HYPOTHESIS AND INNOVATION
Effects of Exercise on Intraocular Pressure
and Ocular Blood Flow
A Review
David Risner, BA, Rita Ehrlich, MD, Nisha S. Kheradiya, BS, Brent Siesky, PhD,
Lynne McCranor, BS (Equiv), and Alon Harris, PhD
Abstract: Glaucoma is a disease characterized by progressive optic
neuropathy resulting in retinal ganglion cell death, which affects
approximately 68 million people worldwide. Risk factors include
intraocular pressure (IOP), genetics, race, age, and vascular factors.
Exercise is known to affect IOP and systemic cardiovascular factors
and, therefore, may affect glaucoma pathophysiology. This review
discusses the results of articles relevant to glaucoma, IOP, ocular
blood flow (OBF), and exercise. Isometric and dynamic exercises
have been studied with respect to effects on IOP and OBF.
Isometric exercise results in an acute decrease in IOP, which
correlates with hypocapnia. Dynamic exercise results in a more
pronounced but also short duration decrease in IOP. Physical
fitness is associated with lower baseline IOP but diminished acute
IOP-lowering response to exercise. Upon cessation of exercise,
values return to pretrained levels within 1 month. In glaucoma
patients, these IOP-lowering effects are greater than in healthy
subjects. In healthy subjects, OBF is unchanged during exercise due
to vascular autoregulation. This autoregulation fails at ocular
perfusion pressures greater than 70% above baseline. In conclusion
exercise in glaucoma patients results in acutely lowered IOP and
lower baseline IOP. The effects of exercise on the prevention of
glaucoma and glaucomatous progression remain unknown. The
role of exercise in glaucoma management should be investigated.
Key Words: exercise, IOP, ocular blood flow, glaucoma
(J Glaucoma 2009;18:429–436)
G laucoma is a disease characterized by progressive optic
neuropathy resulting in retinal ganglion cell death.
Approximately 68 million people worldwide are affected by
glaucoma making it a leading cause of blindness globally.1
Risk factors include intraocular pressure (IOP), genetics,
race, age, and vascular factors.2 The only currently
treatable risk factor for glaucoma remains IOP. Hypoten-
sive therapies have been shown to decrease disease
progression in terms of visual field loss and visual acuity
changes.3–10 However, the Early Manifest Glaucoma Trial
demonstrated that as many as 45% of patients continue to
show disease progression despite IOP lowering.10 In many
Received for publication February 27, 2008; accepted September 27,
2008.
From the Department of Ophthalmology, Indiana University School of
Medicine, Indianapolis, IN.
Sources of funding: an unrestricted grant from Research to Prevent
Blindness Inc.
Reprints: Alon Harris, PhD, MS, Lois Letzter Professor of
Ophthalmology, Professor of Cellular and Integrative Physiology,
Department of Ophthalmology, 702 Rotary Circle, Room 137,
Indianapolis, IN 46202 (e-mail: alharris@indiana.edu).
Copyright r 2009 by Lippincott Williams & Wilkins
DOI:10.1097/IJG.0b013e31818fa5f3
J Glaucoma  Volume 18, Number 6, August 2009
patients, etiologies beyond IOP and treatments beyond
pharmacologic and surgical IOP modulation must be
considered. Vascular factors have become an important
area of research in glaucoma management and other
methods for IOP lowering have also been explored both
recently and in past literature.
Exercise has long been known to decrease risk of
many diseases. Exercise reduces risk for type 2 diabetes,
hypertension, and various cardiovascular pathologies.11–15
As early as Cooper et al16 in 1965, the link between exercise
and glaucoma has been studied; specifically, that exercise
transiently decreases IOP. The precise mechanism by which
exercise lowers IOP has yet to be clearly defined. With the
advent of imaging technologies used to assess ocular blood
flow (OBF), numerous studies have explored the effects of
exercise on the vascular component of glaucoma. As IOP
and ocular perfusion are known risk factors for glaucoma,
it is important to understand the effects of exercise on these
ocular parameters.
This review article explores the relevant published
literature regarding exercise, IOP, OBF, and glaucoma.
