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Stress and Eye Pressure

It has been the conventional wisdom of the medical profession that stress and other psychological states have no discernable influence on eye pressures or glaucoma progression. However, we invite you to read from the perspective of our FitEyes self tonometry community, our doctors own reports, and recent research.

Stress and Eye Pressure

The ophthalmology community is not in full agreement as to the effect of stress on intraocular pressure (IOP) because it is hard to quantify subjective experiences in a clinical setting using the standard methods of testing and research.  However, there has been research which builds a case for the involvement of stress on IOP,  for example in the article Intraocular pressure changes: the influence of psychological stress and the Valsalva maneuver, pressure increases are noted, but these don't fully test the full gamut of stress. Additionally, many professionals in this field have witnessed these effects both clinically and in anecdotal observations from patients.  The most important input, however, comes from the group of FitEyes pioneers who as glaucoma patients, have begun practicing self tonometry and documenting important, relevant data concerning the behavior of their eye pressures.
Trying to define stress in light of intraocular pressure influences needs to be approached carefully, as there is no universal definition of stress without relating appropriate experiences in context. Stress which elevates eye pressure may not always meet the definition of a 'negative emotion.' For example, many who practice home based self tonometry, report that excessive stimulation (being in crowds, at parties, movies, sporting events etc) can raise pressures. Additionally, overthinking, scheming, and excessive mental activity can raise IOP. However, it is not just the activities alone which can raise IOP, but more likely, unconscious psychological factors. Therefore, to get a true picture of the often subtle effects of stress, requires considerable practice in home monitoring of eye pressures - while employing as scientific an approach as possible. Much insight and many beneficial lifestyle changes can be realized! For more on this, see "Evolution of a Self Tonometrist.'
For some, the effects of  transitory stress on IOP  are evident, but for others the effects are quite subtle and can even have a latent effect following a particularly stressful period. Here are a few examples and related commentary by one glaucoma doctor;
Some patients have asked whether a stressful incident (argument with a child earlier in the day over homework or something, for example) would affect their IOPs. I've been inclined to tell them I didn't think that experiencing transient stress on a particular day had much effect, and anyway, it is part of life. There are patients whose IOP has been well controlled for quite some time, and one day they come in with an IOP 15-20 mm Hg higher than usual.  If you ask, many (I dare say most) will tell you of a major chronic stress - - a very recent death of a spouse, in the midst of bitter divorce proceedings, and in one instance seen by Paul Palmberg, a woman whose son had the day before been found guilty of first degree murder.
 I remember one time a resident came to my clinic while I was in the midst of examining a patient to say he had a patient with a pressure in the 30s, when before it had always been in the teens.  He wanted to know how to proceed to identify a cause, as he could not find one.  I told him to go ask the patient whether his brother died recently, or some other major emotional event.  The resident returned in 5 minutes, amazed, and reported that indeed the patient's twin brother died the day before and they were in the midst of making funeral arrangements.
My experience with relatively chronic stress (a prolonged divorce proceeding, prolonged grief over death in the family, etc.) can keep the IOP high and pretty much uncontrollable for months, but (n=10 or so) progression of disc damage and fields has not happened.  I have tried various tranquilizers, but none seem to affect the IOP, but I may not be good at choosing the right drug for the person's emotional state.  Eventually the IOP comes back down, except in one case of a woman with marital troubles who said they were resolved, but IOP didn't come down much.  It could be that it was still weighing on her mind that she had been betrayed.
Anyway, I am convinced that everyday stress, even in stressful jobs, doesn't seem to impact IOP, and neither does a transient event that causes anger.  However, I am equally certain that a deep-seated emotion that is prolonged can have a big effect on IOP, but will gradually go away, and generally before it causes much harm.  So I tended to treat with maximum medicine and wait, watching for progression (in which case I might contemplate surgery), but never did have to resort to pressure lowering with surgery even though the pressure was clearly above the goal I would have in mind or the IOP I thought should be dangerous for that person.

