Glaucoma and Exercise: What to Tell Your Patients

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Can I or can’t I? Should I or shouldn’t I? Ophthalmologists are often asked about the effects of exercise—particularly yoga—on glaucoma. As the science is continuing to unfold, considerable uncertainty remains. But a combination of evi­dence-based recommendations and common sense can go a long way when talking with glaucoma patients about exercise.

EXERCISE CAUTION. Patients with glaucoma may need to modify or skip certain poses, such as downward-facing dog.

Aerobic Exercise: Definitely

There’s no question that aerobic exer­cise is crucial to overall good health. As for glaucoma, Robert Ritch, MD, at New York Eye & Ear Infirmary of Mount Sinai in New York City, tells his patients, “It’s simple. If it’s good for your heart, it’s good for glaucoma. If it’s good for your brain, it’s good for glaucoma.”

Dr. Ritch advises 45 minutes of aero­bic exercise three to four times a week. The research supports this guidance:

• In one study, aerobic exercise (such as walking, swimming, biking, or work­ing out on stationary machines) at a brisk level for 30 to 45 minutes three to four times a week lowered intraocular pressure (IOP) and improved blood flow to the brain and the eye.¹

• In a recent study, all measures of physical activity—average steps per day, minutes of basic (nonsedentary) movement, and greater time spent doing moderate-to-vigorous physical activity—were associated with slower rates of visual field (VF) loss in a treated group of glauco­ma patients.

At baseline, participants walked an average of 5,313 steps and averaged 148 minutes of nonsedentary activity and 11 minutes of moderate-to-vigorous activity per day. Each incremental increase in activ­ity was associated with less decline in VF, although the observed effects were small. But significantly boosting those levels each day—walking an additional 5,000 steps, engaging in an additional 2.6 hours of nonsedentary activity, or exercising for 120 minutes at a mod­erate-to-vigorous level—decreased the average rate of VF loss by approximate­ly 10%.²

• Results of a meta-analysis showed that exercise in sedentary people had a greater IOP lowering effect than it did in people who were already active.³ “It’s important for clinicians to tell their patients who are not motivated to ex­ercise that it’s actually the patients who have not been active who do the best in terms of lowering eye pressure with exercise,” said Yvonne Ou, MD, at the University of California, San Francisco.

Clues from animal research. Accord­ing to Dr. Ou, recent animal studies add to the evidence that physical activity protects against glaucoma damage.

In a murine study that examined the role of exercise in a transient ocular hy­pertension model, exercise was able to reverse signs of age-related vulnerabil­ity to optic nerve injury, such that the signs of injury in older mice that had completed the exercise regimen were similar to young mice that were not exercised.⁴ The investigators then went on to show that exercise may prevent the injury-induced loss of brain-de­rived neurotrophic factor (BDNF) in the retina. (The group also has recently demonstrated that a high-fat high-sucrose diet made the mouse optic nerve more vulnerable to injury, but that exercise did not offset the negative effects of this diet.⁵)

Strength Training: Maybe

Lack of clarity. Relatively few studies have been conducted on weight training’s effect on IOP. Moreover, the results have been contradictory:

• Several years ago, Dr. Ritch’s group evaluated the effect of bench pressing on IOP in 29 normal subjects, and a number of them experienced rises in IOP during the exercise.⁶ “The study hasn’t been done in people with glau­coma, but I presume that glaucoma patients would have a more exaggerated response,” Dr. Ritch said.
• In another study of 30 healthy indi­viduals, the opposite occurred: Dynam­ic resistance exercises (chest and leg presses) induced moderate postexercise decreases in IOP.⁷

Advice for patients? Given the lack of clarity, Dr. Ritch’s guidance for glaucoma patients comes down to the amount of weight being lifted. Is a patient working with 10-, 20-, or 30-pound weights—or much more than that? “I caution patients with glaucoma about bench pressing 200 pounds, but a definitive study has not been done. If a patient has mild glau­coma, I tell them to go ahead with their routine unless they [experience] severe damage. I had one patient who lost his 3-degree island of vision in the middle of doing a crunch, and IOP can also rise in patients doing push-ups. I basi­cally tell them to use common sense.”

Avoid the Valsalva maneuver. It’s crucial that the person continues to exhale during periods of maximum ex­ertion. This helps the patient avoid the Valsalva maneuver, in which a person exhales forcefully with a closed mouth and nose and the windpipe is blocked by the closed epiglottis—which can increase IOP dramatically.

Yoga: It Depends

There’s no clear evidence to suggest that certain yoga poses—especially if they are held for short periods—are detrimental to people’s glaucoma, but there is reason for caution.

