Today, more and more patients want to know about the potential relationships between lifestyle choices and their health. Patients are interested in this topic primarily for two reasons: They want to feel that they have some control over their disease; and alternative treatments have become a more accepted part of the physician-patient conversation. So it feels natural for a patient to ask: Are there things I can do that may help minimize my risk of losing vision, beyond drugs and surgery? How can I live my life in a way that will have the greatest positive impact on this disease?

When patients ask about this, I tell them that there are quite a few lifestyle choices that may impact the development and/or modify the progression of glaucoma for better or worse. Below, I have listed a number of pro and con factors you might wish to share with your patients, when appropriate. (Of course, elevated IOP is the major known risk factor for glaucoma, so that’s the easiest issue to address; a number of the lifestyle choices listed below interact with the progression of glaucoma either by potentially raising or lowering IOP.)

Exercise and Glaucoma

If you want to decrease your IOP, aerobic exercise may help (although it’s important to make sure that any patient with cardiac issues has this activity approved by his cardiologist). Some of the relevant data:

• One study found that in non-smoking, healthy volunteers, aerobic exercise increased heart rate and systolic blood pressure while decreasing IOP and diastolic blood pressure.1

• A study of active college-age students found that dynamic resistance exercises lowered IOP.2

• A study of 20 young adult subjects found that IOP (as well as ocular pulse amplitude and axial length) decreased significantly after exercise (p<0.0001)3

• A study of 67 healthy patients under the age of 40 compared the impact of isometric and isokinetic exercises on IOP. Both types of exercise lowered IOP in direct proportion to exercise intensity, but the pressure-lowering effect of isokinetic exercise was more significant.4

The data is mixed regarding weightlifting. Some studies suggest that weightlifting may trigger the equivalent of the Valsalva maneuver, thereby raising IOP. On the other hand, the lifestyle consequences of exercise are generally positive, and weightlifting certainly is a form of exercise. (It’s worth noting one of the big problems with research into these possible associations: Most of these studies were done in young, healthy subjects, not in glaucoma patients.)
It is difficult to arrive at a clear conclusion regarding related considerations such as body mass index and its relation to glaucoma. For example, published data shows a positive relationship between BMI and IOP, but an inverse relationship between BMI and glaucoma.5,6

Of course, lifestyle choices, including exercise, can also play an important role in cardiac health, and there’s considerable evidence that cardiac health influences the development of glaucoma.7-12 Among other things, altered ocular blood flow may be a major factor in the pathogenesis of glaucomatous optic neuropathy.

Activities & Habits

• Cigarette smoking.
I believe a majority of physicians agree that smoking has few, if any, health-related benefits, and may cause serious harm. In terms of glaucoma, one meta-analysis concluded that smokers are at a significantly increased risk of developing open-angle glaucoma13 but another study published in 2003 found no increased risk of glaucoma in smokers.14 On the other hand, cigarette smoking has been linked to macular degeneration and cataract, and in some studies it has been associated with modest IOP elevation.15

• Practicing yoga. I have encountered a number of patients with worsening glaucoma who, when questioned, explained that in an attempt to improve their overall health they had taken up practicing yoga.
Although yoga is often considered a means to improve one’s mental or physical health, head-down positions may cause a significant increase in intraocular pressure—not ideal for a glaucoma patient. (Image
Unfortunately, these yoga enthusiasts are likely to assume various degrees of body inversion—i.e., head-down positions including Sirasana (headstand posture). Being in these yoga positions for more than a few minutes can cause profound elevations in IOP (as much as a two-fold increase).16

Most people don’t realize that head-down positions (in yoga or with other activities) are generally bad for their glaucoma—and doctors seldom think to ask whether their patients are practicing these activities.

• Playing high-resistance wind instruments. In 2000, Joel S. Schuman, MD, and colleagues reported that musicians who play high-resistance wind instruments such as trumpet and oboe appear to be at increased risk of glaucomatous damage.17 The study found that IOP rose in proportion to the force of blowing, and total life hours of playing high-resistance wind instruments was significantly related to abnormal visual fields (p=0.03) and corrected pattern standard deviation scores (p=0.007). In fact, the latter increased by 0.011 units for every 1,000 hours of playing. (The authors of the study note that the resulting damage could be misdiagnosed as normal-tension glaucoma.)

• Wearing tight neckties. Even in today’s increasingly casual workplace, many men still wear neckties. Wearing them too tight can lead to prolonged periods of elevated IOP.18

Dietary Choices

• Omega fats in the diet. While many general health studies suggest that omega-3 fatty acids may be better for us than omega-6 fatty acids, at least one study suggests that this may not be the case in relation to glaucoma. It found that a high ratio of omega-3 to omega-6 fatty acids in our diet may be associated with an increased risk of POAG, especially high-tension POAG.19 (A theory to explain a possible mechanism for this result has also been proposed.20)

• Alcohol consumption. Some evidence suggests that drinking a modest amount of alcohol may lower IOP a small degree (i.e., 1 mm).21,22 However, I don’t want to encourage alcohol consumption since the evidence is not clear cut. So if asked, I usually just tell patients that alcohol doesn’t have much effect on IOP. A majority of patients often believe the opposite; they think that consuming alcohol excessively may increase their IOP, and if they stop drinking alcohol their eye pressures will suddenly become much lower. This does not appear to be the case.

