Effect of Head and Body Position on Intraocular Pressure

Mehrdad Malihi, MD, Arthur J. Sit, SM, MD

Objective: To investigate the effect of different head and body positions on intraocular pressure (IOP) in a randomized study. Design: Prospective, comparative case series. Participants: Twenty-four healthy volunteers. Methods: Subjects had 2 sets of IOP measurements performed, sitting and recumbent, with the order of these sets of measurements randomized. In the sitting position, IOP was measured in neutral neck position, neck extension, and neck exion, with the order of measurements randomized. In the recumbent positions, IOP was measured in the supine position, and right and left lateral decubitus positions, with the order of measurements also randomized. All IOP measurements were performed with pneumatonometry. Results: Mean IOP of right and left eyes while sitting with the neck in neutral position was 14.82.0 mmHg, which was signicantly lower than IOP measured with neck exion or extension or in the recumbent positions. As well, IOP in neck exion was signicantly higher than IOP in neck extension (all P0.0001). The IOP was higher in the dependent eye when measured in the right lateral decubitus position (18.82.9 vs 17.73.1 mmHg; P 0.016), but did not attain signicance in the left lateral decubitus position (P 0.076). Conclusions: In normal subjects, IOP is lowest when measured while sitting with the neck in the neutral position. All other head and body positions result in an elevation of IOP compared with the position used for typical clinical measurements. Lateral decubitus positions may result in a small increase in the IOP in the lower eye. Further research is required to determine whether similar elevations of IOP occur in glaucoma patients, and elucidate the clinical signicance of these elevations. Financial Disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article Ophthalmology 2012;119:987991 2012 by the American Academy of Ophthalmology.

Glaucoma is a major cause of visual dysfunction characterized by progressive structural and functional damage to the optic nerves. Intraocular pressure (IOP) remains the most important and the only modiable known risk factor for glaucoma. However, IOP is a dynamic process that varies with many different factors and its uctuations may be important in glaucoma development and progression.13 Changes in body position can have signicant effects on IOP, with elevations occurring in the supine and head-down positions.413 The possible impact of these elevations on glaucoma pathogenesis indicates a need to clearly understand the effects of body position on IOP. However, previous studies evaluating IOP and body position have typically utilized a xed measurement sequence. This presents difculties in interpretation because IOP measurements are affected by the measurement sequence,14 and repeated measurements of IOP can result in a decrease in the readings.1517 As a result, the magnitude of the changes owing to body position have been uncertain, with different studies reporting differences between sitting and supine IOP ranging from 0.3 to 5.6 mmHg for normal and glaucoma subjects.412,18,19 No previous studies have investigated the effects of body position in a randomized fashion to eliminate the effects of measurement sequence. In addition, the effect of head position on IOP in human subjects is poorly understood.2022
2012 by the American Academy of Ophthalmology Published by Elsevier Inc.

This information may be important for understanding glaucoma pathogenesis, as well as providing clinical recommendations for glaucoma patients. If signicant elevations in IOP occur in certain positions, then it may be prudent for glaucoma patients to avoid those positions. Thus, our study investigates the effect of head and body positions, including lateral decubitus positions, on IOP in a randomized sequence.

Methods
Our study was conducted in accordance to the principles of clinical research set out by Declaration of Helsinki (1989) and was approved by Institutional Review Board of Mayo Clinic. Healthy volunteers, male and female, with refractive error between 4.00 and 2.00 diopters, were recruited from students and employees of Mayo Clinic, and local area residents. Subjects were given a complete dilated eye examination. Exclusion criteria for participants included systemic use of blockers or steroids, diabetes, sitting IOP 22 mmHg, and any evidence of ocular pathology including history of trauma or surgery, glaucoma, narrow angles, strabismus, infection, corneal scarring, uveitis, or retinal tear or detachment. Subjects who could not tolerate neck exion or extension for 5 minutes duration were also excluded, because maintaining these positions was required during the study. Participants were asked to avoid excess caffeine intake or large deviations from their normal sleep cycle on the day of the examination.
ISSN 0161-6420/12/$see front matter doi:10.1016/j.ophtha.2011.11.024

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Table 1. Intraocular Pressure in Different Body and Head Positions
Intraocular Pressure (mmHg) Position Sitting Neck neutral Neck extension Neck exion Recumbent Supine Right lateral decubitus Left lateral decubitus Right 15.02.1 16.52.6 20.24.1 17.33.1 18.82.9 17.62.6 Left 14.62.0 16.32.8 19.43.7 17.32.9 17.73.1 18.32.8 Bilateral 14.82.0 16.42.7 19.83.8 17.32.9 18.33.0 17.92.7

All values are given as mean standard deviation.

