This article was authored by: Dr. Eileen Javidi, MD, Dr. Georges Durr, MD FRCSC and Dr. Younes Agoumi, MD FRCSC. The PRC Committee wish to acknowledge Félix Plamondon from the University of Laval for their initiative and contribution.

Patients suffering from glaucoma often seek advice on lifestyle changes such as exercise, diet, and other habits that may help them preserve their vision alongside conventional treatments. Although new research is emerging and our understanding of the complex pathophysiology of glaucoma is continuously growing, the relationship between lifestyle habits and glaucoma progression remains to be fully elucidated. This page aims to provide a clear and concise summary of the scientific data currently available, offering guidance for ophthalmologists when counseling their patients on lifestyle changes for glaucoma.

Exercise

Physical activity may be associated with slower rates of visual field loss in patients with glaucoma.¹ Aerobic exercise, beyond its benefits for cardiovascular health, has also been shown to reduce IOP significantly. This effect is greater in previously sedentary people than in those who are already physically active.² When a regular exercise regimen is adopted by previously sedentary individuals, IOP reduction may be sustained for longer periods of time (several weeks).³

Other studies have shown that strength training may increase IOP, particularly when holding one’s breath (Valsalva maneuver) while performing a weight-lifting exercise.⁴ On the other hand, some studies have found that resistance training may slightly decrease IOP in the minutes that follow the exercise.⁵ Since extensive research is still lacking, it may be safer to counsel patients to limit their resistance training to low or moderate intensities, to make sure to breathe out during the exercise and to avoid weigh- lifting altogether in moderate to advanced glaucoma.

Yoga, when practiced vigilantly through exercises involving relaxation and breathing techniques and while making sure to keep the head above the heart, appears to be safe and may even reduce IOP.⁶ However, glaucoma patients must be strongly advised to avoid handstands and head-down positions, as these are known to acutely increase IOP, up to doubling it.^7,8

Sleep

IOP is higher during sleep and in the supine position, increasing to a greater extent in patients with glaucoma and more advanced disease.⁹ It is also higher in lateral decubitus in the dependent eye,¹⁰ and when sleeping face down with contact with a pillow.¹¹ These effects may be mitigated by avoiding sleeping face down or on the side, and by adding a wedge pillow to elevate the head by 30 degrees.¹²

Diet and Supplements

Coffee increases IOP immediately after consumption,¹³ but the data on its long-term impact on IOP and risk of glaucoma remains conflicting. Caffeine consumption may be associated with an increased risk of developing glaucoma in individuals with family history of glaucoma, but no association has been found in those without family history.¹⁴ It seems reasonable for most patients to consume moderate amounts of caffeine, but greater intakes should be discouraged, particularly in those with high IOP, severe glaucoma and a positive family history.¹⁵

Ginkgo biloba extract has gained attention for its potential antioxidant and neuroprotective effects, and benefits on blood circulation. However, current data is inconclusive regarding effects on IOP and visual field progression in glaucoma.¹⁶

Smoking

A large retrospective study has shown that being a current or past smoker is associated with elevated IOP. This association is even greater in glaucoma patients.¹⁷

Marijuana

Marijuana has been discussed as a potential alternative treatment for glaucoma, as it reduces IOP for three to four hours following its consumption by inhalation. However, maintaining adequate IOP control using marijuana would require near-continuous use; therefore, using marijuana for controlling glaucoma is highly ill-advised given its numerous cognitive, respiratory, and other adverse effects such as impairment in functioning.¹⁸

Meditation

Mindfulness meditation has been found to lower IOP and can be used as adjuvant treatment to medical therapy for IOP control in glaucoma.^19-21

References

1.         Lee MJ, Wang JX, Friedman DS, Boland MV, De Moraes CG, Ramulu PY. Greater Physical Activity Is Associated with Slower Visual Field Loss in Glaucoma. Ophthalmology. Jul 2019;126(7):958-964. doi:10.1016/j.ophtha.2018.10.012

2.         Roddy G, Curnier D, Ellemberg D. Reductions in Intraocular Pressure After Acute Aerobic Exercise: A Meta-Analysis. Clin J Sport Med. Sep 2014;24(5):364-372.

