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Editors Selection IGR 24-3

Miscellaneous: Stress and IOP: Can relaxation techniques help?

Comment by Vivek Gupta & Tanuj Dada on:

109682 Effect of various relaxation techniques on the intraocular pressure of patients with glaucoma: systematic review and meta-analysis, Zaher O; Kuchtaruk AA; Malvankar-Mehta MS, Canadian Journal of Ophthalmology, 2023; 0:

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Meditation is a technique to focus the mind and induce a relaxation response which been termed a 'polypill' for comprehensive management of glaucoma patients as it is one intervention that can impact intraocular pressure (IOP), ocular blood flow, neurotrophins, stress hormones, autonomic nervous system etcetera and improve quality of life in glaucoma patients.¹ In a systematic review and meta-analysis, Zaher et al. report on the effects of relaxation techniques on changes in IOP among patients with glaucoma. Both prospective observational studies and randomized controlled trials (RCTs) were included in the systematic review. The main outcome of interest was mean percentage IOP reduction (IOPR%). DerSimonian and Laird methods for random effects meta-analysis or fixed effects meta-analysis were performed based on heterogeneity.

From a total of 424 potentially relevant articles and 62 grey literature records, the authors shortlisted 12 studies for risk of bias assessment and qualitative synthesis. These included eight RCTs and four prospective observational studies. Among the eight RCTs, four were good quality and four were fair; while among four prospective observational studies, one was good and one was fair quality, while rest were poor quality.

Interventions included (a) Mindfulness based meditation (MM); (b) Mindfulness-based stress reduction (MBSR); (c) autogenic relaxation, ocular relaxation exercises, and visual imagery of aqueous humor drainage; and (d) yoga exercises and postures. The period of interventions ranged across 30-90 minutes, practiced for 3-16 weeks ranging across daily to weekly frequency.

The percentage of IOP reduction (IOPR%) ranged from a maximum of 31.8% to 4.5% in trials, while observational studies on head down postures typically showed negative IOPR%. There was significant heterogeneity between trials (I² = 94.2%). Meta analysis of five trials, all using MM or MSBR, showed a significant reduction in IOP in patients with POAG and OHT, with a standardized mean difference of -2.02 mmHg.

This is one of the first systematic reviews examining the impact of various relaxation techniques on the IOP of patients with glaucoma. The meta-analysis demonstrates clinically significant reduction in IOP among patients with POAG with the use of MM / MBSR over and above their use of anti-glaucoma medications. This is strengthened with the coherent observation of 4.5-15.3 IOPR% with autogenic relaxation and 22.0 IOPR% with yoga ocular exercises. Similar conclusions of benefit have been reported in another recent meta-anal-ysis and trials.^2-4

Mind-body interventions which induce relaxation with a lowering of IOP and other physiological benefits can potentially improve overall health related quality of life

The study underscores the need for educating both caregivers and patients about the benefits of relaxation techniques like meditation. Managing a glaucoma patient is like a marathon where mind-body interventions which induce relaxation with a lowering of IOP and other physiological benefits can potentially improve overall health related quality of life. The time has come for multi-country assessments of MM/MSBR-based interventions (with standardization of techniques) across different ethnicities to study the impact on glaucoma progression, and subsequent mainstreaming of these interventions as part of the standard of care for POAG management.

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