Subjects were randomized to having either sitting or recumbent IOP measurements performed rst, with measurements in the alternate position performed second. For the sitting position, IOP was measured in 3 different head positions: neutral neck position, neck extension, and neck exion. The sequence of these measurements was randomized. For the recumbent position, IOP was measured in the supine position, and right and left lateral decubitus positions. The sequence of these 3 measurements was also randomized. The measurements in the sitting position were performed using a standard ophthalmic examination chair. To ensure a uniform amount of neck extension, and to facilitate the maintenance of this position for 5 minutes, the examination chair was reclined 20 from vertical, and the subjects neck was extended until the cornea was parallel with the oor.23 Subjects were asked to lean forward a similar amount during neck exion to bring the corneal surface to a horizontal position, with subjects extending their arms to the seat of the examination chair to stabilize their position. In the lateral decubitus position, a rm foam pillow was placed to support a subjects head to maintain the neck in a neutral position. Meticulous attention was given to avoid any external pressure on the globes. Specically, patients were asked to put their head near the end of the pillow so that it touched only the temporal bone and did not extend anterior to the lateral orbital rim, avoiding any compression of the lids or globe. A minimum of 5 minutes was allowed in each position before measurement for IOP to reach steady state. After topical anesthesia with proparacaine 0.5% in both eyes, IOP was measured in each position using a pneumatometer (Model 30 Classic; Reichert, Inc., Depew, NY). Three measurements were performed and averaged for each eye in each position. Measurements that were 3 mmHg different than the mean IOP were rechecked and a new mean was calculated. Using previous published data19 and assuming sitting IOP to be 13.82.3 mmHg, the necessary sample size to detect at least 15% increase when brought to a recumbent position was calculated to be 24 ( 0.05 and 0.2). The IOP measurements for right and left eyes in each position were compared using paired t-tests. The IOP of both eyes were then averaged and paired t-tests were used to compare the measurements in different positions. Statistical signicance was assumed for P0.05.

subjects were Caucasian (reecting the ethnic makeup of the Olmsted County, Minnesota, area) and low myopes, with a mean refractive error of 2.60.77 diopters (mean standard deviation, spherical equivalent). Table 1 summarizes the IOP measurements in different positions and Table 2 provides a summary of the statistical comparisons between the different positions. The IOPs measured in the sitting positions were lowest when measured with the neck in neutral position (14.82.0 mmHg). The IOP was signicantly higher when measured with neck exion (19.83.8 mmHg; P0.0001) or extension (16.42.7 mmHg; P0.0001). In addition, IOP in neck exion was signicantly higher than IOP in neck extension (P0.0001). The IOP measured in each of the recumbent positions was higher than IOP measured while sitting with the neck in neutral position (P0.0001). Compared with the sitting position, IOP in the supine position increased to 17.32.9 mmHg, whereas mean IOP in the right lateral decubitus position increased to 18.33.0 mmHg, and mean IOP in the left lateral decubitus position increased to 17.92.7 mmHg (Table 1). The mean IOP in the right lateral decubitus position was signicantly higher than the supine position (P 0.006). In the left lateral decubitus position, the IOP was not different than the IOP in the supine position (P 0.058). There was no difference in IOP between the right and left eyes in any of the sitting positions, or in the supine position (P0.1 for all comparisons). However, the IOP was higher in the dependent eye when measured in the lateral decubitus positions. In the right lateral decubitus position, the IOP in the dependent (right) eye was 18.82.9 mmHg compared with 17.73.1 mmHg for the nondependent (left) eye (P 0.016). In the left lateral decubitus position, the difference in IOP between the dependent (left) eye (18.32.8 mmHg) and the nondependent (right) eye (17.62.6 mmHg) did not attain signicance (P 0.076; mean detectable difference 1.09 mmHg).