From the perspective of what is reported in the self tonometry community, most can agree with this doctor's comments. However, the part relating to things like stressful jobs not having an impact, is probably not correct. Here is another excellent example as reported by renowned glaucoma specialist Dr Robert Ritch of the New York Eye & Ear Infirmary, which illustrates effects of both transitory and life change stresses;

Over the years I have had a number of patients who were well controlled for long periods whose IOP rose 10 mmHg for several weeks after the death of a spouse. I also had a lawyer whose IOP was 20 mmHg consistently except when after she got out of arguing in front of a jury, it was 40 mmHg.

It was further reported that the lawyer was not able to bring down her pressures in spite of medications. Therefore, in susceptible individuals, certain stressors can even overwhelm glaucoma medications!
Adding to the above, Bailey of FitEyes says that his own glaucoma specialist reports seeing an often high spike of eye pressure in patients who have gone through a divorce, lost a job, or have had other major life changes and stressors.

Examples of IOP and Stress from the FitEyes Self-Tonometry Community

An excerpt from Dave's Blog on FitEyes  Medication Less Effective Under Stress?
In recent weeks my eye pressure have been higher, on average. I presume that situation coincides with the meetings and discussions about my new business venture. We had casual conversations for a while, but the beginning of serious meetings and the financial negotiations, correlates closely with the increased average eye pressure values. (Of course, there could be something else that changed around this time that I'm overlooking, so I'll try to keep an open mind.)
The Timoptic, which had been working so well when I used only 1 drop in my right eye every 3-5 days, seemed to become ineffective during this recent period (beginning the last week of October through yesterday). I even switched to a brand new bottle of Timoptic just to rule out the question of whether there was a problem with the medication itself. The switch made no difference.
From Sally,
My IOP can fluctuate rapidly (within seconds) depending upon the situation, my thoughts, and feelings. During one period of IOP measurements several years ago, the first 2 measurements were in the mid-high teens. Then just as I was taking a third measurement, my husband called to me, saying that an ambulance was at his niece's house next door. That measurement was in the low 30s. After we checked and found that everything was OK, I took my IOP again and it was back down to low 20s.
Similarly, another individual reported that his elderly father was visiting him from out of town and had to have an emergency heart procedure. His pressures had been measuring in the teens, but he decided to check his pressure shortly before taking his dad in for the procedure and found his eye pressures to be 30. In addition to being fearful regarding the outcome of the procedure, he was also stressed that his dad might be with him for a long rehab. When the situation was resolved, his pressures returned to normal.
Here is a report from Marvin, Things That Lower My IOP ( other than eye drops ). These illustrate the flip side of stress, namely, enjoyable activities;
  • Laughing ( light-heartedness )
  • Enjoying company of friends and family ( probably laughing involved )
  • 1 or 1/2 drink of alcoholic beverage ( perhaps increasing the chance of feeling light-hearted )
  • A light schedule at work ( perhaps these are all different ways of saying the same thing? )

There are many such examples, and they illustrate that there can be an immediate reaction to stress (which can correspondingly resolve appropriately), and there can also be a prolonged elevation of IOP resulting from a chronically unresolved stress state. In the latter case, it may take a concerted effort and lifestyle changes to bring pressures down. 