DYNAMIC EXERCISE AND IOP
Dynamic exercise can be defined as work performed by
a muscle while changing the length of that muscle. In
practice, this can be achieved by walking, running, or
cycling for a period of time. In the studies reviewed, IOP
was typically measured in the minutes immediately after
cessation of exercise; however, this interval is not always
clearly defined. Dynamic exercise’s ability to decrease IOP
was established in a 1963 paper by Janiszewska.17
Subsequent publications have confirmed these findings18,19
(Table 1). Specifically, Qureshi20 showed that IOP is
lowered by 5.07 ± 1.76 mm Hg after jogging. All
of these studies agreed that IOP is lower in the imme-
diate postexercise period compared with values taken
before exercise. The underlying mechanism of IOP reduction
during dynamic exercise has not been fully defined.
It is reasonable to consider the possibility that systemic
changes associated with exercise play a role in IOP
modulation and regulation. A study of systemic blood
pressure changes created by dynamic exercise and the
observation of a postexercise decrease in IOP confirmed that
both phenomena are present and significant, but they are
unrelated to each other.21 Furthermore, Krejci et al22
concluded that there is no correlation between heart rate
and lowering of IOP during dynamic exercise. Another study
showed no link between the decrease in IOP seen with
exercise and coincident elevation of blood pressure or the
subject’s body mass index.23
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Risner et al J Glaucoma  Volume 18, Number 6, August 2009

TABLE 1. Summary of Publications Documenting Change in Intraocular Pressure With Dynamic Exercise
Exercise IOP Reported Change in
Study Subjects Protocol Effect IOP (mm Hg) Other findings
Leighton and 14 healthy 50 min brisk walk k OD 2.28, OS 2.07 —
Phillips18
Myers19 16 bikers, 10 min bicycle k Biking 1.5, running 2.27 —
63 runners ergometry,
marathon
Qureshi20 15 healthy Sitting, walking, and k Sitting 1.20 ± 0.66, —
sedentarians jogging walking 3.20 ± 1.19,
jogging 5.07 ± 1.76
Karabatakis 29 healthy Jog 20 min k 1 to 8 No correlation to BP or HR
et al21
Krejci et al22 17 healthy Bicycle ergometry to k OD 4.7, OS 5.1 Decrease was observed during
85% maximum HR exercise
Qureshi et al23 25 healthy 40%, 60%, and 80% k 40% of maximum HR 2.9 ± 1.1, IOP decrease is closely related
sedentarians maximum HR 60% of maximum HR to intensity of exercise
3.3 ± 0.9,
80% of maximum HR 4.5 ± 0.7
Marcus et al24 12 healthy 4 min treadmill k 5.9 —
Kielar et al25 7 athletes Bicycle ergometry k 60% maximum exertion 3.8, —
80% maximum exertion 3.9
Ashkenazi 22 healthy 110 kg march k 4.1 Correlated to osmolarity
et al26
Martin et al27 15 healthy Bicycle ergometry to k Hydrated 3.8, dehydrated 3.9
Related to colloid osmotic
exhaustion pressure
Vieira et al28 30 healthy 4th of 4 bench press m Exhaling +2.2 ± 3.0, Increase in IOP observed,
repetition breath held +4.3 ± 4.2 thought to be related to
Valsalva
Dane et al29 25 fit, Submaximal exercise, m and k Athlete OD +0.33 ± 1.99, Fit initially increased, then
24 sedentary not specified OS +0.29 ± 1.88; decreased at 30 min.
