann D. The effect of caffeine on intraocular pressure in glaucoma patients. Ophthalmology. 1989 May;96(5):624-6. 9. Avisar R, Avisar E, Weinberger D. Effect of coffee consumption on intraocular pressure. Ann Pharmacother. 2002 Jun;36(6):992-5. 10. Chandrasekaran S, Rochtchina E, Mitchell P. Effects of caffeine on intraocular pressure: the Blue Mountains Eye Study. J Glaucoma. 2005 Dec;14(6):504-7. 11. Kang JH, Willett WC, Rosner BA, Hankinson SE, Pasquale LR. Caffeine consumption and the risk of primary open-angle glaucoma: a prospective cohort study. Invest Ophthalmol Vis Sci. 2008 May;49(5):1924-31. 12. James JE. Critical review of dietary caffeine and blood pressure: a relationship that should be taken more seriously. Psychosom Med. 2004;66(1):63-71. 13. Ozkan B, Yuksel N, Anik Y, Altintas O, Demirci A, Caglar Y. The effect of caffeine on retrobulbar hemodynamics. Curr Eye Res. 2008 Sep;33(9):804-9. 14. Pasquale LR. Vascular and autonomic dysregulation in primary open-angle glaucoma. Curr Opin Ophthalmol. 2016 Mar;27(2):94-101. 15. Leske MC, Heijl A, Hussein M, Bengtsson B, Hyman L, Komaroff E, et al. Factors for glaucoma progression and the effect of treatment: the early manifest glaucoma trial. Arch Ophthalmol. 2003 Jan;121(1):48-56. Dr Jinni Yoon Prof Helen Danesh-Meyer About the authors *Dr Jinny Yoon is a neuroophthalmology research fellow. She studied neuroscience at the University of Auckland and graduated with a PhD. After completing basic medical training in Auckland, she followed her passion for eye health and joined the Department of Ophthalmology. Professor Helen Danesh-Meyer is an international authority on glaucoma and neuroophthalmology and chair of Glaucoma NZ. She is a sought after international speaker, has published more than 150 articles and is a respected international journal editor.
MyHealth1st now in NZ BY LESLEY SPRINGALL Klaus Bartosch knows more than most the importance of being able to act on a whim and book a health appointment quickly and easily, out of hours. The co-founder of patient booking and engagement software MyHealth1st, and managing director of the platform’s parent company 1stGroup, had just finalised plans for his Vision Crusaders cycling team to complete the Australian Ride to Conquer Cancer fundraising races when his family urged him to get the swelling of his right knee looked at. Bartosch thought it was just a symptom of his recently diagnosed arthritis, but given his family’s concerns he somewhat begrudgingly went online, using his own platform, at 9pm to book an appointment the next day with a local doctor. He had no white blood cells left in his body. The doctor packed him off to a specialist pronto and he was diagnosed with advanced-stage leukaemia and committed to hospital for emergency treatment. If he’d gone cycling; if it had not been so simple to book the appointment, he could easily have died, he says. The memory is a powerful one, and few at the Auckland launch of MyHealth1st didn’t tear up when Bartosch went on to share how his daughter took his place in the endurance race, raising the promised funds for much-needed cancer research. That was 2013 and neatly illustrates why Bartosch, together with an experienced team of online and health practice veterans, had joined forces to shake up the age-old way of booking healthcare appointments and engaging with patients. Background Since launching in Australia in 2012, first in dentistry before moving into other health areas, MyHealth1st has netted more than 6,000 customers and booked more than 6.5 million online appointments. It began selling the platform to Australian optometry practices just over a year ago and today books online appointments for more than 1,200 Australian practice owners; over 60% of the country’s independent optometry market. Of the optometry bookings made online in Australia today, 43% are new customers and 57% are existing. But perhaps the most interesting statistic of all, says Bartosch, is that 70% of all online bookings are made during business hours, demonstrating that the vast majority of patients, if given the choice, would rather book online than have to call a practice. A Kiwi case study Sharing the Auckland launch platform in March for MyHealth1st in New Zealand, was Whangarei-based practice Visualeyez director Craig Robertson. Frustrated by his own business’ inability to allow new and existing customers to book online, last year Robertson asked his practice management software provider, Optomate, for help and was referred to 1stGroup. After just two months of using the MyHealth1st booking system, Robertson was hooked. It helped drive bookings to his practice, was simple to use and integrated seamlessly with Optomate, his website and his Facebook page, he says. He also can’t wait to add 1stGroup’s patient recall service, EasyRecall, to his online marketing toolbox, despite the extra cost, he says, as soon as it becomes available in New Zealand. “As a consumer I want to be part of the digital revolution. I want to contact people with emails and book online and I found it very frustrating that I couldn’t do that with my own practice, so that’s why I tried it. It’s a cost effective, very simple platform. It’s easy,” Robertson told the Auckland