Just say no to headstands. Back in 1980, Dr. Ritch saw a 45-year-old wom­an with normal-tension glaucoma who had 5-degree fields. She had continued to progress despite consultation with clinicians at 12 institutions.

As it turned out, she had been standing on her head for 20 minutes a day for 20 years. When her IOP was mea­sured while she was performing a head­stand, it was 60 mm Hg. In contrast, it was 15 mm Hg while she was sitting. Dr. Ritch proceeded to take all of his lab colleagues and stand them on their heads. Everyone’s IOP roughly doubled.

Subsequent studies and case reports tested headstand pose, demonstrating a twofold rise in IOP.⁸ “Doing headstands and shoulderstands is a real no-no for glaucoma patients, especially if you’re going to do them for 20 minutes a day,” Dr. Ritch said.

What about downward-facing dog? But what about other head-down posi­tions? Yoga students routinely practice a number of poses in which the head is positioned below the heart.

In a recent study, Dr. Ritch and his colleagues had glaucoma patients and a cohort of healthy participants perform a series of four inverted yoga positions—downward-facing dog, standing for­ward bend, plow, and legs-up-the-wall poses.⁹ The researchers captured the IOP in each group at five time points: 1) at baseline, while seated, 2) imme­diately after assuming the pose, 3) two minutes later, while still holding the pose, 4) immediately after performing the pose, in a seated position, and 5) 10 minutes later, after resting in the seated position.

Both groups of participants showed a rise in IOP in all four yoga positions, with the greatest increase of pressure—almost 10 mm Hg—occurring during downward-facing dog. After a few min­utes of rest, all eye pressures returned to normal.

Can modifications help? For glauco­ma patients, the safest way to practice yoga is to avoid inversions altogether, said Roger Cole, PhD, a research scien­tist and Iyengar yoga instructor based in Del Mar, California. However, he said, when a patient who has mild glau­coma also has a passion for yoga, their ophthalmologist and yoga teacher may be able to help them design a modified practice that diminishes the potential effects on IOP.

“The most important factor deter­mining an inverted posture’s effect on IOP appears to be the vertical distance of the eyes below the heart,” said Dr. Cole. “Elevating the legs, pelvis, and ab­domen above the heart may also raise IOP but seems to have a smaller effect.”

For example, he noted, “in Dr. Ritch’s yoga study, the two postures that placed the eyes furthest below the heart [downward-facing dog and standing forward bend poses] raised IOP by about 10 mm Hg even though the feet remained on the floor.” In contrast, he said, “the two postures that kept the eyes at or only slightly below heart level while lifting the legs, pelvis, or abdomen the most [plow and legs-up-the-wall poses] raised IOP by 4 mm Hg, on average.” Knowing this makes it easier to select and modify inversions based on their likelihood of raising IOP (see “Analyz­ing Asana”).

Take-Home Message

The last thing a clinician wants to do is discourage patients from exercising. Rather, it’s critical to ask patients about their activities and discuss limits and modifications when necessary.

Finally, what about Dr. Ritch’s patient, who had been standing on her head for 20 minutes a day for 20 years? She stopped doing headstand pose—and her glaucoma stopped progressing.

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MORE ON AAO.ORG. Review this “Ask an Ophthalmologist” video, which covers activities that have potential to worsen glaucoma.

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1 Schmidt KG et al. Graefes Arch Clin Exp Oph­thalmol. 1996;234(8):527-532.

2 Lee MJ et al. Ophthalmology. Published online Oct. 10, 2018.

3 Roddy G et al. Clin J Sports Med. 2014;24(5):364-372.

4 Chrysostomou V et al. Aging Cell. 2016;15(6):1082-1091.

5 Chrysostomou V et al. Exp Eye Res. 2017;162:104-109.

6 Vieira GM et al. Arch Ophthalmol. 2006;124(9):1251-1254.

7 Chromiak JA et al. J Strength Cond Res. 2003;17(4):715-720.

8 Baskaran M et al. Ophthalmology. 2006;113(8):1327-1332.

9 Jasien JV et al. PLoS One. Published online Dec. 23, 2018.

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Dr. Cole is a research scientist and a certified Iyengar yoga teacher. He is based in Del Mar, Calif. Relevant financial disclosures: None.

Dr. Ou is associate professor of ophthalmology at the University of California, San Francisco. Relevant financial disclosures: None.

Dr. Ritch is professor of ophthalmology at the New York Eye & Ear Infirmary of Mount Sinai in New York City. He holds the Shelley and Steven Einhorn Distinguished Chair in Ophthalmology and is Surgeon Director Emeritus and Chief of Glaucoma Services Emeritus. Relevant financial disclosures: None.

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