Inversions Glaucoma Suspects Retinal Tears Detachments

Admittedly, there is some gratification in knowing that medical advice now supports what should have been part of asana teaching for decades. A 45-year old woman, a glaucoma suspect, is advised by an ophthalmolgist to avoid inverted positions such as a headstand and  “semi-inversions” such as downward dog. This was discovered in the post by the ophthalmologist Dr. Carolina Valdivia on her blog http://www.glaucoma-eye-info.com/yoga-positions.html.

With increased attention regarding yoga injuries in the main stream media, there is some openness now that did not exist some years ago. This is a welcome change for everyone. Yoga injuries are not a badge of honor or any indication of a high level of personal commitment to an asana practice. This attitude to yoga is completely misguided. The risks and limitations of asanas are still not part of most yoga teacher training programs.

Dr. Valdivia answers the following question by a 45-year old woman from New South Wales, Australia:

“Hi Dr. Valdivia. I have been very recently diagnosed as a glaucoma suspect, but at the moment my eyes are healthy. I am not taking any medication for it.

I practice yoga and my eye specialist has told me that because I am a glaucoma suspect I should not attempt any fully inverted yoga poses (legs above the head, for example: headstand) and to limit time spent in semi-inverted yoga poses and postures (head below the heart, for example: downward dog).

My question is, how many seconds can I safely hold the semi-inverted yoga poses and postures before I create an eye pressure problem?”

In response to that question. Dr. Valdivia gives an extended and thorough explanation that readers can read via the above link. However, for people who do not like to click, here are the commonly identified triggers which cause a temporary increase in intra-ocular pressure (IOP) that must be avoided not just for glaucoma but for macular degeneration, high myopia, retinal tears, and retinal detachments.

  • Abrupt or sustained physical exertion, such as lifting a heavy object.
  • Squatting.
  • Bending over, while standing or sitting, so that the head is below the heart.
  • Straining during defecation.
  • Playing a brass or woodwind musical instrument.
  • Wearing constrictive clothing around the neck.
  • Various acrobatic or gymnastic maneuvers.
  • Certain yoga positions.

 Several scientific studies have specifically investigated the effects of yoga positions on generating high intra-ocular pressure in adults. The concern has been that not only do certain yoga positions carry a risk of creating a transient eye pressure problem, these positions often are held for extended periods, which carries the risk of sustained high intra-ocular pressure.

Here is an outstanding table from Dr. Valdivia’s post that illustrates how some commonly practiced inversions increase intro-ocular pressure:

The table below presents combined (meta-analysis) data obtained from 12 published studies looking at the effects of various yoga positions on intraocular pressure (IOP). Particular emphasis is given to inverted yoga poses and those that are semi-inverted. Participants in the studies were free of ocular disease, were between the ages of 22-63 years, and ranged from intermediate to advanced levels of proficiency. Average intraocular pressure at a seated position for this combination of studies was 15.2 mmHg.

YOGA POSE

AVERAGE IOP AFTER
INITIATION

INCREASE IN IOP

Salamba Sirsasana
(headstand)
33.6 mmHg +18.4 mmHg
Urdhva padmasana
(Inverted Lotus)
33.2 mmHg +18.0 mmHg
Parsva Sirsasana
(side headstand)
33.5 mmHg +18.0 mmHg
Parivrttaikapada Sirsasana
(Revolved Split-Legged
Headstand)
33.9 mmHg +18.7 mmHg
Pincha Mayurasana (peacock
feather pose)
31.5 mmHg +16.3 mmHg
Eka Pada Viparita Dandasana (one-legged inverted-staff
pose)
28.2 mmHg +13.0 mmHg
Utthita Pada Sirsasana
(extended-leg headstand
pose)
33.7 mmHg +18.5 mmHg
Valsalva Maneuver
(attempting to forcibly exhale
while keeping the mouth and
nose closed)
38.1 mmHg +22.9 mmHg
Adho Mukha Vrksasana
(handstand)
34.8 mmHg +19.6 mmHg
Salamba Sarvangasana
(Shoulder Stand)
25.4 mmHg +10.2 mmHg
Urdhva Dhanurasana
(wheel pose)
22.4 mmHg +7.2 mmHg
Halasana (plow pose) 19.0 mmHg +3.8 mmHg
Adho Mukha Svanasana
(downward-facing dog)
19.9 mmHg +4.7 mmHg
Setu Bandha Sarvangasana
(bridge pose)
24.3 mmHg +9.1 mmHg
Urdhva Mukha Svanasana
(upward-facing dog)
14.5 mmHg -0.7 mmHg
Viparita Karani
(legs-up-the-wall pose)
14.0 mmHg -1.2 mmHg
Virasana (hero pose) 13.8 mmHg -1.4 mmHg
Padmasana (lotus pose) 13.7 mmHg -1.5 mmHg

Meta-analysis by Carolina Valdivia Cáceres, MD and Ángela Pattatucci Aragón, Ph.D., 2011.

Dr. Valdivia advises the woman:

Spikes in high intraocular pressure appear to be immediate upon entering yoga poses and postures. Thus, there appears to be no safe period of time for you to practice either inverted yoga poses or semi-inverted yoga positions.

Here we have one doctor saying no inverted or semi-inverted positions and one saying semi-inverted positions are not to be held for extended periods of time. What is “extended period of time”? To me, it is anything beyond 10-15 seconds but depending on the individual experience even that may be too much–we generally did not hold more than 5 seconds.