launch audience. More compelling numbers Of the 30-plus practice owners and managers at the Auckland launch, all the ones NZ Optics’ spoke too were having the same frustrations and were keen to provide an easy and effective online booking service to their current practice management systems. Many Klaus Bartosch presenting at the Auckland launch Klaus Bartosch, MD of MyHealth1st platform, and Visualeyez director Craig Robertson at the Auckland launch signed up on the night. Bartosch, quoting from an international survey, says these frustrations are common among consumers, with 90% saying they wanted to use digital channels to manage their healthcare, 88% preferring digital reminders and a worrying 37% who switched providers to ones who offered online appointments. Using an online booking and engagement platform like MyHealth1st allows you to convert your website and social media traffic into booked appointments, 24/7, says Bartosch. To date, the average return on investment for practices which have joined MyHealth1st’s booking and patient recall service is A$5,000 to A$20,000 a month per practice, with an average 41% of bookings being new patients, according to the ASX-listed company’s own data. Other services As well as its patient online booking and EasyRecall services, 1stGroup will also be rolling out its EasyFeedback service, allowing patients to engage more easily with the practice and let it know how it’s performed and what it can do better. The company also runs a free, optional contact lens service, designed to encourage more patients to consider contact lenses as an option. On average, those practices which have opted in to the contact lens addon are having 20% more discussions about contact lenses, says Bartosch, 62% of which are converted into contact lens sales. As in Australia, 1stGroup also intends to launch a MyHealth1st portal in New Zealand in June or July, which acts as an independent online directory to drive consumers to your practice, says Bartosch. Once a consumer selects and books with a practice, however, those consumers won’t see any competitor practices when they decide to sort out their next booking, just the first practice they booked with, and complimentary local healthcare service providers, such as dentists or GPs, until they’ve built up a group of their preferred suppliers and can then use the portal to book all their health requirements online, whatever the time of day or night, he explains. The pitch Given the way the internet is changing the way we do business, you can’t just sit idly by, Bartosch tells his audience. “Here we are, in the age of the internet and yet nearly all of us still require patients to pick up a telephone in business hours to do something as simple as book an appointment… Can you imagine booking hotels like we used to… looking for a job, browsing for a home? “The way we do business is changing, whether we like it or not. We can’t stop it. The question is how are you going to engage with it, leverage it, get ahead of the curve and do it, before others do!” ▀ Focus on Business sponsored by Independent spirit, collective strength FOCUS Too small ON BUSINESS for How independent to become advice? a better BY DAVID PEARSON* independent the optical sector assume that Many small business owners in company boards are for the big boys, yet the BY benefits JANE SMITH* of independent directors or advisors apply to all businesses, Accabo. 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THE INDEPENDENT OPTOMETRY GROUP, PROVIDING parum THE re id ADVICE quidi dist AND SERVICE INDEPENDENTS NEED TO THRIVE. Apitiis es experferem raturio corepero temporum quo doles aut quias as eati simus aut il ipsandi THE INDEPENDENT OPTOMETRY GROUP, PROVIDING THE ADVICE The To find AND Independent out SERVICE more contact Optometry INDEPENDENTS Neil Group, Human NEED providing on 0210 TO THRIVE. 292 the 8683 advice and service or firstname.lastname@example.org independents need to thrive To find out more contact Neil Human On 0210 292 8683 To find out more contact Neil or email@example.com Human on 0210 292 8683 or firstname.lastname@example.org April 2018 NEW ZEALAND OPTICS 14 NEW ZEALAND OPTICS April 2018 that is the case, it is still worthwhile having an external advisor. 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Um About facimusam the author la doluptatum quae. Erspe sandae *David Pearson ex estiores is managing pa dollitiuste partner of pro chartered quaturiat ellaut accountants alit et and dolore business ni doluptatiur? advisors BDO Central Osamus and arciant. has a speciality Um facimusam interest in advisory la doluptatum services to quae. the Erspe sandae ex estiores pa dollitiuste optometry pro sector. quaturiat ellaut alit et dolore He ni doluptatiur? has extensive experience Osamus arciant.earit volecus. assisting both small and medium About sized the entities Author Ga. Ad with es dolo a wide corem ea dolo etur range re omnihilique of advisory pa voloreptat. services. Caes For que se nihiliquodi more information bea sequatur? Atio. Lorrovidia contact David peliquamus at utenderat david.pearson@ enimpore exerorepuda bdo.co.nz parum or visit re id quidi www.bdo.nz distr? Atio. Lorrovidia peliquamus utenderat enimpore exerorepuda 23