Treatment of Glaucoma Patients with Flammer Syndrome

Flammer syndrome (FS) describes a phenotype characterized by the presence of primary vascular dysregulation along with a number of symptoms and signs. Although most people with FS are healthy, FS favors the occurrence of certain diseases, such as normal tension glaucoma. This is because disturbed autoregulation makes the eye more sensitive to intraocular pressure (IOP) spikes or blood pressure drops. Treatment of FS is generally appropriate when patients either suffer greatly from their symptoms or if we can assume that it has contributed to a disease. In glaucoma, this may be the case if the glaucoma damage progresses despite well-controlled IOP. Both the still sparse scientific studies and our long clinical experience suggest that FS-targeted therapy not only relieves the symptoms of FS but also slows the progression of glaucoma damage in selected cases. This description is intended not only to help affected patients but to also motivate clinicians and researchers to conduct therapy studies to confirm or refute our observations.

Flammer Syndrome & Glaucoma

The need of blood flow to different organs varies rapidly over time which is why there is a need for sophisticated local regulation of blood flow. The term “dysregulation” just simply means that blood flow is not properly adapted to this need. Dysregulative mechanisms can therefore lead to an over- or under-perfusion. A constant over- or under-perfusion does not normally induce long-term damage. A repeated under-perfusion, such as a repeated mild reperfusion injury, however, leads to damage. Systemic dysregulation can be primary or secondary of nature. A secondary dysregulation (SVD) is due to other diseases such as autoimmune diseases. The term Flammer Syndrome (FS) named after the famous physician J. Flammer refers to a clinical entity comprising a complex of clinical features caused mainly by dysregulation of the blood supply which has previously been called primary vascular dysregulation. People with FS tend to have cold extremities, prolonged sleep-onset time, altered drug sensitivity, low blood pressure and higher smell score, and increased retinal venous pressures as measured by means of ophthalmodynamometry. In the eye, the spatial irregularity of the retinal arteries is increased, and optic nerve head blood flow is correlated with finger blood flow indirectly indicating that the local regulation is disturbed. Blood flow is, on average, reduced in glaucoma patients, particularly in patients with normal-tension glaucoma suffering from FS, and in patients with high-tension glaucoma, which progress despite a normalized intraocular pressure (IOP). A constant reduction of blood flow (as we see in SVD) can lead to atrophy but does not contribute to glaucomatous atrophy. An increased variation of microcirculation as commonly seen in glaucoma patients with FS, however, is clearly linked to occurrence and progression of glaucomatous optic neuropathy (GON). Oxygen supply to the eye fluctuates, either if IOP fluctuates on a high level or blood pressure on a low level or if autoregulation is disturbed. Autoregulation is disturbed in patients with primary vascular dysregulation (PVD). Unstable oxygen supply to the optic nerve head leads to oxidative stress, which in turn, leads to the production of peroxynitrite (ONOO-) which finally kills the cells. In this review, we are talking about pathogenesis of the FS and some suggested therapeutic options for it.

THE ROLE OF OCULAR BLOOD FLOW IN THE PATHOGENESIS OF GLAUCOMA

Glaucoma is currently the second leading cause of blindness worldwide and the prevalence is expected to increase. Despite lowering of IOP, vascular risk factors, genetics, and other systemic conditions could progress the glaucoma damage. Ocular blood flow has emerged as an increasingly prevalent glaucoma risk factor in large population-based trials. Abnormal perfusion and the subsequent ischemia of the ONH play a major role in the glaucomatous damage. Ocular Blood flow is unstable if IOP fluctuates on a high enough or blood pressure on a low enough level to exceed temporarily the autoregulation capacity. IOP fluctuation is also related to both an increase in scotomas and an increase in diffuse visual fields damage. OBF is unstable if autoregulation itself is disturbed. In glaucoma the response of retinal and optic nerve head blood flow to flicker stimulation is reduced. Primary vascular dysregulation appears to be associated with abnormal retinal neurovascular coupling, because vasospastic subjects show a reduced response to flicker stimulation.Keywords: ocular blood flow, glaucoma

Migraine as a risk factor for glaucoma

This article contains a review of the literature on the issue of migraine and glaucoma interrelation. At the present time, despite the controversial nature of the results of global research, we can talk about an authentic increase of glaucoma risk in patients with a history of migraine. It is assumed a significant role of the primary vascular dysregulation in the pathogenesis of both diseases. Also we considered the issue of increasing the risk of angle-closure glaucoma during a migraine therapy with anticonvulsant called «Topiramate».