Intraocular pressure variation in response to yoga ocular exercises

Satish Kumar Gupta; S Aparna

doi:10.4103/jacs.jacs_31_22

CASE REPORT

Year : 2023 | Volume : 11 | Issue : 2 | Page : 120-125

Intraocular pressure variation in response to yoga ocular exercises

Satish Kumar Gupta, S Aparna
Department of Optometry and Vision Science, Sankara Academy of Vision, Sankara College of Optometry, Sankara Eye Hospital, Bengaluru, Karnataka, India

Date of Submission	20-Oct-2022
Date of Acceptance	11-Apr-2023
Date of Web Publication	29-Aug-2023

Correspondence Address:
Mr. Satish Kumar Gupta
L V Prasad Eye Institute, Kallam Anji Reddy Campus, L V Prasad Marg, Banjara Hills, Road No. 02, Hyderabad - 500 034, Telangana
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jacs.jacs_31_22

Abstract

Elevated intraocular pressure (IOP) beyond the normal range (10–21 mmHg) plays a major role in optic nerve damage in long run, leading to glaucoma. This report describes a case of an individual with raised IOP (baseline), i.e., 25 mmHg in the right eye (RE) and 24 mmHg in the left eye (LE). Optical coherence tomography reported a mild optic disc cupping in both eyes with the cup: disc ratio of 0.68:1 in RE and 0.54:1 in LE. The anterior chamber angle and visual fields were normal in both eyes. The clinical findings revealed a diagnosis of “non-glaucomatous optic disc cupping” in both eyes. The patient was advised to practice yoga ocular exercises for 30 min/day for 5 days a week for upto 6 weeks. The IOP was measured for both eyes at the end of each week for upto 6 weeks, and then, the patient was followed up after 1 month, 2 months, and 10 months. The baseline IOP significantly reduced to 16 mmHg in RE and 15 mmHg in LE after 6 weeks, which suddenly elevated to 22 mmHg in RE and 21 mmHg in LE after 1 month of exercises cessation. All other ocular parameters were stable at 10 months follow-up. The yoga ocular exercises exhibit a significant reduction in IOP until they are practiced and demonstrate a rebound effect as well. Hence, it can be considered an adjunct therapy for the treatment and management of various ocular diseases associated with ocular hypertension such as glaucoma.

Keywords: Case report, glaucoma, intraocular pressure, ocular hypertension, physiological optic disc cupping, yoga ocular exercises

How to cite this article:
Gupta SK, Aparna S. Intraocular pressure variation in response to yoga ocular exercises. J Appl Conscious Stud 2023;11:120-5

How to cite this URL:
Gupta SK, Aparna S. Intraocular pressure variation in response to yoga ocular exercises. J Appl Conscious Stud [serial online] 2023 [cited 2023 Oct 4];11:120-5. Available from: http://www.jacsonline.in/text.asp?2023/11/2/120/384451

Introduction

The continuous and gradual mechanism of production and drainage of aqueous humor determines the normal intraocular pressure (IOP). The normal IOP ranges between 10 and 21 mmHg with a mean IOP of 15.50 ± 2.60 mmHg (Gupta and Mehta, 1971). It is reported that elevated IOP beyond the normal range (ocular hypertension) exhibits mechanical and neuronal damage to the optic nerve (CN II) leading to glaucoma (Weinreb et al., 2014). Glaucoma is defined as a multifactorial optic neuropathy, where there is a characteristic acquired loss of retinal ganglion cells (nerve fibers) and atrophy of the optic nerve head with corresponding visual field damage and may or may not be associated with a risk factor of raised IOP (Weinreb et al., 2014). Currently, medical therapy is the primary treatment for glaucoma, which aims to reduce IOP. Advanced glaucoma intervention study indicates that the current medical regimen alone is insufficient to reduce IOP to target levels (Gyasi et al., 2014). Further, invasive and expensive surgical interventions are required in addition to medical therapy to achieve the target IOP levels. Hence, any novel treatment/management protocols in addition to the current medical and surgical interventions to achieve the target IOP are preferable.

Many yoga practitioners recommend yoga ocular exercises intending to maintain normal eye health. It is reported that a short-term practice of yoga ocular exercises for about 5 min exhibits a significant decrease in IOP (Dimitrova and Trenceva, 2017). Furthermore, another investigation by our group in young adults indicated that the regular practice of yoga ocular exercises exhibited a gradual decrease in IOP after 6 weeks (Gupta and Aparna, 2019a). However, evidence on the extended effects of yoga ocular exercises in subjects with glaucoma or elevated IOP and alteration in IOP after the cessation of yoga ocular exercises (rebound effect) are lacking. Here, we report a clinical ophthalmic case of a young adult with ocular hypertension without other signs, investigating the prolonged and rebound effects of yoga ocular exercises.