Sedentary OD 1.72 ± 2.78, Sedentary decreased
OS 1.92 ± 2.81 throughout
Dane et al30 25 fit, Submaximal exercise, m and k Athlete OD 12.56%, Male athletes increased,
24 sedentary not specified OS 6.52%; female sedentary decreased,
sedentary OD 25.87%, no effect in sedentary males
OS 28.8% or athletic females
Harris et al31 17 fit, 7 min bicycle k 30 W 2.7 ± 0.4, 90 W 4.7 ± 0.4 IOP decrease directly related to
11 sedentary ergometry at 30 W, intensity
90 W
Kiuchi et al32 Unknown 15 min running to k 40% maximum HR 4.3 ± 0.7, IOP decrease directly related to
healthy 40%, 55%, and 55% maximum HR 2.2 ± 0.7, intensity
70% maximum HR 70% maximum HR 0.6 ± 0.5
McDaniel 13 health Bicycle ergometry, k 3.4 Returned in 20-30 min
et al33 3-5 min, HR 130-
150
Qureshi34 7 healthy, Walking, jogging, k Walking 2.43 ± 0.30, Glaucoma patients experienced
7 glaucoma and running jogging 3.85 ± 0.55, greater drop, and longer
running 4.0 ± 0.37 duration
Ozmerdivenli 20 fit, Treadmill 30 min to k Aerobic 4.08, IOP decrease is diminished in
et al35 20 sedentary 60%-70% anaerobic 2.55 fit, aerobic better than
maximum HR, anaerobic
bicycle max speed
30 s
Price et al36 18 healthy Bicycle ergometry k 5.5 Baseline IOP returned in 30 min
4 min
Chromiak 30 healthy 3 sets of 10 at 70%, k Chest 8% to 14.5%, —
et al37 chest or leg press legs 6.9% to 13.2%
Sargent et al38 32 with IOP> 6 mo training k OD 2.0, OS 1.3 No change in average baseline
18 mm Hg IOP with fitness.
Passo et al39 10 sedentary 4 mo training k Before training 5.9 ± 0.6, Return to baseline after 37 min,
after training 1.6 ± 0.4, less IOP decrease in trained
baseline with training 1.3
Passo et al40 9 glaucoma 3 mo training k Baseline 4.6 ± 0.4 —
suspects
BP indicates systemic blood pressure; HR, heart rate; IOP, intraocular pressure; OD, right eye, OS, left eye.

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J Glaucoma  Volume 18, Number 6, August 2009
In 1970, a series of animal and human studies were
performed measuring IOP immediately after dynamic
exercise on a treadmill showing a significant decrease in
IOP from 15.5 to 9.5 mm Hg in humans. The study showed
that increased plasma osmolarity, increased blood lactate,
and decreased blood pH were present in postexercise
subjects. A significant but less prominent fall in IOP was
elicited by infusing sodium lactate, and a correlation was
drawn between elevated blood lactate and a decrease in
IOP.41 The decrease in IOP was reproducible in rabbits by
infusions of hyperosmolar sodium lactate and isosmotic
hydrochloric acid in quantities mirroring those in the
postexercise period.24 A follow-up by Kielar et al25 studied
aerobic versus anaerobic exercise. Exercise is considered
aerobic when the intensity level allows for sufficient oxygen
transfer to facilitate oxidative metabolism of glucose at the
cellular level; with insufficient oxygen exchange, anaerobic
exercise has an abbreviated metabolism cycle and results in
lactate production. The study showed that an increased
blood lactate and decreased pH were seen only after
anaerobic exercise. As such, infusion of lactate and
hydrochloric acid in the previous study are only represen-
tative of anaerobic exercise, and not exercise in general.
Ashkenazi et al26 determined that only osmolarity corre-
lates to lower IOP and that blood pH and lactate have no
correlation to IOP lowering with dynamic exercise. Martin
et al27 showed that dehydration resulting in elevated colloid
osmotic pressure significantly reduced IOP compared with
hydrated subjects with normal colloid osmotic pressure.
Other indices of hydration such as hematocrit, plasma
protein concentration, and plasma osmolality did not
correspond to lower IOP. They suggested 3 mechanisms
for the reduction in IOP: osmotic dehydration of the globe,
reduced aqueous production due to reduced ultrafiltration,
and a hypothalamic reflex.42–44
The premise that dynamic exercise lowers IOP is
widely accepted in the literature; however, the mechanism is
poorly understood. Three leading theories of etiology in the
literature involve decreased blood pH, elevated plasma
osmolarity, and elevated blood lactate. Although all these
findings are present in anaerobic exercise, only increased
osmolarity is seen in aerobic exercise. There has been
support in the literature for all 3 factors; however, the
hyperosmolarity theory has the most support. Hypocapnia
has not been shown to correspond with lower IOP in
dynamic exercise.27 Further research must be conducted to
develop a more complete understanding of the etiology and
mechanism of IOP lowering in dynamic exercise before
specific recommendations can be made concerning therapy.