White Coat Syndrome and Eye Pressure
White coat hypertension as seen in blood pressure elevation during doctor visits, also effects the eye pressures of many (especially those with ocular hypertension and/or glaucoma). This is another argument for the role stress plays in eye pressure and is demonstrated by the following examples:
  • Tonometry measurements on doctor visits will in many cases result in lower pressures on successive measurements as the patient relaxes (or when taken by a technician versus the doctor).
  • Eye pressures following a visual field test have been demonstrated as being higher as shown by this study; Elevation of intraocular pressure in glaucoma patients after automated visual field testing
  • Measurements taken at home are usually lower on immediate successive measurements. As in the first point, this demonstrates anticipation anxiety on initial measurements and therefore, demonstrates an effect of stress.
  • Doctor office visits have been reported to be higher than 'at home' before-and-after measurements by those who self monitor. This might be due to discrepancies in the type of tonometers being used, but some have reported taking their tonometers into the doctors office to do side-by-side comparisons in order to rule this out. Additionally, there have been other comparisons such as in Non-contact tonometers... they get no respect. Note this quote:Comparative Analysis of Intraocular Pressure Measurements with Different Ophthalmologic Devices
    • Myth: The NCT is not accurate. I've actually found them to be quite accurate, especially the newer models. I've had 4 NCTs over the years. Two that I'd call "first generation" and my two present identical machines, used in our two pre-test rooms. I've compared IOP measurements from these NCTs with Goldmann readings on thousands of patients, and they are consistently within 1-2 mms.
An excellent example of 'White Coat' effecting IOP as reported by Dave of FitEyes:
I usually measure my eye pressure many times per day at home with my Reichert AT555 tonometer. Today I measured my eye pressure throughout the day, as usual, and it averaged about 12 mmHg. Just before my eye doctor appointment I measured my eye pressure again. It was 13.0 in my right eye and 12.0 in my left eye.
Then I left for my appointment and I took my tonometer from my house to my doctor’s office. At the doctor’s office, we measured my IOP six times using both a Goldman applanation tonometer and my AT555 side by side. The Goldman tonometry was done by the doctor. I did the AT555 measurements exactly like I do at home. My doctor observed all my AT555 measurements. In short, my eye pressure (right eye) went from 13 at home (immediately before leaving) to 20 in the doctor’s office and then back to 12 when I returned home.
Read the full article with experiment results: White Coat Syndrome for Eye Pressure.

Effects of Meditation on Eye Pressure

While it might seem intuitive that if stressful states raise eye pressure, meditation and relaxation training would have the opposite effect of lowering them. Unfortunately, for many, it doesn't seem to work that way, and in fact, many report that certain meditation practices can noticeably raise intraocular pressures. This is not the same as a having a quiet time or 'kicking back' which is very beneficial, but it pertains more to the active practice of different meditation forms. There are certain types of meditation like Serene Impulse which are reported to have beneficial lowering effects on IOP.  Because there are many with glaucoma and/or ocular hypertension with type “A” personality, it is conceivable that meditation practices can raise eye pressures by increasing mental energy involved in concentration etc.

Mechanisms by which stress might elevate eye pressure

While there may not yet be sufficient scientific studies to pinpoint all the possible causes, the mechanisms by which stress and mental states affect intraocular pressure can be:
  • The body under stress releases higher amounts of cortisol (a natural steroid), and it is known that steroids can have a dramatic effect on IOP in susceptible individuals. There are many other hormones and chemicals released by the body during stress which could have an effect on raising IOP – including an increase in aqueous fluid production.
  • Stress can dilate the pupils and this can have an effect on eye pressure in some individuals - especially those with narrow angles.
  • The production of aqueous fluid in the eye can be heightened under stress.
  • Stress affecting the facial muscles, and among them, the extraocular or orbital eye muscles (those outside the eye) have been shown to cause increases of IOP. Here is an excerpt from an article alluding to this, intraocular pressure responses among ocular-hypertensive subjects.
  • Several animal and human investigations have indicated that intraocular pressure (IOP) levels may be associated with extreme drug-induced changes in the extraocular muscles. Further, recent data suggest that, among individuals with normal IOP level, moderate increases in facial muscle (EMG) activity around the eye while the eye is open are associated with increases in IOP.
All of the above points can probably be summarized by the fact that stress contracts the entire body, and we feel that this is bound to have an effect on the trabecular and uveoscleral outflows (the 'drains' by which the eye relieves built-up aqueous fluid).