Case Report

A 24-year-old South Asian male presented for a comprehensive eye examination with chief complaints of occasional mild ocular pain and eye fatigue in both eyes for 4–5 years. He was not wearing any refractive correction and did not undergo for an ophthalmic consultation previously. There was no history of any sort of ocular or head injury. He did not have a history of any ocular or systemic illness as well as comorbidities. He did not have any prior surgeries or lasers done and was not under any medications in any form at the time of his visit. Any significant and relevant family history was absent. He was not aware of an allergy to any sort of medications or chemicals. His personal and nutritional history was normal. Furthermore, the general, systematic, and psychosocial assessments were within the normal limits. His blood pressure measured at 12:00 PM was normal, i.e., 130/80 mmHg. The height and body weight were measured to be 170 cm and 70 kg, respectively. The body mass index was calculated to be 24.20 kg/m², which was within the normal range (National Heart, Lung, and Blood Institute, 2019). The baseline IOP (adjusted for central corneal thickness [CCT] {Ehlers et al., 1975)) was 25 mmHg in the right eye (RE) and 24 mmHg in the left eye (LE) [Figure 1], [Table 1]. Optical coherence tomography (OCT) reported a mild optic disc cupping in both eyes with the cup: disc ratio of 0.68:1 in RE and 0.54:1 in LE [Figure 3]a, [Figure 4]a. However, the angle of the anterior chamber and visual fields [Figure 2]a was normal in all quadrants in both eyes. Further details of comprehensive ocular evaluation for both eyes are provided in [Table 1].

Figure 1: IOP measurements for both eyes at baseline and subsequent follow-up visits. RE: Right eye, LE: Left eye, IOP: Intra ocular pressure

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Table 1: Baseline ocular evaluation findings in both eyes

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Figure 2: HVF report for both eyes at baseline (a) and follow-up after 10 months (b). GHT: Glaucoma hemi-field test, VFI: Visual field index, MD: Mean deviation, PSD: Pattern standard deviation, RE: Right eye, LE: Left eye, HVF: Humphrey visual field

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Figure 3: Optic disc photograph for both eyes at baseline (a) and follow-up after 10 months (b). T: Temporal retina, N: Nasal retina, RE: Right eye, LE: Left eye

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Figure 4: Average RNFL thickness and optic disc topography for both eyes as reported by OCT at baseline (a) and follow-up after 10 months (b). CDR:Cup: disc ratio, DD: Disc diameter, RE: Right eye, LE: Left eye, RNFL: Retinal nerve fiber layer, OCT: Optical coherence tomography

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Based on the clinical findings, the patient was diagnosed to have “nonglaucomatous optic disc cupping” in both eyes and it was decided to keep the patient under close observation to monitor IOP and optic disc changes if any.

Yoga ocular exercises (intervention)

Given the previous evidence that yoga ocular exercises such as Palming, Blinking, Sideways viewing, Front-sideways viewing, Diagonal viewing, Rotational viewing, Preliminary nose tip gazing, Near-distant viewing, Concentrated gazing (Trataka), and the Acupressure point on the palm exhibit significant IOP lowering effect (Dimitrova and Trenceva, 2017; Gupta and Aparna, 2019a), the patient was counseled to practice these yoga ocular exercises for 30 min (8:30 AM–9:00 AM) for 5 days a week for upto 6 weeks. The IOP measurements (adjusted for CCT (Ehlers et al., 1975)) were obtained for both eyes at the end of each week for up to 6 weeks after monitoring the diurnal variation of IOP [Figure 1].

Results (Follow-up visits and Outcomes)

The patient was asked to stop practicing yoga ocular exercises after 6 weeks of yoga therapy and was followed up after 1 month, 2 months, and 10 months. The IOP measurements at subsequent follow-up visits are given in [Figure 1]. It was observed that the baseline IOP (RE: 25 mmHg and LE: 24 mmHg) started to decrease after 2 weeks and this reduction in IOP persisted until the yoga ocular exercises were practiced (6 weeks). At the end of 6^th week, the IOP significantly reduced to within the normal range, i.e., 16 mmHg in the RE and 15 mmHg in the LE. After the cessation of yoga ocular exercises, a sudden hike was seen in the reduced IOP within 1 month as it tends to mildly elevate (22 mmHg in the RE and 21 mmHg in the LE). When the patient was followed-up after 10 months, the IOP measurements were 20 mmHg in the RE and 18 mmHg in the LE, which was still towards the bordeline values of raised IOP. Other ocular examinations including visual field examination [Figure 2]b, optic disc examination [Figure 3]b, and OCT parameters [Figure 4]b were stable. This confirmed the diagnosis of “nonglaucomatous optic disc cupping” in both eyes. Hence, any type of active medical or surgical treatment was not intervened. However, the patient was advised to re-initiate yoga ocular exercises and follow up with the glaucoma clinic every 6 months to monitor IOP and optic disc changes, if any.

