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Medical Marijuana and Glaucoma: The United States Experience

  • May 2017
  • Conference: Association Research Vision and Ophthalmology
  • At: Baltimore, Maryland
Authors:
Denise A Valenti at IMMAD Impairment Measurement Marijuana and Driving Technology in support of the responsible use of cannabis
Denise A Valenti
  • IMMAD Impairment Measurement Marijuana and Driving Technology in support of the responsible use of cannabis
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Abstract

Research abstract/poster
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Objective: There are twenty-eight states that allow for the use of medicinal plant cannabis
and all but six have glaucoma specified as an approved pathology for which cannabis can be
used. This is an analysis of the data related to the certification to use marijuana/cannabis as a
means to treat glaucoma. Of note; Israel, considered to be on the forefront in cannabis
medicine, recently dropped glaucoma as an approved disease for marijuana/cannabis
treatment.
Methods: A review was made of each state’s website. Some had statistical reports, those
that did not and specified glaucoma, were contacted by email. Not all states collect
information specific to a diagnosis. There were diagnosis specific information for eleven
states. The number of certifications specific to glaucoma were compared to the prevalence
data related to glaucoma for each state as published by Prevent Blindness. The number of
glaucoma certifications were compared to the total state certifications for all pathologies in
each respective state. The data from the first quarter of 2017 were used for all but
Massachusetts and Montana. For those states the data from Fall of 2016 were used.
Results: An estimated 4,416 patients are using cannabis/marijuana related to glaucoma.
Twenty-two states have glaucoma as a disease to be treated with marijuana. Of these, there
were data from eleven states. Of the twenty-two states, four states had new programs not
yet enrolling. Three states stand out when comparing rate of certifications to the rate of
prevalence. Montana and Colorado for having high rates and Minnesota for having low rates.
Massachusetts did not respond to requests for an update and Montana had listed cancer, HIV
and glaucoma in one category for the January 2017 report. Alaska, Florida, Maine and
California responded and acknowledged they do not collect diagnosis data that is available to
the public. Connecticut, Illinois and Washington did not respond to multiple requests.
Discussion: The higher prevalence in Colorado may be influenced by the recreational products being taxed
higher compared to medicinal marijuana. Oregon has a higher rate of glaucoma certification and the reasons
may also be related to taxation. The low prevalence rate in Minnesota may have been influenced by greater
restrictions on the recreational style of consumption. New Jersey and Florida maintained data bases accessible
by patients listing clinicians that can certify for marijuana use. New Jersey listed specialties and there were
eight ophthalmologists listed. New Jersey does not specify glaucoma among allowable diseases but report 220
patients being treated for glaucoma out the total 6126 certifications (3.59%) and glaucoma prevalence of 83,913
(0.26%). New York maintains a data base of clinicians and specialty but this was only accessible to referring
clinicians. Minnesota’s program is unique as it restricts the mode that marijuana can be consumed to primarily
to medicinal vaping systems and oral tinctures. Smoking plant materials, edibles such as candy and brownies
are not allowed. Minnesota has developed systems to track patient self response. The survey of self response
included four glaucoma patients, one reported no benefit and the other three reported positive response.
Connecticut has a very different system. That state rescheduled cannabis to a Schedule Two drug requiring all
dispensing to be supervised by a licensed pharmacist. While they do certify for glaucoma, there was no
response to two email inquiries. Montana does not yet have dispensaries and all medical cannabis is grown by
patients or caregivers. Montana does have the ruling that should a medicinal patient receive a conviction for
marijuana DUI, they must surrender their medicinal certification.
Conclusion: The certification to use cannabis for glaucoma varies across states and there is
no consistent reliable data collection among many states. There is little indication of patients
being followed in a manner optimum for vision health. Data collection in cases where an eye
care provider is involved will help clarify efficacy. The use of cannabis/marijuana to treat
glaucoma is a public health concern.
617 347-8737 IMMAD Impairment Measurement Marijuana and Driving deniseavalenti@gmail.com
Arizona 765/50,879 1.50%
Colorado 1,183/35,859 3.30%
Hawaii 302/15,064 2.00%
Massachusetts* 227/58,588 0.39%
Minnesota 43/42,873 0.10%
Montana* 281/ 8,461 3.32%
Nevada 408/20,459 1.99%
New Hampshire 42/10,798 0.34%
New Mexico 225/17,352 1.30%
Oregon 919/ 31,900 2.88%
Rhode Island 21/9,718 0.22%
Prevalence data of glaucoma rate in each state from:
http://www.visionproblemsus.org/glaucoma/glaucoma-map.html
IMMAD
Cairns EA, Baldridge WH, et al. "The Endocannabinoid System as a
Therapeutic Target in Glaucoma." Neural Plast. 2016;2016:9364091. doi:
10.1155/2016/9364091.
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Russo E, Mathre ML, et al. (2002). "Chronic Cannabis Use in the
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A comparison of ocular effects of delta 9-tetrahydrocannabinol and
cannabigerol.