Effects of stress on glaucoma as a whole

New research is shedding light on the fact that eye pressure is only one factor in glaucoma damage. Recent findings reveal that an underlying mechanism of inflammation and oxidative damage of the nervous system is involved. It is equally important in considering the impacts of the effects of stress on these as well.
Vascular dysregulation via vasospasm and autonomic dysfunction have been demonstrated to be a primary suspect in normal tension glaucoma (glaucoma with normal pressures). See Ocular blood flow and optic neuropathy. Psychological stress is a contributing factor in these conditions as evidenced by the other effects on related symptoms like migraine, blood pressure, body temperature irregularities etc which are influenced by stress levels.
Most glaucoma is now believed to be part of an overall body and/or nervous system disorder. As stress has been shown to be involved in most disease processes and be harmful to many functions of the brain, nervous system, and cardiovascular system (of which the eyes are intricately involved), reducing stress should be of primary concern for those with glaucoma.
Glaucoma damage ultimately involves oxidation and inflammatory stresses to the optic nerve and retinal nerve cell layers (and even the unseen brain side of the visual nervous pathway). Stress increases the release of adrenalin, cortisol, and inflammatory substances like TNF alpha - which is involved in the end stages of optic nerve cell death. Stress is also known to negatively affect the body's response to insulin, and this can also have an effect on glaucoma.
Medical science is just now beginning to fully recognize the systemic effects of stress on inflammation (a key factor in glaucoma). Here is an excellent example:  Greater Traumatic Stress Linked With Elevated Inflammation in Heart Patients. Stress also interferes with uniform blood circulation, which results in diminished and inconsistent blood supply to the optic nerve. Finally, stress also affects the ability to receive restful, restorative sleep, and sleep disturbances have been implicated in glaucoma risk factors. There is no disease which is not worsened by stress, and glaucoma is no exception!

Jacqueline wrote 6-22-2019:

My experience is that glaucoma, for me, is stress-based. Since I got a Reichart 7CR back in February I  have been able to track my IOPs many times a day. An average day had me in the mid-20s during the day with an occasional dip down to the high teens later in the day and evenings.

I worried about nutrition a lot, despite the fact that I own an organic / biodynamic farm and eat incredibly healthy. I added many supplements, worried every day about my situation, slept in a tilted bed, got blue blocking screen on my computers, and then I worried more.

Since getting the 7CR, I am able to make immediate and longer term assessments about what affects IOP. Given the high quality of my diet, I see that food was not an issue. I eat organic, farm-raised, nothing refined. I eat meat maybe twice a week (ours), eggs, whole grains, raw dairy and a lush amount of veggies and fruits daily, raw nuts, honey, olive oil and coconut oil. That’s my diet in a nutshell.

But stress surely was a biggie. I have realized that charting stress was not simple at first. It takes a lot of self-perception to catch myself in stressful thoughts, which I chart-note aside the IOP for that hour. In the past five months I have learned a lot about myself.

When I am stressing about a real-or-imagined thing, I have an internal heckler that has a good deal to say about every thought. If I choose to continue on with that worrisome thought, my IOPs will rise. When I have the presence of mind to opt out of that one-sided conversation, my IOP readings drop. When working in the garden, I can listen to reworking of an argument I had five years ago or I can choose to see the beauty of the flowers around me. Between February and April I made steady progress.

I was about to check-in in early May because I had gotten my IOPs down to a more healthy place, but that same week we got rear-ended while stopped in traffic and I pulled some muscles where the seat belt yanked. My IOPs were strangely calm the rest of that day but the very next day they went right back up to my February normals, mid-20s day and high teens at night with a few spikes even higher.

For the next month I had Feldenkrais sessions with my physical therapist and cranio-sacral sessions with my osteopath. The first few weeks they made some difference but I was physically hurting still so I couldn’t maintain the results. By the fourth week I saw 8-10 pt drops in IOP during the afternoon following the sessions, from 25 down to 15-16. And I got a lot better.

The past few weeks I have stabilized more. Average now is mid-teens when I wake up. If I have a meeting or am rushed, I may hit the low 20s briefly, but I can immediately (no kidding!) decrease my IOP 3-4 points in 15 minutes by doing calm and slow deep breathing, clearing my mind of extraneous thoughts, letting go of any imaginable transgression (forgiveness is very powerful), and relaxing my body. Within the hour I am able to get back into mid-teens and even lower.

Last week I discussed my IOP charts with my doctor and we agreed that I could decrease the brimonidine that I had been taking 3x day for the past few years. My new schedule is to take them when I wake up. I don’t take the afternoon drops if my readings are mid-teens which is becoming my new normal. I rarely take them in the evening because IOPs are usually 12-15 and have been as low as 10. After all that time in the mid-20s months ago, I now have entire days in mid-teens.

Access to my IOPs has been a game-changer for me. I have been able to develop a communication with my own body and psyche that are very useful.


Some relevant links for your review:
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