• Caffeine consumption. I tell my patients that a little coffee is fine; however, loading up on caffeinated coffee is not ideal for their glaucoma. Data from the Blue Mountains Eye Study showed that subjects with open-angle glaucoma who reported regular coffee drinking had significantly higher mean IOP than subjects who said they didn’t drink coffee (p=0.03). However, the association between coffee consumption and elevated IOP was not found in those with ocular hypertension or no open-angle glaucoma at all.23 In addition, Louis R. Pasquale, MD, and colleagues observed a positive association between heavier coffee consumption and increased risk of exfoliation glaucoma or becoming an exfoliation glaucoma suspect.24 Given this data, I tell my glaucoma patients that it’s probably not a good idea to routinely order a large double espresso.

• Magnesium. Several published papers have suggested that an adequate intake of dietary magnesium may be beneficial for patients with glaucoma; it appears that a deficiency interferes with a number of ocular processes.9,25,26 However, the Rotterdam Study, using data from 3,502 participants, suggested that a high intake of magnesium may be associated with an increased risk of open-angle glaucoma.27

• Ginkgo biloba. The use of ginkgo biloba is very controversial. When I visited South Korea recently, I was told by a glaucoma specialist that up to three-quarters of patients with normal-pressure glaucoma may be prescribed this supplement in addition to their IOP-lowering medications. (That’s anecdotal; I’m not aware of any reported data backing up that claim.) Nevertheless, studies have indeed found potential neuroprotection benefits from ginkgo;28 possible effects on blood flow;29 and short-term visual field improvements in patients with normal-tension glaucoma.30

In terms of other dietary factors, it’s quite difficult to separate truth from fiction. Some papers have suggested that consumables that reduce oxidative stress may be protective. These may include dark chocolate, ubiquinone, melatonin, bilberries (because of their anthocyanosides) and tea, coffee and red wine (because of their polyphenolic flavonoids).9,31 Anti-oxidants as a group have not shown a definitive risk impact on open-angle glaucoma.32

Other Health-related Issues

• Antihypertensive drugs at bedtime. Many elderly patients take antihypertensive drugs, but lowering blood pressure excessively at night can lead to a hypotensive crisis; blood pressure can dip too low to support ocular perfusion. If your glaucoma patient is taking this type of drug, he should talk to his internist to make sure he’s not becoming too hypotensive at night.

• Sleep apnea. Studies have shown that moderate to severe obstructive sleep apnea is linked to increased risk of glaucoma development and progression.33 If a patient is aware of snoring a lot at night and/or complains of being tired all the time, it’s worth suggesting that the patient talk to his or her internist about this possibility.

A potential downside here is that one of the ways of addressing sleep apnea is to have the patient use a continuous positive airway pressure machine at night. While it is often an effective non-surgical treatment for sleep apnea, CPAP therapy was recently shown to increase IOP, especially at night,34 so it’s important to consider whether the benefits of CPAP therapy will be worth its potential downside.

• Migraines. If one of your patients complains of migraine headaches, make sure the patient is discussing this issue with an internist/neurologist. Migraines can increase the risk of progression in patients who have normal-tension glaucoma.35

• Marijuana. While smoking marijuana has been demonstrated to lower IOP in both normal individuals and in those with glaucoma, its short duration of action (only three to four hours) and its deleterious mood-altering effects are less-widely appreciated, as noted in the American Glaucoma Society’s position statement on this topic.36

There is also the real possibility that marijuana’s systemic effect of lowering blood pressure might prove deleterious to the optic nerve in glaucoma by compromising blood flow. Thus, the AGS position statement concludes, “Although marijuana can lower the intraocular pressure, its side effects and short duration of action, coupled with a lack of evidence that its use alters the course of glaucoma, preclude recommending this drug in any form for the treatment of glaucoma at the present time.” (The position statement can also be viewed on the AGS website at

Empowering Your Patients

Given this information, when patients ask what they can do on their own to minimize their chances of losing vision from glaucoma, I advise them to: Do some aerobic exercise; limit cigarette smoking; try to eat a diet high in antioxidants and low in fat; avoid excessive caffeine; avoid head-down positions, especially if doing yoga; and consider taking a magnesium supplement (if they’re not already taking one). I also ask whether they wear a necktie; play a wind instrument; take antihypertensive medications; have any symptoms that might indicate sleep apnea; or have a problem with migraines.

One of the worst parts of having a disease like glaucoma is feeling that you’re relatively powerless against it. Giving our patients some knowledge about lifestyle factors like the ones outlined above can help empower them—and that can improve their quality of life immediately.  REVIEW

Dr. Tsai is the Delafield-Rodgers Professor and chair of the Department of Ophthalmology at the Icahn School of Medicine at Mount Sinai. He also serves as president of the New York Eye and Ear Infirmary of Mount Sinai.

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