Arizona 765/108,883 0.70%
Colorado 1,183/94,577 1.25%
Hawaii 302/15,334 1.97%
Massachusetts* 227/22,700 1.00%
Minnesota 43/4,017 1.07%
Montana* 281/8,461 1.21%
Nevada 408/24.465 1.67%
New Hampshire 42/2,089 2.01%
New Mexico 225/34,909 0.64%
Oregon 919/63,120 1.46%
Rhode Island 21/16,418 0.13%
Total Glaucoma 4,416 Total 394,973
*Previous Year
Glaucoma Percentage of
State Glaucoma Prevalence
States not specifying glaucoma: Delaware, Maryland,
Michigan, New Jersey, New York and Vermont
Impairment Measurement Marijuana and Driving
A company specializing in the responsible use of cannabis.
Glaucoma Percentage of
All Disease Certifications
Glaucoma & IOP
A Few Cannabis Studies
Medical Marijuana and Glaucoma:
The United States Experience
Denise A. Valenti, OD, FAAO
ResearchGate has not been able to resolve any citations for this publication.
Chronic Cannabis Use in the Compassionate Investigational New Drug Program
Article
Full-text available
  • Feb 2002
The Missoula Chronic Clinical Cannabis Use Study was proposed to investigate the therapeutic bepnefits and adverse effects of prolonged use of “medical marijuana” in a cohort of seriously ill patients. Use of cannabis was approved through the Compassionate Inves-tigational New Drug (IND) program of the Food and Drug Administration (FDA). Cannabis is obtained from the National Institute on Drug Abuse (NIDA), and is utilized under the supervision of a study physician. The aim of this study is to examine the overall health status of 4 of the 7 surviving patients in the program. This project provides the first opportunity to scrutinize the long-term effects of cannabis on patients who have used a known dosage of a standardized, heat-sterilized quality-controlled supply of low-grade marijuana for 11 to 27 years.Results demonstrate clinical effectiveness in these patients in treating glaucoma, chronic musculoskeletal pain, spasm and nausea, and spasticity of multiple sclerosis. All 4 patients are stable with respect to their chronic conditions, and are taking many fewer standard pharmaceuticals than previously.Mild changes in pulmonary function were observed in 2 patients, while no functionally significant attributable sequelae were noted in any other physiological system examined in the study, which included: MRI scans of the brain, pulmonary function tests, chest X-ray, neuropsy-chological tests, hormone and immunological assays, electroencepha-lography, P300 testing, history, and neurological clinical examination.These results would support the provision of clinical cannabis to a greater number of patients in need. We believe that cannabis can be a safe and effective medicine with various suggested improvements in the existing Compassionate IND program.
Effect of Marihuana on Intraocular and Blood Pressure in Glaucoma
Article
Marihuana inhalation was accompanied by increased heart rate and decreased intraocular and blood pressure in 18 subjects with heterogenous glaucomas. The hypotensive effects appeared in 60 to 90 minutes as the decrease in intraocular pressure (IOP) appeared to follow the decrease in blood pressure. In addition to any local effect, the mechanism of lowered to any local effect, the mechanism of lowered IOP may also involve the decreased pressure perfusing the ciliary body vasculature as a result of the peripheral vasodilatory properties of marihuana. Postural hypotension, tachycardia, palpitations, and alterations in mental status occurred with such frequency as to mitigate against the routine used in the general glaucoma population. Our data indicate that further research should be directed to local means of delivering the ocular hypotensive cannabinoid to the glaucomatous eye.
The human eye expresses high levels of CB1 cannabinoid receptor mRNA and protein
Article
  • Apr 2000
We used reverse transcriptase polymerase chain reaction to detect the expression of the central and peripheral cannabinoid receptors (CB1 and CB2, respectively) mRNA, and Western blotting to show the presence of the CB1 protein in subregions of the human eye. CB2 mRNA transcripts were undetectable, while levels of CB1 mRNA were significantly expressed in the human retina (25.8 +/- 2.46%), ciliary body (210 +/- 11.55%) and iris (62.7 +/- 5.94%) when compared with those of the normalizing reference gene beta2 microglobulin. The CB1 gene encodes a functional protein which is detected in its glycosylated (63 kDa) and unglycosylated (54 kDa) form in the same areas by a specific purified antibody raised against the amino terminus (residues 1-77) of the CB1 receptor. These results further support the proposed role of the CB1 receptor in controlling intraocular pressure, helping to explain the antiglaucoma properties of marijuana.