Discussion
Previous studies have reported that IOP is typically higher in the supine position compared with the sitting position.
Table 2. Statistical Comparison of Intraocular Pressure in Different Body and Head Positions
P Values Position Sitting Neck neutral Neck extension Neck exion Recumbent Supine Right lateral decubitus Left lateral decubitus Right Versus Left 0.24 0.45 0.15 1.00 0.016 0.076 Sitting Neutral Supine

0.0001 0.0001 0.0001 0.0001 0.0001

0.010 0.0001 0.006 0.058

Results
Twenty-four subjects, age 19 to 47 years, were recruited including 7 men and 17 women with a mean age of 28.68.5 years. All

Paired t-tests were used to compare intraocular pressure (IOP) in different body and head positions. There were no differences between right and left eyes except in the right lateral decubitus position, where IOP was higher in the dependent (right) eye. In the left lateral decubitus position, the difference between eyes did not attain signicance. The IOP while sitting with the neck in neutral position was signicantly lower than all other positions. The IOP in the supine position was lower than the right lateral decubitus and neck exion positions, but higher than the neck extension position.

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Most studies indicate that the amount of increase in IOP from sitting to supine position is greater in open-angle glaucoma, ocular hypertension, or normal tension glaucoma compared with normal subjects.68,11,18 The amount of increase with body position reported in literature has varied signicantly from 0.3 to 5.6 mmHg or more in studies on normal healthy subjects and glaucoma patients.412,18,19 However, most of these studies have performed measurements in a xed sequence, with either the sitting or supine measurements performed rst. This presents a confounding factor, because the measurement sequence utilized may have affected the magnitude of the IOP change that occurs with body position. Previous studies have reported that repeated measurements of IOP can result in a decrease in the readings.1517 Gaton et al17 reported that patients with glaucoma show a decrease in IOP on repeated applanation tonometry measurements. Similarly, AlMubrad et al15,16 reported that that repeated corneal applanation leads to a signicant reduction in IOP in normal eyes. Pekmezci et al14 analyzed data from the Ocular Hypertension Treatment Study and found that IOP measured in the rst eye was higher than in the fellow eye, regardless of whether the right or left eye was measured rst. By randomizing the measurement sequence, we controlled for the possible effects of repeated IOP measurements and measurement sequence. As far as we are aware, and based on a thorough literature search, our study is the rst to assess the effect of head and body position on IOP using a randomized sequence of measurements. Other factors that may affect the degree of IOP change with body position are incompletely understood. However, certain characteristics have been associated with the magnitude of change in previous studies. As indicated, most studies indicate that the amount of increase in IOP from sitting to supine position is greater in open-angle glaucoma, ocular hypertension, or normal tension glaucoma compared with normal subjects.68,11,18 Axial length also seems to be associated with the magnitude of postural IOP change. Loewen et al24 reported that subjects with shorter axial length had a larger increase in IOP with supine position, whereas Liu et al25 showed that moderate to severely myopic (greater than 4 diopters) eyes with larger axial lengths had a smaller increase in IOP from sitting to supine when compared with the control group with less than 2 D of myopia. In our study, we examined normal subjects with a mean refractive error of 2.60.77 D, and we observed a 2.5-mmHg increase from sitting to supine, approximately the middle of the range reported by other investigators. The mechanisms for IOP change with body position are incompletely understood. Previous studies have reported an increase in the episcleral venous pressure (EVP) in a recumbent position,2628 but the change has typically not been precisely equivalent to the change in IOP, as expected by the Goldmann equation. It is not clear if this is simply a reection of the imprecision in EVP measurements,29 or if other factors may be contributing to the IOP change. Choroidal vascular engorgement caused by redistribution of body uids in the recumbent position may be another possible mechanism.30 In smaller hyperopic eyes, this engorgement would result in a greater IOP change than in larger myopic eyes, consistent with the results of Loewen et al.24 and Liu et al.25 This effect would be expected to decay over time, because it would be the result of a volume increase, and the degree of change would be related to ocular rigidity according to the Friedenwald equations.31 Information about the time dependence of IOP elevation in the supine position may help to differentiate the changes that occur due to choroidal engorgement, which would presumably be transient, from the longer term changes owing to EVP elevation. However, an evaluation of the time dependence of the change in IOP with body position was beyond the scope of this study, although it warrants future investigation. As far as we are aware, no previous study has reported the effect of neck exion on IOP; Klein et al21 recently reported an increase in IOP during neck hyperextension. We observed a signicant increase in IOP during neck extension, and even a greater increase during neck exion. The IOP elevation owing to a change from the neutral neck position is likely a result of venous compression and an increase in EVP. The greater increase in IOP during exion may be related to hydrostatic pressure effects and increases in EVP caused by the eyes being in a dependent position. Previous studies have reported a similar effect with subjects in the prone position having signicantly higher IOP than in the supine position.3235 However, the magnitude of the IOP difference from the neutral neck position to the extension or exion positions is greater than would be expected from a hydrostatic effect alone. Neck exion may also produce greater venous compression compared with neck extension. Regardless of the cause, the elevation in IOP may be a reason for caution for glaucoma patients. Common activities, such as yoga, involve extended periods of neck extension, whereas sleeping with multiple pillows may result in neck exion. To our knowledge, only 1 previous study has reported IOP changes in the lateral decubitus positions. Hwang et al20 investigated the alteration in IOP after a positional change from supine to a lateral decubitus position in anesthetized patients undergoing lung surgery. They found a 2-mmHg increase of IOP in the dependent eye 5 minutes after being in the lateral decubitus position compared with supine position. This change later increased to around 4 mmHg 30 minutes later and remained relatively stable through approximately 150 minutes of surgery. The IOP in the dependent eye was weakly correlated with central venous pressure, peak inspiratory pressure, and mean arterial blood pressure, although only peak inspiratory pressure increased as time passed during surgery. However, general anesthesia and surgery are not normal conditions, and the effects of anesthetic drugs, intravenous uids and uid loss, intubation, and surgical manipulations necessitate cautious interpretation of those results. In our study, we detected a smaller increase in the dependent eye in both decubitus positions (about 1 mmHg) after 5 minutes, although the difference in the left lateral decubitus position did not attain signicance. The observed increase in the dependent eye may be due to the hydrostatic effects and increase in EVP. Differences in the magnitude of IOP elevation in the dependent eye in the right compared with left lateral decubitus