However, most studies agree that it may be reasonable not
to discourage, but rather encourage dynamic exercise in
glaucoma patients.
ISOMETRIC EXERCISE AND IOP
Isometric exercise can be defined as work performed
by a muscle while maintaining constant muscle length. In
practice, this can be achieved by assuming a squat position
or forcefully clinching ones fist for a period of time.
Isometric exercise has been shown, like dynamic exercise, to
lower IOP in the acute postexercise period by 2.7 mm Hg.45
Decreased IOP following isometric exercise was also
demonstrated by Marcus et al.46 It is well established that
isometric exercise leads to hyperventilation and hypocap-
nia, which correlates with the decrease in IOP.46–49
r 2009 Lippincott Williams & Wilkins
Effects of Exercise on IOP
Voluntary hyperventilation causes a similar lowering of
IOP.50–53 However, isometric exercise has no IOP lowering
effects if isocapnia is maintained.45 Confounding these
findings, one study concluded that although a 20% decrease
from baseline carbon dioxide for 5 minutes was sufficient to
lower IOP, equivalent hypocapnia produced pharmacolo-
gically does not produce significant decrease in IOP.54 This
suggests that there is some aspect of hyperventilation that
affects IOP, which is not accounted for by hypocapnia
alone.
Although the literature is generally in agreement that
there is a decrease in IOP immediately after isometric
exercise, a few publications suggest that IOP remains
unchanged or increases with certain exercises.28–30,55–57
These studies that show increase in IOP tend to focus on
weightlifting or exercise at maximal exertion. One study
compared weightlifting with and without subjects holding
their breath and found that IOP increases are more
prominent when the subject is holding their breath, +4.3 ±
4.2 mm Hg, than when breathing, +2.2 ± 3.0 mm Hg.28 An-
other study concluded that elevated intracranial pressure
reduces ocular venous outflow and at least contributes to
the elevation in IOP in weightlifting subjects who are
essentially performing a Valsalva maneuver, raising IOP an
average of 15 mm Hg with 1 subject reaching IOP of 46 mm
Hg.57 During maximal exertion the subjects are essentially
performing a Valsalva maneuver. Brody et al56 showed that
voluntary Valsalva increases IOP in the absence of other
factors. The IOP quickly returns to normal after cessation
of Valsalva, but these papers do not address the implica-
tions of these short-term increases in IOP. Another
important conclusion from the Brody paper is that physical
fitness results in a smaller increase in IOP in response to
acute stressors. This highlights an important issue regarding
exercise and glaucoma: the determination of whether or not
regular exercise can lower IOP in a reliable and possibly
therapeutic manner. This will be addressed later in the
review.
Although conflicting data remain, the consensus based
on these studies is that isometric exercise results
in a decrease in IOP. Studies correlate hypocapnia with
the observed decrease in IOP; however, at least 1 paper
suggests that there are factors present in isometric exercise,
which lower IOP but are not unique to the hypocapnic
state.54 Maximal isometric exercise resulting in Valsalva
causes increase in IOP,28 which is related to increased
intracranial pressure.57 There is no clearly defined mechan-
ism that links hypocapnia to a decrease in IOP. However, at
this time no deleterious effects have been demonstrated and
it is reasonable to encourage isometric exercise on this
basis.
