From the William and Anna Goldberg Glaucoma Service and Research Center, Wills Eye Institute, Jefferson Medical College, Philadelphia, Pennsylvania.
Address correspondence to Daniela S. Monteiro de Barros, MD, William and Anna Goldberg Glaucoma Service and Research Center, Wills Eye Institute, Jefferson Medical College, 840 Walnut Street, Suite 1150, Philadelphia, PA 19107.
Yoga exercises have increased in popularity as part of an active lifestyle. In addition to physical fitness, yoga has been promoted as an alternative form of therapy for chronic illnesses.1 With the increasing use of these exercises, physicians need to be familiar with the potential side effects in patients with certain medical conditions.2 Recent studies have described an elevation in intraocular pressure (IOP) following the Sirsasana (headstand) yoga posture, particularly in patients with glaucomatous optic neuropathy.3,4 However, to the best of our knowledge, there are no publications describing progressive optic neuropathy in congenital glaucoma associated with yoga exercises. We report a case of progressive glaucomatous optic neuropathy in a patient with a history of congenital glaucoma who had been performing the Sirsasana posture during yoga exercises for the past 5 years.
A 47-year-old woman with a history of congenital glaucoma presented with progressive optic neuropathy and decreased visual acuity in the left eye. She had undergone goniotomy in both eyes in the first year of life and filtration surgery on the left eye 17 years prior to presentation. She recently had had cataract extraction on her left eye. Her best-corrected visual acuity was 20/20 in the right eye and 20/80 in the left eye, with refractive errors of −1.75 + 2.25 × 160 and −2.00 + 2.75 × 180, respectively. IOP was 13 mm Hg in the right eye and 24 mm Hg in the left eye by Goldmann applanation tonometry. At presentation, she was taking brimonidine tartrate, timold ophthalmic solution 0.5%, and travoprost for the left eye only.
The examination was significant for mild corectopia of the left pupil with a trace afferent pupillary defect and buphthalmos in both eyes. The anterior segment examination was significant for Haab’s striae, with the left eye greater than the right eye, and a superior moderately elevated avascular bleb in the left eye. The central corneal thickness was 486 μm in the right eye and 539 μm in the left eye. IOP was unchanged after dilation in both eyes. The optic nerve showed a small healthy cupping in the right eye and larger shallow cupping with a full healthy rim in the left eye.
There was evidence of progressive optic neuropathy and visual field defects in the left eye. IOP was measured with the Tonopen XL (Biorad Ophthalmic Division, Santa Clara, CA) before, during, and after the Sirsasana posture (Figure). The patient’s IOP rose significantly from 13 mm Hg in the right eye and 24 mm Hg in the left eye before the Sirsasana posture to 35 and 50 mm Hg, respectively, during the posture. IOP decreased to 18 mm Hg after the Sirsasana posture. The patient routinely maintained this posture for 10 minutes approximately 3 times a week.
Figure. Representative Image of Individual in Sirsasana (head-stand) Posture.
Yoga exercises have been advocated as complementary and alternative medicine techniques for various diseases in many countries.5 Although these exercises are routinely safe and promote good health, there are risks involved for certain patients. Margo et al.6 reported that maintaining a Sirsasana posture may predispose patients to vascular thrombosis by intermittently increasing conjunctival venous pressure and decreasing venous out-flow. Other reports have described an increase in IOP associated with yoga exercises.1–4
In a prospective case observational series, Baskaran et al.3 demonstrated a uniform two-fold increase in IOP during the Sirsasana posture, which was maintained during the posture in all age groups irrespective of the ocular biometry and ultrasound pachymetry. Of significance, all 75 participants did not have a prior diagnosis of glaucoma or any glaucomatous optic neuropathy. The authors concluded that normal patients performing the Sirsasana posture do not need routine ocular examinations to monitor for glaucomatous damage, but their study did not address how the elevation and fluctuation of IOP may affect patients with preexisting glaucomatous optic neuropathy.
In a presentation similar to our patient, Gallardo et al.4 described a case of a patient with primary open-angle glaucoma, splinter disc hemorrhage, and progression of glaucomatous optic neuropathy in association with the Sirsasana posture.
It is difficult to make a direct, causal relationship between the Sirsasana posture and glaucomatous progression, but the dramatic change in IOP is potentially harmful in patients with preexisting glaucomatous optic neuropathy. The sudden increase in pressure may cause damage to the optic nerve fibers related to ischemic and mechanical pressure.
The increase in IOP that occurs during the Sirsasana posture has been documented in multiple studies, but further controlled studies in patients with glaucoma are needed to make a direct correlation with progression of glaucomatous optic neuropathy. Regardless, it is an important consideration in patients who have seemingly controlled IOP but worsening optic neuropathy. Additionally, the Sirsasana posture should be incorporated into the standard history questionnaire for all patients at risk for glaucoma.
- : Rice R, Allen RC. Yoga in glaucoma. Am J Ophthalmol. 1985;100:738–739.
- : Fahmy JA, Fledelius H. Yoga-induced attacks of acute glaucoma: a case report. Acta Ophthalmol. 1973;51:80–84.
- : Baskaran M, Raman K, Ramani KK, Roy J, Vijaya L, Badrinath SS. Intraocular pressure changes and ocular biometry during Sirsasana (headstand posture) in yoga practitioners. Ophthalmology. 2006;113:1327–1332. doi:10.1016/j.ophtha.2006.02.063 [CrossRef]
- : Gallardo MJ, Agarwal N, Cavanagh HD, Whitson JT. Progression of glaucoma associated with the Sirsasana (headstand) yoga posture. Adv Ther. 2006;23:921–925. doi:10.1007/BF02850214 [CrossRef]
- : Singh V, Raidoo DM, Harries CS. The prevalence, patterns of usage and people’s attitude towards complementary and alternative medicine (CAM) among the Indian community in Chatsworth, South Africa. BMC Complement Altern Med. 2004;4:3. doi:10.1186/1472-6882-4-3 [CrossRef]
- : Margo CE, Rowda J, Barletta J. Bilateral conjunctival varix thromboses associated with habitual headstanding. Am J Ophthalmol. 1992;113:726–727.