3.         Passo MS, Goldberg L, Elliot DL, Van Buskirk EM. Exercise training reduces intraocular pressure among subjects suspected of having glaucoma. Arch Ophthalmol. Aug 1991;109(8):1096-8. doi:10.1001/archopht.1991.01080080056027

4.         Vieira GM, Oliveira HB, de Andrade DT, Bottaro M, Ritch R. Intraocular pressure variation during weight lifting. Arch Ophthalmol. Sep 2006;124(9):1251-4. doi:10.1001/archopht.124.9.1251

5.         Chromiak JA, Abadie BR, Braswell RA, Koh YS, Chilek DR. Resistance training exercises acutely reduce intraocular pressure in physically active men and women. J Strength Cond Res. Nov 2003;17(4):715-720.

6.         Chetry D, Singh J, Chhetri A, Katiyar VK, Singh DS. Effect of yoga on intra-ocular pressure in patients with glaucoma: A systematic review and meta-analysis. Indian J Ophthalmol. May 2023;71(5):1757-+. doi:10.4103/ijo.IJO_2054_22

7.         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. Aug 2006;113(8):1327-1332. doi:10.1016/j.ophtha.2006.02.063

8.         Jasien JV, De Moraes GV, Ritch R. Rise of Intraocular Pressure in Subjects With and Without Glaucoma during Four Common Yoga Positions. Invest Ophth Vis Sci. Apr 2014;55(13)

9.         Prata TS, De Moraes CGV, Kanadani FN, Ritch R, Paranhos A. Posture-induced Intraocular Pressure Changes: Considerations Regarding Body Position in Glaucoma Patients. Survey of Ophthalmology. Sep-Oct 2010;55(5):445-453. doi:10.1016/j.survophthal.2009.12.002

10.       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. Nov 2015;160(5):929-936 e4. doi:10.1016/j.ajo.2015.07.030

11.       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. Apr 2016;134(4):375-82. doi:10.1001/jamaophthalmol.2015.5667

12.       Buys YM, Alasbali T, Jin YP, et al. Effect of Sleeping in a Head-Up Position on Intraocular Pressure in Patients with Glaucoma. Ophthalmology. Jul 2010;117(7):1348-1351. doi:10.1016/j.ophtha.2009.11.015

13.       Higginbotham EJ, Kilimanjaro HA, Wilensky JT, Batenhorst RL, Hermann D. The effect of caffeine on intraocular pressure in glaucoma patients. Ophthalmology. May 1989;96(5):624-6. doi:10.1016/s0161-6420(89)32852-1

14.       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. Jun 2021;128(6):866-876. doi:10.1016/j.ophtha.2020.12.009

15.       Kang JH, Willett WC, Rosner BA, Hankinson SE, Pasquale LR. Caffeine consumption and the risk of primary open-angle glaucoma: a prospective cohort study. Invest Ophthalmol Vis Sci. May 2008;49(5):1924-31. doi:10.1167/iovs.07-1425

16.       Kang JM, Lin S. Ginkgo biloba and its potential role in glaucoma. Curr Opin Ophthalmol. Mar 2018;29(2):116-120. doi:10.1097/ICU.0000000000000459

17.       Lee CS, Owen JP, Yanagihara RT, et al. Smoking Is Associated with Higher Intraocular Pressure Regardless of Glaucoma

®. Ophthalmol Glaucoma. Jul-Aug 2020;3(4):253-261. doi:10.1016/j.ogla.2020.03.008

18.       Green K. Marijuana smoking vs cannabinoids for glaucoma therapy. Arch Ophthalmol-Chic. Nov 1998;116(11):1433-1437. doi:DOI 10.1001/archopht.116.11.1433

19.       Abdelaal A, Fouda MF, Elmallahy M, et al. The Efficacy of Mindfulness Meditation in Medically-Treated Glaucoma. Invest Ophth Vis Sci. Jun 2023;64(8)

20.       Dada T, Mittal D, Mohanty K, et al. Mindfulness Meditation Reduces Intraocular Pressure, Lowers Stress Biomarkers and Modulates Gene Expression in Glaucoma: A Randomized Controlled Trial. J Glaucoma. Dec 2018;27(12):1061-1067. doi:10.1097/Ijg.0000000000001088

21.       Dada T, Mondal S, Midha N, et al. Effect of Mindfulness-Based Stress Reduction on Intraocular Pressure in Patients With Ocular Hypertension: A Randomized Control Trial. American Journal of Ophthalmology. Jul 2022;239:66-73. doi:10.1016/j.ajo.2022.01.017

This article is authored by M. Shayyan Wasim, who has ancestral ties to the African Siddi community in Pakistan
Post reviewed and approved by: Dr. Marie-Josée Aubin and Dr. Anne Xuan-Lan Nguyen

Celebrating Black Excellence in Ophthalmology
Black History Month recognizes the significant contributions of Black individuals in various fields, including medicine. In ophthalmology, Black pioneers have made groundbreaking advancements in clinical practice, research, education, and advocacy. Their work has improved patient care while promoting diversity, equity, and inclusion in the field.