IOP-LOWERING EFFECT OF ISOMETRIC
EXERCISE COMPARED WITH
DYNAMIC EXERCISE
There are a number of studies showing a decrease in
IOP after either isometric or dynamic exercise, but only 1
study has compared the two. That study showed that the
isokinetic (dynamic) exercise had more pronounced IOP-
lowering effects: the IOP drop seen after isometric exercise
was 4.94 ± 2.63 mm Hg compared with a decrease of
8.78 ± 3.43 mm Hg seen after dynamic exercise.58 An
important conclusion of this study was that the decrease
in IOP was directly related to exercise intensity.58 This
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Risner et al
conclusion is supported by a number of other publica-
tions.20,23,27,31–33,59 Specifically, Qureshi34 showed IOP
decreasing 2.43 ± 0.30 mm Hg after walking, 3.85 ±
0.55 mm Hg after jogging, and 4.0 ± 0.37 mm Hg after
running. Importantly, the IOP-lowering effect of exercise
was observed in patients with glaucoma; the effects are
actually magnified in this population: IOP dropped an
average of 7.72 ± 1.25 after walking, 10.86 ± 2.12 after
jogging, and 12.86 ± 2.05 after running in the 7 glaucoma
patients involved in the aforementioned study.34 These IOP
changes have been observed independent of alterations in
blood pressure and heart rate.20 Kiuchi et al32 used a
percentage of maximal heart rate to determine relative
rather than absolute intensity and showed that relative
intensity is most closely correlated to IOP lowering; this
was supported in studies by Harris et al31 and Qureshi
et al.23
In terms of aerobic versus anaerobic exercise, the
previously discussed Kielar paper found that the IOP
decrease was not significantly different between aerobic and
anaerobic trials.25 That study compared the 2 modalities
with matched intensity. However, another study found that
aerobic exercise is more effective than anaerobic exercise in
lowering of IOP in the immediate postexercise period. It
showed that aerobic exercise results in a decrease in IOP
from 14.96 ± 2.12 to 10.88 ± 1.84 mm Hg, a 27% change,
and anaerobic exercise resulting in a decrease from
14.96 ± 2.12 to 12.41 ± 1.87 mm Hg, a 17% change.35 This
study controlled for duration of exercise but did not
attempt to match exercise intensity. Given the correlation
between intensity and IOP lowering mentioned earlier,
conclusions must be drawn from this study with caution.
Overall, the literature indicates that dynamic exercise
has a greater IOP-lowering effect than isometric exercise.58
Importantly, the parameter that most closely corresponds
with IOP-lowering effect is the relative intensity of the
exercise.23,31,32 The consensus is that IOP decrease in
isometric exercise correlates with hypocapnia, whereas
in dynamic exercise lower IOP has been shown to be
independent of carbon dioxide levels. It is important to
point out that there is little available literature regarding
dynamic exercise and carbon dioxide. As such the difference
between the effects of hypocapnia on IOP in dynamic
versus isometric exercise may be an artifact of limited data
and further research should focus on whether a true
difference exists. At this time, a consensus on the etiology
for IOP lowering in dynamic exercise has not been reached;
however, this should not preclude the encouragement of
exercise in the absence of deleterious effects.
LONG-TERM EFFECTS OF EXERCISE ON IOP
The publications discussed to this point have dealt
with acute exercise and changes in IOP seen in the minutes
to hours postexercise. Some of the papers actually comment
on the relatively short-lived nature of these changes,
demonstrating postexercise decreased IOP lasting between
15 and 60 minutes.36,41,60 There are factors that can affect
the duration of IOP drop. One study showed that the
upper-body resistance training had a more lasting effect
on IOP lowering compared with lower-body training.37
Another study focused on a polymorphism of the b
2-adrenergic receptor gene associated with decreased IOP
for up to 3 hours after exercise.60 Even if these 2 factors
could be exploited, it is unlikely that the marginal duration
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J Glaucoma  Volume 18, Number 6, August 2009
of decreased IOP would have a great impact on long-term
glaucoma progression considering the goal of pharmaco-
logic IOP management is consistently lower IOP.
It is important to study the long-term effects of
exercise and fitness on IOP to determine if institution
of an exercise regimen can positively impact a chronic
disease. In this vein, a number of studies have compared
IOP in athletes and sedentary individuals; although,
typically the criteria for athlete are poorly defined and
rarely consistent between studies. One study showed that
postexercise IOP is significantly decreased compared
with preexercise values when measured after both aerobic
and anaerobic exercise in both athletes and sedentarians,
and the amplitude of the decrease was not significantly
different between the athletes and sedentarians.35 Conver-
sely, another study showed that in athletes, IOP immedi-
ately increased to a significant degree before decreasing
when measured at 30 minutes and 2 hours postexercise.
