Often patients ask, “Is there anything I’m doing that’s raising my IOP?” Ophthalmologists might wonder what the best approach is to answering this question when it comes up in the clinic. We should approach this carefully to keep patients motivated as opposed to discouraging them. Here is how I weigh my response when my patients ask what behaviors of theirs are affecting their IOP.

Missing Meds

Foremost, when patients ask this question, I use it as an opportunity to briefly review compliance, given that even the most reliable patients are known to deviate from prescribed regimens.¹ With patients who are unsure of whether their drops are reaching the ocular surface, I will also discuss strategies for eye-drop administration. I invite patients to store their drops in the refrigerator for about a week while they practice because it is often easier to feel cold drops than room-temperature drops landing on the eye.

Steroid Use

Remarkably, some patients are followed for years while using over-the-counter steroid preparations that never make it onto their medication lists. Seasonal use of steroid-containing creams and nasal sprays are common offenders. Additionally, patients may forget to report the use of steroid-containing inhalers. We know that patients with glaucoma are more likely to have a steroid response than those without glaucoma,² so it’s incumbent upon ophthalmologists to educate patients about this and have a low index of suspicion to inquire further about rogue steroid-containing medications when patient IOPs are unexpectedly high. I recently cared for a nun with an inexplicable IOP rise to above 40 mmHg in both eyes, and it turned out that the etiology was a steroid-containing face cream she had been using after it was donated to her monastery.

Other Modifiable Behaviors

Sleep Position

Given that people spend nearly a third of their lives sleeping, it may be worthwhile to educate patients on the interactions between sleep position and IOP. In general, IOP is higher when one is lying down.³ When sleeping on one’s side, the lower eye may have a higher IOP.⁴ Additionally, sleeping face down can elevate IOP, possibly due to pressure on the eyelids.⁵ Although sleep position can be very challenging for patients to modify, given the choice, sleeping with a slight head elevation and avoiding having the worst eye in a dependent position may be desirable modifications.

Caffeine

The effects of caffeine on glaucoma are inconclusive.^6,7 Given my own adoration of a great cup of coffee, together with the mixed literature and my concern that the antioxidant properties of coffee may be overlooked in studies exploring only IOP, I tend not to discuss caffeine moderation as a modifiable target with patients.

Exercise

Aerobic exercise is associated with lower IOP,^8,9 and the IOP benefit of aerobic activity extends beyond the period of exertion. Even walking can be helpful, and the benefits are greater for patients who were previously sedentary, so I think time spent encouraging patients to exercise goes a long way.

However, with respect to IOP, not all exercise is good exercise. Yoga exercises with head-down positions are associated with a rapid rise in IOP in both in glaucomatous and healthy eyes, and the greatest increase in one trial was observed with adho mukha svanasana (“downward dog”).¹⁰ Given the extraordinary physical and mental health benefits of yoga, I encourage patients to maintain their practice but to work with a qualified instructor to modify and avoid head-down positions and all inversions.

Weightlifting has been shown by some groups to be associated with elevated IOP.^11,12 Given the health benefits of weightbearing exercise, I do not usually caution patients against weightlifting, but in patients who lift very heavy weights, lift very frequently, and/or have fixation-threatening disease, this may be worthwhile to discuss.

Recommendations

Above all, I remind patients that following up as directed is the single most important thing they can do for their vision. Highly motivated patients may derive modest additional benefit from adjusting their sleep position and adding aerobic exercise to their daily routine. GP

Sarah H. Van Tassel, MD, is an assistant professor of ophthalmology for glaucoma, cataracts, and general eye diseases at Weill Cornell Medicine Department of Ophthalmology in New York, New York. She reports no related disclosures. Reach her at sjh2006@med.cornell.edu.

References

1. Olthoff CMG, Schouten JSAG, van de Borne BW, Webers CAB. Noncompliance with ocular hypotensive treatment in patients with glaucoma or ocular hypertension an evidence-based review. Ophthalmology. 2005;112(6):953-961. doi:10.1016/j.ophtha.2004.12.035
2. Bojikian KD, Nobrega P, Roldan A, Forrest SL, Tsukikawa M, Chen PP. Incidence of and risk factors for steroid response after cataract surgery in patients with and without glaucoma. J Glaucoma. 2021;30(4):e159-e163. doi:10.1097/IJG.0000000000001785
3. Prata TS, De Moraes CGV, Kanadani FN, Ritch R, Paranhos A. Posture-induced intraocular pressure changes: considerations regarding body position in glaucoma patients. Surv Ophthalmol. 2010;55(5):445-453. doi:10.1016/j.survophthal.2009.12.002
4. Lee TE, Yoo C, Lin SC, Kim YY. Effect of different head positions in lateral decubitus posture on intraocular pressure in treated patients with open-angle glaucoma. Am J Ophthalmol. 2015;160(5):929-936.e4. doi:10.1016/j.ajo.2015.07.030
5. Flatau A, Solano F, Idrees S, et al. Measured changes in limbal strain during simulated sleep in face down position using an instrumented contact lens in healthy adults and adults with glaucoma. JAMA Ophthalmol. 2016;134(4):375-382. doi:10.1001/jamaophthalmol.2015.5667
6. Kim J, Aschard H, Kang JH, et al. Intraocular pressure, glaucoma, and dietary caffeine consumption: a gene-diet interaction study from the UK Biobank. Ophthalmology. 2021;128(6):866-876. doi:10.1016/j.ophtha.2020.12.009
7. Jiwani AZ, Rhee DJ, Brauner SC, et al. Effects of caffeinated coffee consumption on intraocular pressure, ocular perfusion pressure, and ocular pulse amplitude: a randomized controlled trial. Eye Lond Engl. 2012;26(8):1122-1130. doi:10.1038/eye.2012.113
8. Roddy G, Curnier D, Ellemberg D. Reductions in intraocular pressure after acute aerobic exercise: a meta-analysis. Clin J Sport Med Off J Can Acad Sport Med. 2014;24(5):364-372. doi:10.1097/JSM.0000000000000073
9. Passo MS, Goldberg L, Elliot DL, Van Buskirk EM. Exercise training reduces intraocular pressure among subjects suspected of having glaucoma. Arch Ophthalmol Chic Ill 1960. 1991;109(8):1096-1098. doi:10.1001/archopht.1991.01080080056027
10. Jasien JV, Jonas JB, de Moraes CG, Ritch R. Intraocular pressure rise in subjects with and without glaucoma during four common yoga positions. PloS One. 2015;10(12):e0144505. doi:10.1371/journal.pone.0144505
11. Vera J, Perez-Castilla A, Redondo B, De La Cruz JC, Jiménez R, García-Ramos A. Influence of the breathing pattern during resistance training on intraocular pressure. Eur J Sport Sci. 2020;20(2):157-165. doi:10.1080/17461391.2019.1617354
12. Hecht I, Achiron A, Man V, Burgansky-Eliash Z. Modifiable factors in the management of glaucoma: a systematic review of current evidence. Graefes Arch Clin Exp Ophthalmol Albrecht Von Graefes Arch Klin Exp Ophthalmol. 2017;255(4):789-796. doi:10.1007/s00417-016-3518-4