Why the gratification? Because ever since I have been teaching yoga, new students were asked about any medical conditions and family history of eye problems. Returning students were asked about changes in medical conditions. This way, they could be cautioned about what to avoid and modifications, where possible, could made for them. When people who said they had a family history of glaucoma (or high blood pressure, cardiac problems, GERD, high myopia, hernia, etc.) were told they could not do the only inversions we did sometimes do–the shoulderstand and the plough (a modified plough), the explanation was almost always received with disbelief. They said that no other teacher said this to them and it was taken as an unnecessary restriction that limited the physically challenging practice they wanted.

9 thoughts on “Inversions Glaucoma Suspects Retinal Tears Detachments

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  1. Thank you for this informative and very useful post! I will be able to refer to this next time I have a conversation with someone who has a condition such as glaucoma about the risks of inversions. In my public classes I teach Viparita Karani, but no longer teach headstand, – only in individual classes. In an open class, too many participants are keen to throw themselves into strong inversions regardless of medical conditions, or even simply despite the fact that they have not practised preparatory asana regularly enough to have the shoulder & upper spine flexibility and strength required to do these asanas safely. Very interesting to note that Bridge Pose, according to the chart, produces a strong increase in IOP! This is definitely something that needs to be covered in teacher training courses. I think the strong effects of asana are often underestimated. Thanks again for a very helpful post.

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    1. Thank you for your comment! You are right that the body must be prepared for it and these asanas cannot be part of a beginner’s class or routine. Around here, they are part of a general beginner’s class.

      Apart from glaucoma, these precautions also apply to many other eye conditions. Recently, I had a big retinal tear (had nothing to do with yoga or any physical activity). It was just one of those things that happen and my high myopia, prescription of 6 Diopeters and above, puts me in a higher risk group. So inversions such as headstands and hanstands are out, not that I ever did them with my eyesight. But even downward dog cannot be held for more than a few seconds and it can only be done after the retina has healed. I will build up to it slowly with some forward bends. Normal healing is six to eight weeks.

      Inversions are contraindicated for more than just the eyes–they have caused strokes in even young people. The rewards of these inversions must be weighed against the risks. They are unquestionably off-limits for people with high blood pressure, cardiac problems, GERD, hernias, slipped discs, and more.

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  2. Could anyone give me advice in regards to yoga poses and macular degeneration. I am an Iyengar yoga practitioner training to be a teacher. This query is for participants in my classes as well as for me. I have wet MD in one eye and dry in the other

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    1. You can talk to your doctors but most that I have spoken to do not know anything about yoga poses and often reluctant to advice due to liability issues. The ones who are willing to talk have very mixed views on what can and cannot be done–there are few clear answers for grey areas such as retinal tears. I think the answers are clearer for MD, glaucoma, and detached retinas. That is one of the reasons for this blog post. Another suggestion, in addition to all the information on this blog, is the book “Asana Pranayama Mudra Bandha” by Swami Satyananda. It remains by far the best book on yoga therapy (all yoga is meant to be therapeutic but no longer is). You will find a review on my website http://www.mahasriyoga.com/bookreviews. You may try Desikachar’s work though I do not recall reading anything specific to eyes in his book.

      In any case, in your place I would totally avoid inversions including deep forward bends where the head goes below the heart. Being a little conservative never hurts and like in medicine, the first principle in yoga is to do no harm. Studies indicate that holding positions more than 90 seconds weakens the muscles and our optimum time for holding is 15-20 seconds.

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      1. Thank you for your reply. My ophthalmologist does know yoga and she has advised me that inversions and forward bends are ok for Wet MD. I am totally confused. I attended a 3 weeks intensive recently and my eyesight on return had improved. Currently though the therapeutic mentors in my yoga world advise me no inversions and the wearing of bandages

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  3. Thanks for this study! I’ve got so many people asking questions about this in my yoga contacts and on this blog post http://www.ompathy.com/yoga-and-retinal-tears/ and have asked quite a few surgeons and they dismiss the connection (or are not interested) I’ve had two detachments and was told no limitations whatsoever on yoga but three top retinal surgeons but I can’t dismiss the incidence of people I have met encountering this issue

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    1. It is challenging to get answers to many questions as there is not enough information or research. Several retinologists say there is no connection to retinal tears and yoga, there is no logical evidence to support this. But my retinologist wondered why anybody would want to do yoga, inversions, as they cannot possibly be good for you anyway. The doctor already had an in-built prejudice to yoga so that was not an objective answer but a personal one. A leading retinologist has asked people within my yoga circle if they do yoga inversions as part of his medical history intake. He has not published anything on it but privately does appear to tell his patients to avoid them.

      Following my major retinal tear due to high myopia and thinning membranes, I was told not to exert myself in any way until the retina had healed–that was about three months of healing. After that I could slowly build up my physical activities and do some moderate inversions–I never did do headstands and handstands before so that was irrelevant to me. However a year after my tears, doing downward dog, ashtanga namaskar, cause temporary clouding in the eye, the eye feels heavy, there is throbbing pain. These are clear indications that these positions are not good for my eye, regardless of what medical advice is given. Listening and being deeply aware of the body seems to be the best advice.

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  4. I just had a retinal tear after resuming a long-neglected yoga practice. I was so pleased to finally be able to get back into a proper shoulder stand and plow pose without discomfort and a few days later I started seeing lines moving around in my left eye. I got an exam, a retinal tear was noted, I had laser surgery to correct it and apparently it is OK now. The doctor didn’t think there was any connection with yoga or inversions, but it seems like I’m not the only one that has had an experience like this. I had -8.25 with astigmatism corrected with Lasik surgery about 20 years ago, so I’m in a high risk group for retinal tears. Fortunately no detachment, but I guess I have to take it easy. I’m hoping I can do surya namaskar with a transient down dog, but I’ll wait a month anyway and do some more research.

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