In sedentarians, IOP immediately decreased and remained
decreased at 30 minutes and 2 hours postexercise.30
Another study looking at individual sexes showed that
male athletes were shown to experience an increase in IOP
whereas in sedentary males IOP was not changed to a
significant degree. Female athletes had no significant
change in IOP, whereas sedentary females had a significant
decrease in IOP.29 Qureshi61 showed that the acute
postexercise effect on IOP lowering is greatly diminished
in physically fit subjects compared with sedentarians. In
summary, the postexercise IOP-lowering effects are no
better, or even diminished, in physically fit individuals. It is
important to understand the long-term effects of physical
fitness on baseline IOP, as this would have the greatest
impact on chronic disease progression.
An early study on the effects of fitness on baseline IOP
conducted by Sargent et al38 in 1981, found that physically
fit individuals had a lower baseline IOP compared with
before starting exercise training. However, the control
group experienced a significant and comparable decrease,
and the paper concluded that there is no correlation
between fitness and baseline IOP. That is the only published
study, which has concluded that physical fitness is
a nonfactor. Subsequent studies suggest the opposite.
Qureshi et al62 showed in a prospective comparative cohort
study using 40 subjects that exercise conditioning producing
physical fitness—defined by increased oxygen uptake—
results in lower baseline IOP by approximately 0.8 mm Hg
compared with levels before initiation of conditioning. This
decrease in baseline IOP seen in chronic exercise is an
important conclusion with respect to therapeutic applica-
tion. However, as the paper describes, the impact to
glaucoma patients in terms of outcomes is yet to be defined.
Passo et al39 demonstrated that initiation of exercise
training resulted in baseline IOP approximately 1.3 mm
Hg lower than before training, and it also showed that the
same was true in a group of glaucoma patients where mean
baseline IOP decreased by 4.6 ± 0.4 mm Hg after 3 months
of training.40 It is important to mention that the baseline
IOP returned to pretrained levels within 3 weeks of exercise
cessation.40 This is one of the few papers to test the IOP-
lowering ability of exercise on glaucoma patients.
Overall the literature agrees that institution of a
regular exercise program results in lowering of baseline
IOP, while the acute decrease in IOP in the postexercise
period is diminished.39,62 This phenomenon has also been
demonstrated in glaucoma patients.40 At this time, there is
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J Glaucoma  Volume 18, Number 6, August 2009
no long-term data on the effect of regular exercise in terms
of outcomes with glaucoma patients.
EXERCISE AND OBF
In patients who continue to show glaucomatous
progression despite well-controlled IOP,10,63 a vascular
etiology has become increasingly implicated as contributory
to the chronic disease process.64–67 A review by Siesky
et al68 summarizes the support for vascular etiologies in the
literature and states that vascular risk factors for glaucoma
include aging, systemic blood pressure, nocturnal hypoten-
sion, ocular perfusion pressure (OPP), migraine, disk
hemorrhage, and reduction of OBF.
DYNAMIC EXERCISE AND OBF
A recent study of 20 healthy individuals measured a
number of parameters at rest and immediately after stair
climbing. Although IOP and systemic blood pressure
increased significantly, there was no significant change in
retinal blood flow measured using Heidelberg retinal
flowmetry.69 Michelson et al70 supported these findings by
demonstrating perfusion of the eye is constant despite
elevation of systemic blood pressure. Similar conclusions
were drawn using color Doppler imaging to measure central
retinal artery and vein mean blood flow velocities, which
were found to be stable after exercise. That study also
looked at the ophthalmic artery and actually found
overregulation indicated by a decrease in blood flow due
to vasoconstriction.71 Lovasik et al72 confirmed that OPP
(defined as 2/3 mean arterial blood pressure–IOP) and
choroidal blood flow are not associated with each other,
suggesting an autoregulatory component. However, in
another study retinal blood flow was shown to increase
after a period of dynamic exercise. This study used scanning
laser Doppler flowmetry and laser speckle flowgraphy. The
results showed that choroidal blood flow was increased at
both 15 and 60 minutes whereas retinal blood flow was
increased only at the 15-minute measurement.73 Another
study supports the findings of increased OBF but looked
specifically at pulsatile blood flow and concluded that there
is a transient but significant increase in pulsatile blood flow
after exercise.36 Lovasik and Kergoat74 confirmed this
finding. The increase in choroidal blood flow lasts only 5 to
10 minutes, making it shorter lived than the concomitant
decrease in IOP, which tends to support the thought that
the 2 parameters change independently. Harris et al75
showed that dynamic exercise correlates with retinal
vasoconstriction and increased flow velocity with a net
increase in overall blood transit in the immediate post-
exercise period.
