Exercise and Glaucoma

Hello I’m Dr. David Richardson. I’m a cataract and glaucoma surgeon in Southern California. I’ve been discussing a holistic approach to glaucoma treatment. In other words, a treatment that takes into account things other than intraocular pressure.

In one of my earlier videos, I mentioned that what’s good for cardiovascular health should be good for glaucoma. And exercise is one of the things that we all know is good for cardiovascular health. As far as whether it’s good for glaucoma that’s not as clear. So, today, I’d like to discuss some of the nuances of exercise and glaucoma. So let’s get going!

Valsalva Maneuver and Glaucoma

There are some things that we know increase intraocular pressure. Any kind of valsalva maneuver, which is what’s associated with straining— straining with constipation, straining with holding ones breath, straining with exercise—that maneuver results in an increase in pressure. ^[1] And depending on how hard one holds the breath and strains, the pressure can go up from 4 mmHg above baseline, all the way up to or even 20 mmHg above baseline.

Weightlifting and Glaucoma

In one study that looked at weightlifters, one of the weightlifters in the study had an intraocular pressure above 40 mmHg during weightlifting.^[2] So we know that exercises such as weightlifting can result in an incredible increase in intraocular pressure. Now, not everybody has pressures go up as high as 40 mmHg during weightlifting but it is possible. And for most people they just won’t know how high their pressures are. So transient fluctuations and pressures, such as with weightlifting, could be damaging to the optic nerve. Now, what we don’t know is whether or not these brief fluctuations, when repeated multiple times in (you know) short periods during, say a weightlifting training session, cause any kind of permanent damage. One of the things that happens immediately after exercise is that the intraocular pressure actually goes down for a period of time^[3] , which ranges anywhere from 5 minutes to an hour after exercises.

Now, one of the things that is worth noting also is that it’s not just how high one’s intraocular pressure is that results in glaucomatous damage. A number of recent studies—the Collaborative Initial Glaucoma treatment study (or CIGTS)^[4] and the Advanced Glaucoma Intervention Study (AGIS)^[5] both showed, pretty conclusively, that fluctuation in pressure as well as elevation of pressure can result in glaucomatous damage. So, it stands to reason that if during exercise one is having pretty severe fluctuations and pressure (during exercise the pressure is going up in the eye, after exercise the pressure goes down), then exercise itself could be detrimental to the optic nerve.

General Recommendations Regarding Exercise and Glaucoma

So what do I recommend to my patients who have glaucoma and are interested in exercise? Well, again, taking a holistic approach and realizing that there’s a person attached to that eye and that person has a heart, a brain, kidneys, and other things that would benefit from cardiovascular fitness.^[6] I still recommend to the vast majority of my patients that they exercise on a regular basis. I do however encourage aerobic exercises and in terms of weight lifting, I generally recommend multiple repetitions of smaller weights rather than fewer repetitions of much heavier weights. And again, that’s because of the known increased in intraocular pressure with the valsalva maneuver.

Yoga and Glaucoma

Some other things that I tend to discuss with my patients with glaucoma… I have a number who enjoy yoga. I think yoga is a particularly great form of exercise which seems to have benefits not only for one’s physical health but one’s mental and emotional health as well.^[7]

There are, however, some caveats there. It is known that any type of inverted position, such as what can occur with downward dog and some of the other yoga positions, results in a transient increase in intraocular pressure, which can be quite severe.^[8] So, I do recommend for my patients who prefer yoga that they avoid the inverted positions. I also recommend that my patients avoid inversion tables and extended head stands.^[9]

So, basically, you try to keep your head above your heart. It is known you don’t have to be upside down. Just lying down in a supine position, which is lying on your back increases pressure in the eye.^[10] And line in a prone position which is face down increases your pressure even more.^[11] So as much as possible, again, you want to perform your exercises upright. So bench press is actually not great for the intraocular pressure because you get both an elevation from lying supine on your back as well as from the straining of the bench press itself.

So, those are some of my thoughts about exercise and glaucoma, as well as a review of some of the literature that’s available (there’s a lot of literature available). Unfortunately it’s not conclusive, in the sense that there is a definite recommendation that is right. And as we go through these videos together, you’re going to find out that a lot of glaucoma treatment fits that. We don’t have a bright line or a black-and-white answer. So, again, apropos today…it’s a great day and I’ve got a bit of a grey answer or description about exercise and glaucoma but hopefully you found it somewhat informative, if not all that great of a guide as to what to do. All right, take care!

References

1. Rosen D.A., Johnston V.C. Ocular pressure patterns in the Valsalva maneuver. Arch Ophthalmol. 1959;62:810-816.
2. Dickerman R.D., Smith G.H., Langham-Roof L., McConathy W.J., East J.W., Smith A.B. Intra-ocular pressure changes during maximal isometric contraction: does this reflect intra-cranial pressure or retinal venous pressure. Neurol Res. 1999;21:243-246.
3. Vieira G.M., Oliveira H.B., Tavares de Andrade D., Bottaro M., Ritch R. Intraocular pressure variations during weight lifting. Arch Ophthalmol. 2006;124:1251-1254.
4. Musch D.C., Gillespie B.W., Lichter P.R., Niziol L.M., Janz N.K., CIGTS Study Investigators Visual field progression in the Collaborative Initial Treatment Study. Ophthalmology. 2009;116:200-207.
5. The AGIS investigators. The Advanced Glaucoma Intervention Study: 7 The relationship between control of intraocular pressure and visual field deterioration. Am J Ophthalmol. 2000;130:429-440.
6. Shephard RJ. Aging and exercise. In: Fahey TD, ed. Encyclopedia of sports medicine and science. Internet Society for Sport Science. Available at: http://sportsci.org.
7. Smith C, Hancock H, Blake-Mortimer J, Eckert K. A randomised comparative trial of yoga and relaxation to reduce stress and anxiety. Complement Ther Med. 2007 Jun;15(2):77-83. Epub 2006 Jun 21.
8. Jasien JV, Jonas JB, de Moraes CG, Ritch R (2015) Intraocular Pressure Rise in Subjects with and without Glaucoma during Four Common Yoga Positions. PLOS ONE 10(12): e0144505. https://doi.org/10.1371/journal.pone.0144505 https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0144505
9. O’Connor P.S., Poirier R.H. Ocular effects of gravity inversion. JAMA. 1985;254:756
10. Yamabayashi S., Aguilar R.N., Hosoda M., Tsukahara S. Postural change of intraocular and blood pressures in ocular hypertension and low tension glaucoma. Br J Opthalmol. 1991;75:652-655.
11. Lam A.K.C., Douthwaite M.A. Does the change of anterior chamber depth or/and episcleral venous pressure cause intraocular pressure change in postural variation. Optom Vis Sci. 1997;74:664-667.

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