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positions may be caused by rightleft differences in the cardiovascular system. Because the heart is left-sided, the right atrium would be in a lower position in right lateral decubitus position compared with the supine or left lateral decubitus positions. It has been postulated that this lower position would result in easier venous return to the heart, causing attenuation of sympathetic modulation, lower norepinephrine levels, and higher serum levels of atrial natriuretic peptide.3638 These changes may affect EVP and IOP and cause different responses during right and left lateral decubitus positions. Whether or not the increase in IOP in the dependent eye is clinically signicant remains to be demonstrated. An important limitation of this study is that only young, healthy subjects were included, and the results cannot necessarily be extrapolated to older healthy subjects or glaucoma patients. Numerous factors that potentially contribute to positional changes in IOP are potentially affected by aging, including scleral rigidity, anterior chamber depth, angle anatomy, rigidity of blood vessels in the neck, and cardiovascular hemodynamics. In addition, the effect of circadian rhythms on IOP changes with body position are unknown, and may be affected by the variations that occur with aqueous humor dynamics.19 Further research is required to investigate the positional changes in IOP in older subjects and glaucoma patients, and their role in the development and progression of glaucomatous optic neuropathy. In summary, IOP in the sitting position with the neck in neutral position is signicantly lower than other head or body positions in young healthy subjects. As well, lateral decubitus position may result in a small increase in the IOP in the lower eye. These alterations in IOP with head and body position suggest potential areas of caution that need to be further investigated in glaucoma patients. In particular, IOP elevation in the dependent eye while in lateral decubitus positions needs to be investigated as a potential contributor toward the development of asymmetric or unilateral glaucoma. Also, IOP elevation during neck exion and extension needs to be investigated as a potential risk factor for glaucoma, particularly during sleep when these positions may be maintained for long periods of time. Further work is also necessary to elucidate the effect of head and body position on other potentially important parameters in glaucoma, such as ocular perfusion pressure and retrolaminar cerebrospinal uid pressure.
garding body position in glaucoma patients. Surv Ophthalmol 2010;55:44553. Chiquet C, Custaud MA, Le Traon AP, et al. Changes in intraocular pressure during prolonged (7-day) head-down tilt bedrest. J Glaucoma 2003;12:204 8. Hirooka K, Takenaka H, Baba T, et al. Effect of trabeculectomy on intraocular pressure uctuation with postural change in eyes with open-angle glaucoma. J Glaucoma 2009;18:689 91. Kiuchi T, Motoyama Y, Oshika T. Postural response of intraocular pressure and visual eld damage in patients with untreated normal-tension glaucoma. J Glaucoma 2010;19:1913. Liu JH, Zhang X, Kripke DF, Weinreb RN. Twenty-four-hour intraocular pressure pattern associated with early glaucomatous changes. Invest Ophthalmol Vis Sci 2003;44:1586 90. Longo A, Geiser MH, Riva CE. Posture changes and subfoveal choroidal blood ow. Invest Ophthalmol Vis Sci 2004; 45:546 51. Parsley J, Powell