The consensus in the literature is that in healthy
subjects, retinal blood flow is autoregulated during dynamic
exercise by increased vascular resistance in proportion to
increase in OPP such that there is only a minor increase in
blood flow with increased OPP.72 The choroid is similarly
autoregulated, but to a lesser degree as choroidal blood
flow increases somewhat in the immediate postexercise
period.73 At least 2 papers reported increase specifically in
pulsatile OBF, presumably to maintain perfusion with
increased global demand.36,74
ISOMETRIC EXERCISE AND OBF
A study by Kiss et al76 used fundus pulsation
measured by laser interferometry as a means to monitor
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Effects of Exercise on IOP
choroidal blood flow during isometric exercise. It is worth
pointing out that this is the first study discussed to this
point that has measured parameters during exercise.
Presumably this is due to the difficulty associated with
taking delicate IOP or OBF measurements on exercising
subjects. The paper concluded that although mean arterial
pressure increased as expected, there was no significant
change in choroidal perfusion. The mechanism to maintain
stable perfusion has been shown to be ocular vasoconstric-
tion.77 This suggests autoregulation in the choroid, a
conclusion echoed by Movaffaghy et al78 in a paper
concerning optic nerve head blood flow after exercise.
It is important to note that this study found no correlation
between autoregulation and carbon dioxide levels.76 This is
in contrast to the mechanism of IOP lowering seen in
isometric exercise and supports the concept that pressure
and vasculature factors are not simply 2 surrogate markers
of the same phenomenon. Riva et al79 found that although
the autoregulation through increased choroidal vascular
resistance maintains consistent OBF to a point, the
autoregulation fails once OPP increases more than 67%
above the baseline. This is supported by Kiss et al.76 These
autoregulatory changes have been shown to be enhanced in
normal tension glaucoma patients.80 Interestingly, this
autoregulation is impaired in smokers.55 Although the
implications of these findings are not known, presumably
the increased OBF would benefit ocular tissues in general
and ameliorate the decreased perfusion that has been
proposed as the pathophysiologic consequence of elevated
IOP that leads to glaucomatous progression.
Nitric oxide (NO) was the subject of a study of
individuals performing isometric exercise while taking NO
synthase inhibitors intended to decrease NO production.
The paper concluded that NO plays a role in choroidal
blood flow autoregulation during isometric exercise.81
Okuno et al73 also concluded that NO has a role in OBF
regulation based on increased NO levels found in the
postexercise period. Fuchsjäger-Mayrl et al82 in addition
found that endothelin-1 but not angiotensin-II have roles in
choroidal blood flow regulation during isometric exercise.
In contrast b-blocker or atropine did not show any effect on
the choroidal blood flow during isometric exercise.83
The consensus in the literature regarding choroidal
blood flow of healthy patients in isometric exercise is that
there is autoregulation similar to that seen with dynamic
exercise. Choroidal blood flow is autoregulated by vascular
resistance in proportion to increase in OPP up to the point
of 67% to 70% above baseline OPP, which maintains blood
flow within 10% to 12% of baseline.76,79 Carbon dioxide
levels have no association with choroidal blood flow
regulation.76 At this time, there is little research addressing
the effects of isometric or dynamic exercise on OBF in
glaucoma patients.