Pioneers in Ophthalmology

Dr. David K. McDonogh (c. 1821–1893)
Born into slavery, Dr. McDonogh pursued medical education after gaining his freedom and became one of the first Black physicians in the United States. He specialized in ophthalmology and dedicated his career to improving eye care for underserved populations while advocating for increased opportunities for Black medical students. 

Dr. Charles Victor Roman (1864–1934)
Dr. Roman was a pioneering ophthalmologist and educator who founded and chaired the Department of Ophthalmology and Otolaryngology at Meharry Medical College. Born to parents who were fugitive slaves, he overcame significant hardships to become a respected advocate for Black healthcare and medical education. 

Dr. Patricia Bath (1942–2019)
A trailblazing ophthalmologist, inventor, and academic, Dr. Bath was the first Black female physician to receive a medical patent for her invention of the Laserphaco Probe, which revolutionized cataract surgery. She was also the first Black female ophthalmology resident at NYU and co-founded the American Institute for the Prevention of Blindness. 

Dr. Maurice F. Rabb Jr. (1932–2005)
Dr. Rabb was a renowned ophthalmologist recognized for his work in cornea and retinal vascular diseases. As one of the first African American students at the University of Louisville, he later became the first Black chief resident at the University of Illinois Eye and Ear Infirmary. His leadership in ophthalmic research and education remains influential today. 

Dr. Howard P. Venable (1913–1998)
Dr. Venable played a pivotal role in desegregating hospitals and ophthalmology training programs. A dedicated mentor, he expanded opportunities for Black physicians in the field. His civil rights activism extended beyond medicine, as he fought against racial discrimination in housing and healthcare. 

Dr. Lois Young-Thomas
Dr. Young-Thomas was the first Black female graduate of the University of Maryland School of Medicine in 1960. She dedicated her career to serving disadvantaged communities and fostering medical education. She later became a professor and mentor, receiving numerous teaching awards for her contributions to ophthalmology education. 

Dr. Eve Higginbotham
A leader in academic medicine, Dr. Higginbotham became the first Black woman to chair an ophthalmology department in the United States at the University of Maryland. A glaucoma specialist, she has made significant contributions to research, healthcare policy, and diversity in medicine. 

Dr. Keith Carter
Dr. Carter is a distinguished leader in academic ophthalmology. As Chair of Ophthalmology at the University of Iowa and past president of the American Academy of Ophthalmology (AAO), he has championed diversity initiatives and mentored underrepresented medical students and residents. 

Dr. Fasika Woreta
A pediatric ophthalmologist and geneticist, Dr. Woreta is an Associate Professor at Johns Hopkins University. She has conducted significant research on congenital cataracts and retinal diseases in children while advocating for global pediatric eye care access and increasing diversity within ophthalmology. 

Conclusion
These individuals have left a lasting impact on the field of ophthalmology and beyond. Their perseverance, innovation, and advocacy continue to inspire future generations of physicians and researchers. As Black History Month is celebrated, their contributions are acknowledged, reaffirming a commitment to fostering diversity and equity in medicine.

The February 2025 CJO is now available online. Here are some of the highlights: 

Resident Perspectives + visual abstract: Our talented team of residents have summarized 4 articles from this issue with a focus on what’s most relevant to ophthalmology learners here in Canada and around the globe. And our February visual abstract provides a visual summary of an article on the Morphometric analysis of bony nasolacrimal canal and sinonasal anatomical variations in primary acquired nasolacrimal duct obstruction.

Reviews and Original Research Articles:

• The state of eyecare and health among Indigenous Peoples in Canada
• Trends in immediate sequential bilateral cataract surgery in Ontario
• Cardiovascular risk in anti-VEGF treatment of neovascular age-related macular degeneration
• Visual impairment, employment status, and reduction in income: the Canadian Longitudinal Study on Aging
• Pars plana vitrectomy and scleral-fixated intraocular lenses: comparison of Gore-Tex suture and flanged intrascleral haptic fixation techniques
• ChatGPT and retinal disease: a cross-sectional study on AI comprehension of clinical guidelines

Research Letters, Photo Essays, Case Reports, and more:

• Appointment patterns and patient perspectives in corneal telemedicine
• Attitudes of Canadian ophthalmology residents on rural and Indigenous ophthalmology education 
• Impact of a slit lamp program on medical student competence, confidence, and career interests  
• Illuminated depressor enhanced fundus photography  
• Frontal periosteum flap: an approach for improved vascular supply for buccal membrane graft
• Isolated case of noninfectious and nontraumatic panophthalmitis
• F. Y. EYE Column

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BlueSky: @cjo-jco.bsky.social

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LinkedIn: CJO – JCO

The following CJO Highlight summarizes key findings from the journal article “Acute Angle-Closure Glaucoma Risk: A Comparative Study of Escitalopram and Antidepressants.”¹

Acute angle-closure glaucoma (AACG) is an ophthalmic emergency that has been linked to selective serotonin reuptake inhibitors (SSRIs) due to their mild anticholinergic effect and possibility of mydriasis. Escitalopram, one of the most prescribed SSRIs, has been implicated in the risk of AACG in case reports. However, prior to this CJO study by Khan et al., it remained unclear whether AACG secondary to escitalopram is a class effect or carries a higher risk than other SSRIs. The highlighted study investigated whether escitalopram poses a greater risk of AACG compared to other SSRIs or non-SSRI antidepressants. A total of 865,546 subjects were included to assess the incidence of AACG among new users of citalopram, escitalopram, sertraline, and venlafaxine. Results indicated trends toward a lower AACG risk in users of citalopram, escitalopram, and venlafaxine compared with sertraline, though none of these differences reached statistical significance. Findings suggest that escitalopram may be associated with a reduced risk of AACG, but further research with larger cohorts is needed. Clinicians should remain cautious when prescribing antidepressants, particularly for patients at risk of glaucoma.

To access the full article, please follow the link below:

Download Full Article PDF

Reference:

1. Khan HM, Schendel S, Mikelberg FS, Etminan M. Acute angle-closure glaucoma risk: a comparative study of escitalopram and antidepressants. Can J Ophthalmol. 2025 Jan 24:S0008-4182(25)00004-3. doi: 10.1016/j.jcjo.2025.01.004. Epub ahead of print. PMID: 39870359.

Submitted by: Audrey-Anne Lapierre
Reviewed and Approved by: Anne Xuan-Lan Nguyen, MD

The October 2024 CJO is now available online. Here are some of the highlights: 

Resident Perspectives + visual abstract: Our talented team of residents have summarized 3 articles from this issue with a focus on what’s most relevant to ophthalmology learners here in Canada and around the globe. In addition, our October visual abstract provides a visual summary of an article on the Long-term effect of fluid volumes during the maintenance phase in neovascular age-related macular degeneration: results from Fight Retinal Blindness!

Reviews and Original Research Articles:

• Advancements in the diagnosis, prognosis, and treatment of retinoblastoma

• Evaluating smartphone fundoscopy as a pedagogical tool in medical education: a narrative review

• Routine history and physical examinations prior to cataract surgery are not beneficial

• Outcomes and risk factors for Kahook Dual Blade excisional goniotomy with concomitant phacoemulsification: a multicentre Canadian study

• Breaking bad news in ophthalmology: a pilot skills workshop for residents

• Ophthalmic diseases in meningitis within the pediatric population

Research Letters, Photo Essays, Case Reports, and more:

• Patient knowledge of pentosan polysulfate maculopathy in Alberta: a population wide survey-based study 

• Massive ciliochoroidal melanoma masquerading as conjunctival melanoma  

• Ocular Jarisch-Herxheimer reaction causing a transient sub-foveal lesion in ocular syphilis  

• Advanced intraocular retinoblastoma: evolving criteria for group E disease

• Exudative retinal detachment following laser photocoagulation for retinopathy of prematurity

• Diagnosis of a uveal melanoma arising from the choroid beneath a congenital hypertrophy of the retinal pigment epithelium: the value of microvascular flow imaging

• F. Y. Eye Column — October 2024

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The August 2024 CJO is now available online. Here are some of the highlights: 

Resident Perspectives + visual abstract: Our talented team of residents have summarized 3 articles from this issue with a focus on what’s most relevant to ophthalmology learners here in Canada and around the globe. In addition, our August visual abstract provides a visual summary of an article on the Epidemiology of ocular emergencies in a large Canadian eye centre.