RG, Keightley SJ, Elkington AR. Postural response of intraocular pressure in chronic open-angle glaucoma following trabeculectomy. Br J Ophthalmol 1987;71:494 6. Carlson KH, McLaren JW, Topper JE, Brubaker RF. Effect of body position on intraocular pressure and aqueous ow. Invest Ophthalmol Vis Sci 1987;28:1346 52. Weinreb RN, Cook J, Friberg TR. Effect of inverted body position on intraocular pressure. Am J Ophthalmol 1984;98: 784 7. Buys YM, Alasbali T, Jin YP, et al. Effect of sleeping in a head-up position on intraocular pressure in patients with glaucoma. Ophthalmology 2010;117:1348 51. Pekmezci M, Chang ST, Wilson BS, et al. Effect of measurement order between right and left eyes on intraocular pressure measurement. Arch Ophthalmol 2011;129:276 81. Almubrad TM, Ogbuehi KC. On repeated corneal applanation with the Goldmann and two non-contact tonometers. Clin Exp Optom 2010;93:77 82. AlMubrad TM, Ogbuehi KC. The effect of repeated applanation on subsequent IOP measurements. Clin Exp Optom 2008; 91:524 9. Gaton DD, Ehrenberg M, Lusky M, et al. Effect of repeated applanation tonometry on the accuracy of intraocular pressure measurements. Curr Eye Res 2010;35:4759. Jain MR, Marmion VJ. Rapid pneumatic and Mackey-Marg applanation tonometry to evaluate the postural effect on intraocular pressure. Br J Ophthalmol 1976;60:68793. Sit AJ, Nau CB, McLaren JW, et al. Circadian variation of aqueous dynamics in young healthy adults. Invest Ophthalmol Vis Sci 2008;49:14739. Hwang JW, Jeon YT, Kim JH, et al. The effect of the lateral decubitus position on the intraocular pressure in anesthetized patients undergoing lung surgery. Acta Anaesthesiol Scand 2006;50:988 92. Klein A, Shemesh G, Loewenstein A, Kurtz S. Intraocular pressure measurements in relation to head position and through soft contact lenses: comparison of three portable instruments. Ophthalmic Surg Lasers Imaging 2011;42:64 71. Komaromy AM, Garg CD, Ying GS, Liu C. Effect of head position on intraocular pressure in horses. Am J Vet Res 2006;67:12325. Selvadurai D, Hodge D, Sit AJ. Aqueous humor outow facility by tomography does not change with body position. Invest Ophthalmol Vis Sci 2010;51:14537. Loewen NA, Liu JH, Weinreb RN. Increased 24-hour variation of human intraocular pressure with short axial length. Invest Ophthalmol Vis Sci 2010;51:9337. Liu JH, Kripke DF, Twa MD, et al. Twenty-four-hour pattern of intraocular pressure in young adults with mod-

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Footnotes and Financial Disclosures

Originally received: July 8, 2011. Final revision: November 14, 2011. Accepted: November 17, 2011. Available online: February 17, 2012. Supported by the Mayo Foundation for Medical Education and Research, and an unrestricted departmental grant from Research to Prevent Blindness. Dr Sit is supported by the Research to Prevent Blindness Helen and Robert Schaub Special Scholar Award. The sponsors or funding organizations had no role in the design or conduct of this research.

Manuscript no. 2011-1008.

From the Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota. Presented at: the Annual Meeting of the American Glaucoma Society, Dana Point, California, March 2011. Financial Disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Correspondence: Arthur J. Sit, SM, MD, Department of Ophthalmology, Mayo Clinic, 200 First St. SW, Rochester, MN 55905. E-mail: sit.arthur@mayo. edu.

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