DISCUSSION
Nearly half a century of research has been conducted
regarding exercise and its effect on IOP. It is well
established that acute exercise, both dynamic and iso-
metric, transiently lowers IOP in the acute postexercise
period.16–19,45,46,84 It is important to note that the
parameter most closely associated with IOP-lowering effect
is intensity of exercise.20,23,27,31–33,59 This is true and
perhaps even enhanced in glaucoma patients.34 It is also
widely accepted that physical fitness due to an exercise
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Risner et al
regimen results in lower baseline IOP; although, in fit
individuals the acute IOP-lowering effect of exercise may be
diminished.39,40,62 On the basis of these findings, it would
be interesting to see the effects of a moderately intense
exercise regimen as adjunct to treatment for glaucoma.
At this time, the consensus recommendations are that
exercise is most likely not harmful in terms of IOP and
should not be discouraged in glaucoma patients. These
conclusions cannot be applied to all glaucoma patients,
however. Young adults with advanced glaucoma have been
shown to experience a ‘‘vascular steal’’ during exercise,
which can result in temporary loss of vision.85 It has also
long been known that exercise provokes increased IOP in
patients with the pigmentary subtype of glaucoma.86–89 In
these patients, exercise could be harmful and so should not
be recommended.
Compared with IOP, there is much less published
literature concerning the effects of exercise on OBF. This
may be due to the difficulty associated with obtaining data.
There is also limited information available regarding the
long-term effects of exercise and fitness on OBF. However,
it has been shown that both isometric and dynamic
exercises result in an increase in OPP whereas overall
ocular perfusion remains relatively stable, indicating auto-
regulation.70–72,77,78 A brief increase in OBF is seen in
dynamic exercise before return to baseline,73 and pulsatile
flow also increases somewhat.36,74 Autoregulation is effec-
tive at OPP levels up to 70% above baseline and then they
begin to fail.76,79 At this time, there is not enough research
to determine any differences in the autoregulatory mechan-
isms between glaucoma patients and age-matched control
groups. Although an increase in OBF may be good for
glaucoma patients and may have a positive effect on
slowing progression of the chronic disease, it is unlikely that
the brief increase in OBF before the autoregulatory return
to baseline is clinically significant. Therefore, while there
seem to be no deleterious effect of exercise on glaucoma in
terms of OBF, there is not sufficient evidence to encourage
exercise with the goal of OBF modulation in glaucoma
patients.
In the past few years, low OPP has been shown to be
an important risk factor associated with prevalence90,91 and
incidence of open angle glaucoma.91 As exercise causes a
decrease in IOP and increase in blood pressure the net effect
is an increase in OPP. As this was not investigated in
the past it would be interesting to see the effect of this
increase in perfusion pressure on glaucoma incidence and
progression.
CONCLUSIONS
In healthy and glaucomatous subjects, acute exercise
results in acutely lowered IOP postexercise and exercise
training results in lowered baseline IOP values. In healthy
subjects, vascular autoregulation results in stable OBF
despite elevation of OPP, systemic blood pressure, and
heart rate during exercise. It is important to consider these
parameters in the management of glaucoma because
elevated IOP and vascular abnormalities are known to be
risk factors in the development of glaucoma. Although
there are a number of strong studies and publications in the
available literature, many of them leave the same questions
unanswered because they are beyond the scope of that
specific study. The role of exercise as an adjunct to the
management of glaucoma should be investigated with
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J Glaucoma  Volume 18, Number 6, August 2009
specific attention paid to clinically significant outcomes. It
is important that future research is directed at elucidation
of the mechanism for IOP-lowering parameters including
hypocapnia, plasma osmolality, and plasma lactate.
A uniform method for exercise and timeframe for IOP
measurement would have to be defined to allow for
interstudy data comparison.
LITERATURE SEARCH
A literature search was performed including all articles
published up to February 2008. A PubMed search with
reference cross matching was used to identify all relevant
articles pertaining to glaucoma, IOP, OBF, exercise,
isometric exercise, dynamic exercise, choroidal blood flow,
and retinal blood flow.
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