Discussion

The current case report investigated the variation in IOP and its rebound effect in response to yoga ocular exercises in an individual with ocular hypertension. This case study reports a significant decline in IOP until the yoga ocular exercises are practiced. Previous studies reported that IOP decreased in acute and dynamic exercises in proportion to the intensity of exercises, but not the duration of these exercises (Harris et al., 1994; Kiuchi et al., 1994; Qureshi et al., 1996). In our case study, there was a significant decrease in IOP to within the normal range after regular practice of yoga ocular exercises for 6 weeks. This finding is consistent with the previous literature that reports a significant decrease in IOP in response to the both short-term (5 min) (Dimitrova and Trenceva, 2017) and long-term (6 weeks) (Gupta and Aparna, 2019a) practice of yoga ocular exercises. In addition, the yoga ocular exercises in the current case report not only incurred an acute IOP lowering effect but also exhibited a prolonged IOP lowering effect, which persisted until these exercises were regularly practiced. A sudden hike was seen in the reduced IOP within 1 month as it tends to elevate mildly after the cessation of yoga ocular exercises, which was consistent even after 10 months. Besides IOP lowering effect, previous investigations also reported the yoga ocular exercises to exhibit significant improvement in eye fatigue symptoms (Gupta and Aparna, 2020) and binocular vision functions (Gupta and Aparna, 2019b). In addition to yoga ocular exercises, a recent clinical trial reported that the regular practice of yogic pranayama and diaphragmatic breathing exercises for 6 months also significantly reduced IOP in patients with primary open-angle glaucoma (Udenia et al., 2021).

Although yoga ocular exercises exhibit both short-and long-term reduction in IOP, the accurate factors that provoke this response remain ill-defined. It appears that yoga ocular exercises possess a complex IOP reduction mechanism. While practicing yoga ocular exercises (except palming), there occurs maximum and continuous stretching of the extra-ocular muscles in all gazes, which increases the metabolic demand in these muscular tissues (Dimitrova and Trenceva, 2017) resulting in increased intra-orbital blood circulation and possibly triggering intra-orbital venous outflow and IOP decline (Martin et al., 1999; McMonnies, 2016). Vasodilation of episcleral veins exhibited by palming exercise is also considered to accelerate the aqueous humor circulation and outflow leading to IOP reduction (Dimitrova and Trenceva, 2017; Gupta and Aparna, 2019a). Further, a few yoga ocular exercises such as preliminary nose tip gazing, near-distant viewing, and concentrated gazing (Trataka Kriya) involve the accommodative mechanism via simultaneous contraction and relaxation of ciliary muscles in the eyes (Saraswati, 2009). The ciliary muscles, being the primary site for aqueous humor production, may stimulate the uveo-scleral outflow of aqueous humor (unconventional pathway) leading to an instant lowering of IOP (Sankalp et al., 2018).

(Martin et al., 1999) extensively investigated the osmotic characteristics of ocular hypotension induced by dynamic exercises and proposed that increased colloid osmotic pressure may lead to ocular dehydration via the osmotic changes in the retinal and uveal vasculature (Martin et al., 1999). This may result in decreased vitreous volume leading to IOP decline (Martin et al., 1999; McMonnies, 2016). A further detailed proposed scientific explanation of the action of yoga ocular exercises on human eyes has been described previously (Gupta and Aparna, 2019a; Gupta and Aparna, 2019b; Gupta and Aparna, 2020).

One limitation of the current study is that it reports the case of a single young adult patient with ocular hypertension. Therefore, future studies including clinical trials on a larger diseased cohort evaluating the longitudinal and rebound effects of yoga ocular exercises are crucial to establish the potential benefits of these exercises for the prevention, treatment, and management of various ocular diseases associated with ocular hypertension such as glaucoma.

Conclusions

To the best of our knowledge, this is the first case report accessing the long-term and rebound effects of yoga ocular exercises on IOP. In summary, yoga ocular exercises exhibit a significant short-term and persisting long-term reduction in IOP, until these exercises are practiced. Cessation of yoga ocular exercises demonstrates potential rebound effects as it leads to a sudden increase in IOP when the practice of these exercises is stopped. Hence, these exercises may be considered as an adjunct therapy for lowering IOP in various ocular diseases or disorders associated with ocular hypertension such as glaucoma. However, they are not substitutes for pharmacological or surgical interventions. Further clinical trials are required to establish these effects.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Acknowledgements

The authors acknowledge Ms. Krupa Patel and Mr. Ankur Patel (yoga instructors), who instructed yoga ocular exercises to the patient. Special thanks to Dr. Meena Gopinath Menon and Dr. Lalitha who aided in the clinical examination of the patient. This case report was presented as a scientific poster at the 2^nd IVI International Optometry Conference-Eye Health in a Changing World organized by the India Vision Institute on September 09–11, 2021.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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