Reviews and Original Research Articles:

• Advances in conjunctival melanoma: clinical features, diagnostic modalities, staging, genetic markers, and management
• Advances in multimodal imaging for diagnosis of pigmented ocular fundus lesions
• Research productivity of first-year Canadian ophthalmology residents: a 12-year trend
• Visualization of preretinal membranes using trypan blue in patients with traction retinal detachments
• Artificial intelligence chatbot performance in triage of ophthalmic conditions
• Retinal and choroidal microvascular changes during pregnancy detected with OCTA

Research Letters, Photo Essays and Case Reports:

• Performance of three artificial intelligence chatbots on Ophthalmic Knowledge Assessment Program materials
• Scleral patch graft for emergency open-sky repair
• Cavitary ciliary body melanoma with extensive pigment dispersion
• Acute macular neuroretinopathy following uncomplicated epiretinal membrane removal
• Bilateral circumscribed choroidal hemangiomas in 2 patients: a rare finding
• 532-nm laser for sub-internal limiting membrane hemorrhage associated with retinal macroaneurysms
• Syndromic PRD: case report of McArdle retinopathy and review of literature

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The second issue of the Video Journal of Cataract, Refractive, & Glaucoma Surgery is live!  The program is entitled: The Essential Partnership with Industry. 

Dick Lindstrom and David Chang give a great introduction detailing the synergy between ophthalmologists and industry that results in innovative products which address unmet needs.  For the first time in our 40 year history, we are publishing videos submitted from industry showcasing new products and company philosophies. To view more, please visit: http://www.vjcrgs.com/ and view the table of contents below!

The June 2024 CJO is now available online. Here are some of the highlights: 

Resident Perspectives + visual abstract: Our talented team of residents have summarized 4 articles with a focus on what’s most relevant to ophthalmology learners here in Canada and around the globe. In addition, our April visual abstract provides a visual summary of an article on Comparison of pain perception in patients undergoing manual cataract surgery versus refractive laser-assisted cataract surgery

Original research articles:

• Retinal vein occlusion in patients with primary angle closure: a prospective case-control study
• Effectiveness of the Eyesi Surgical Simulator for ophthalmology trainees: systematic review and meta-analysis
• Incidence of ophthalmologic pathology and associated risk factors in orbital fractures at a level 1 trauma centre
• Herpes zoster ophthalmicus: frequency and risk factors for developing uncommon ocular manifestations
• Burnishing of exposed porous polyethylene orbital implant: is it useful?
• Diabetic retinopathy screening integrated in multidisciplinary diabetes eye care clinic: a pilot project

Photo essays and case reports:

• Scleromalacia after extrusion of a senile calcific plaque [photo essay]
• Bacillary layer detachment due to retinal arterial macroaneurysm [photo essay]
• Early ophthalmic findings in Hermansky-Pudlak syndrome type 9 [photo essay]
• Corneal ulcer as the presenting sign of prolonged contact lens retention over 25 years [case report]
• Monocular Charles Bonnet syndrome secondary optic neuritis and the utilization of artificial intelligence to illustrate visual hallucinations [case report]
• Rhegmatogenous retinal detachment associated with an epibulbar tumour [case report]
• Beyond the norm: unusual orbital manifestation of hairy cell leukemia [case report]

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The April 2024 CJO is now available online. Here are some of the highlights: 

Resident Perspectives + visual abstract: Our talented team of residents have summarized 4 articles with a focus on what’s most relevant to ophthalmology learners here in Canada and around the globe. In addition, our April visual abstract provides a visual summary of an article on OCT outcomes as biomarkers for disease status, visual function, and prognosis in diabetic macular edema.

Original research articles:

·        Development and validation of the first Canadian Aboriginal syllabics visual acuity chart

·        Zonular dialysis and cataract surgery: results from a UK tertiary eye care referral centre

·        Development of a standardized Canadian undergraduate medical education ophthalmology curriculum

·        Incidence of ocular surface squamous neoplasia in pterygium specimens

·        Effect of race and ethnicity on surgical outcomes for rhegmatogenous retinal detachments

• Characterization of pentosan polysulfate patients for development of an alert and screening system for ophthalmic monitoring

Photo essays, correspondence, and case reports:

·        Bilateral conjunctival melanosis in diffuse melanosis cutis and metastatic melanoma

·        Unilateral acute idiopathic maculopathy in hand, foot, and mouth disease

·        Laser pointer-induced maculopathy with secondary macular neovascularization

·        A virtual Canadian Ophthalmology Mentorship Program (COMP) for medical students

·        Surgical technique enhancements for successful subretinal gene therapy delivery

·        Ocular syphilis with coincident Bartonella infection

·         Unveiling ocular surface squamous neoplasia within a conjunctival epithelial inclusion cyst

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