Effect of WIN 55212-2, a Cannabinoid Receptor Agonist, on Aqueous Humor Dynamics in Monkeys
Article
To evaluate the effects of WIN 55212-2, a cannabinoid receptor agonist, on intraocular pressure and aqueous humor dynamics in normal monkeys and monkeys with glaucoma. Intraocular pressure was measured prior to and up to 6 hours after the topical administration of WIN 55212-2 to 1 eye of 5 normal monkeys and to the glaucomatous eye of 8 monkeys with unilateral laser-induced glaucoma. Tonographic outflow facility and fluorophotometric flow rates of aqueous humor were measured in 6 normal monkeys before and after treatment. In normal monkeys, a single dose of WIN 55212-2 reduced intraocular pressure for 4, 5, or 6 hours, with a maximum reduction of 1.4 +/- 0.4 (mean +/- SEM) mm Hg, 2.9 +/- 0.4 mm Hg, and 3.4 +/- 0.6 mm Hg following the 0.07%, 0.2%, and 0.5% concentrations, respectively (P =.08). In 8 glaucomatous monkey eyes, the ocular hypotensive effect was maintained for 5 days with twice-daily administration of 0.5% WIN 55212-2. Outflow facility was unchanged (P =.34) and aqueous humor flow was decreased by 18% (P =.04) in the treated eyes compared with vehicle-treated contralateral control eyes in normal monkeys. WIN 55212-2, a cannabinoid agonist at the CB(1) receptor, reduces intraocular pressure in both normal and glaucomatous monkey eyes. A decrease of aqueous flow appears to account for the intraocular pressure reduction in normal monkey eyes. Cannabinoid agonists at the CB(1) receptor, a new class of antiglaucoma agents that is different from currently used clinical drugs, may have clinical potential.
Delta-9-tetrahydrocannabinol (THC) in the treatment of end-stage open-angle glaucoma
Article
Evidence exists that the administration of cannabinoid derivatives can lower intraocular pressure. Some patients with glaucoma believe they are being deprived of a potentially beneficial treatment. Therefore, the Research Advisory Panel of California instituted the Cannabis Therapeutic Research Program to permit compassionate access to cannabinoid derivatives. Data about the potential therapeutic usefulness and toxicity of these agents were collected. This study reviews the results of this program with the specific aim of providing further direction for these investigational efforts. A survey of local ophthalmologists indicated an impressive interest in participating in and contributing patients with glaucoma unresponsive to treatment to this study. Appropriate patients were treated with either orally administered delta-9-tetrahydrocannabinol capsules or inhaled marijuana in addition to their existing therapeutic regimen. Although 20 ophthalmologists were approved as investigators, only nine patients were enrolled in the study. An initial decrease in intraocular pressure was observed in all patients, and the investigator's therapeutic goal was met in four of the nine patients. However, the decreases in intraocular pressure were not sustained, and all patients elected to discontinue treatment within 1 to 9 months for various reasons. This uncontrolled, unmasked, nonrandomized study does not permit definitive conclusions about the efficacy or toxicity of cannabinoids in the treatment of glaucoma. There is an impression that this treatment can lower intraocular pressure, but the development of tolerance and significant systemic toxicity appears to limit the usefulness of this potential treatment. Both patients and ophthalmologists greatly appreciated the opportunity to participate in this study.
Effect of Sublingual Application of Cannabinoids on Intraocular Pressure: A Pilot Study
Article
The purpose of this study was to assess the effect on intraocular pressure (IOP) and the safety and tolerability of oromucosal administration of a low dose of delta-9-tetrahydrocannabinol (Delta-9-THC) and cannabidiol (CBD). A randomized, double-masked, placebo-controlled, 4 way crossover study was conducted at a single center, using cannabis-based medicinal extract of Delta-9-THC and CBD. Six patients with ocular hypertension or early primary open angle glaucoma received a single sublingual dose at 8 AM of 5 mg Delta-9-THC, 20 mg CBD, 40 mg CBD, or placebo. Main outcome measure was IOP. Secondary outcomes included visual acuity, vital signs, and psychotropic effects. Two hours after sublingual administration of 5 mg Delta-9-THC, the IOP was significantly lower than after placebo (23.5 mm Hg vs. 27.3 mm Hg, P=0.026). The IOP returned to baseline level after the 4-hour IOP measurement. CBD administration did not reduce the IOP at any time. However, the higher dose of CBD (40 mg) produced a transient elevation of IOP at 4 hours after administration, from 23.2 to 25.9 mm Hg (P=0.028). Vital signs and visual acuity were not significantly changed. One patient experienced a transient and mild paniclike reaction after Delta-9-THC administration. A single 5 mg sublingual dose of Delta-9-THC reduced the IOP temporarily and was well tolerated by most patients. Sublingual administration of 20 mg CBD did not reduce IOP, whereas 40 mg CBD produced a transient increase IOP rise.
Prevalence data of glaucoma rate in each state from: http://www.visionproblemsus.org/glaucoma/glaucoma-mapThe Endocannabinoid System as a Therapeutic Target in Glaucoma
  • Jan 2016
  • 9364091-9364101
  • Ea Cairns
  • Wh Baldridge
Prevalence data of glaucoma rate in each state from: http://www.visionproblemsus.org/glaucoma/glaucoma-map.html IMMAD Cairns EA, Baldridge WH, et al. "The Endocannabinoid System as a Therapeutic Target in Glaucoma." Neural Plast. 2016;2016:9364091. doi: 10.1155/2016/9364091.
Topical THC and aqueous dynamics in glaucoma
  • Jan 1981
  • 467-471
  • Jc Merritt
  • Dd Perry
Merritt JC, Perry DD, et al. Topical THC and aqueous dynamics in glaucoma. J Clin Pharmacol. 1981;21(8-9 Suppl):467S–471S.