(0093-7002/87/6411-0866802.00/0 AMERICAN JOURNAL OF OPTOMETRY & PHYSIOLOG Copyright © 1987 AMERICAN ACADEMY OF OPTOMETRY clinical note L Opnics Vol. 64, No. 11, pp. 868-870 Printed in U.S.A Psychophysiological Stress, Elevated Intraocular Pressure, and Acute Closed-Angle Glaucoma B. G. SHILY* Los Angeles, California ABSTRACT The literature suggests that stress may play a part in the precipitation of acute closed-angle glaucoma because intraocular pressure (IOP) can be affected by th emotional state of the patient. This study considers this evidence in light of what is known concerning the possible relations between psychophysiological stress and elevated IOP. Two common threads run through these observations. The first is the suggestion that stress is a significant factor in the etiology of acute closed-angle glaucoma. The second is a growing suspicion concerning the role of stress in open-angle glaucoma. There is some evidence that glaucoma induc- tion is associated with psychophysiological stress. The role of psychosomatic factors in precipitating angle closure in eyes with an anatomically narrow angle and in raising the IOP in eyes with open angles has been noted in the literature. The implication is that stress reduction might prevent angle closure and re- duce the IOP. Suggested methods for achiev- ing these results include biofeedback, medi- tation, and relaxation exercises. Key Words: psychophysiological stress, ele- vated intraocular pressure, acute closed-angle glaucoma Both chronic and acute illnesses have been linked to psychological and environmental fac~ tors. Psychosomatic disorders attributable to Received August 8, 1986; revision received July 7, 1987, * Optometrist, M.A. tressors have been in evidence ‘ince at least 500 B.C., when Socrates asserted, “There is no illness of the body apart from the mind.” Despite the pervasiveness of the view that such a connection exists, the precise causal nexus remains obscure. Stress is often related to the onset of physical illness. Much of the current research in stress and psychosomatic disorders focuses upon the relation of life events to illness and upon deter- mining the precise nature of the mind-body in- teraction that leads to the development of dis orders. It has not been determined whether stress overload merely predisposes a person to illness or actually precipitates it, but there is a link.'’ The conservative scientific approach, in the absence of evidence of a direct link between stress and glaucoma, would be to abandon the simple causative model (i.e., that stress alone is sufficient to cause glaucoma) in favor of a dual causation model—namely, that glaucoma prob- ably occurs in persons who both (1) are predis- posed (e.g., genetically) and (2) encounter stress ful life events. In philosophical terms, this dual mode is a cluster-conditions model as opposed to a single sufficient-condition model. The role of psychophysiological stress in the etiology of acute closed-angle glaucoma has been suggested However, less frequently ac- knowledged is the potential association between stress-generated heightened IOP and open-an- gle glaucoma.” ASSOCIATION OF STRESS AND ACUTE CLOSED-ANGLE GLAUCOMA An association between environmental stres- sors (and consequent _psychophysiological stress) and acute closed-angle glaucoma has been studied by ophthalmologists since the 1940s." There are essentially no systematic, 865 psychosocialNovember 1987 controlled, empirical studies of this association. Case reports provide some evidence that such attacks may be precipitated by stress. La- Grange" said that in glaucoma there is “a sick eye in a sick body.” The sick eye is the eye rendered vulnerable by having a narrow anterior chamber angle, a condition usually associated with hyperopia. ‘This vulnerability increases in late middle age because the lens enlarges and moves forward, narrowing the angle still further and increasing the likelihood of pupillary ob- struction. The “sick body” could refer to an instability of vasomotor control, which would lead to congestion of the iris and ciliary body and to an increased production of aqueous. A swollen iris may tend to cause obstruction of the pupil, and a swollen ciliary body may push the iris forward and obstruct the angle." Cohen and Hajoft” speculate that such congestion could be the result of emotional influences on the vaso- motor system and that the concurrent vasodi lation could lead to an increased production of aqueous. Emotions could also influence the uation through an increase in the secretion of steroids, which in turn may influence the volume of the aqueous. Anxiety dilates the pupil. It is known that when the dilator pupillae dilates the pupil, the resistance within the trabecular net- work is increased and the drainage of aqueous is slowed.” ‘The following case history'® is an anecdotal account of a patient having an episode of acute closed-angle glaucoma. The 48-year-old patient was chief steward of a Boston club. His wife had died sometime previously, and his only son was a star athlete. The first time the son left home was in 1948, when he flew to London to compete in the Olympic Games. That same night the patient was admitted to the hospital with acute closed-angle glaucoma in his right eye. He was not treated again until 4 years later, the very evening after his son had left to compete in the 1952 Olympic Games at Helsinki. On this occa- sion, he was diagnosed as having acute closed- angle glaucoma in the left eye. There were no prodromal symptoms on either occasion. He ex- plained that he had been apprehensive because his son was leaving home and might possibly get into some trouble. Croll and Croll" described three patients whose attacks of acute closed-angle glaucoma were apparently precipitated by emotional up- sets after surgery for unrelated conditions. They suggested two predisposing factors: a pre-exist ing shallow anterior chamber and superimposed emotional stress. Piers,"’ @ psychoanalyst who studied 30 pa- tients in some depth, concluded that there was a close connection between attacks of acute closed-angle glaucoma and specific emotional Stress and Glaucoma—Shily 867 events to which individual patients were partic- ularly vulnerable, such as being involved in emo- tional conflict with a relative or friend, or wit- nessing a serious accident involving someone close to the patient. He noted that these patients were overconscientious, came from large fami- lies, and had unusually vivid visual images of real or imagined accidents. Schoenberg,"* describing the association of glaucoma and anxiety, concluded that “mental and emotional conflicts, whether conscious or buried in the unconscious, may product a dis- turbance of physiological processes and even cause reversible or irreversible organic lesions.” He reported that episodes of acute closed-angle glaucoma have been precipitated by a sudden psychophysiological shock, by the ordeal of an operation, or by other severe illnesses in the patient or in some member of his immediate family. Schoenberg contended that the eyes of some patients with glaucoma reacted to anxiety states, just as those of other persons with glau- coma were influenced by changes in weather, poor light, poor diet, cardiovascular disturb- ances, acute fever, and sudden increase of blood pressure. Investigating the occurrence of emo- tional distress of which the patient may not even be aware, Inman’ reported the case of a patient developing an acute attack of glaucoma after a discussion with his son concerning the son's life after the patient's death. Glaucoma in one eye may precipitate angle- closure glaucoma in the other eye. Weinstein” referred to this linkage as “glaucoma sympathi- cum.” An operation for glaucoma in one eye represents a shock to the nervous system which, through a reflex mechanism, may produce a sudden rise in IOP. Egan” described a patient who developed “shock glaucoma” because the glaucoma was induced by physical shock in the form of a fall. Emergency measures to lower IOP were carried out, but 24 h later the tension was still 45 mm Hg. After a basal iridectomy was performed the patient did very well without medication. Gartner and Billet” in 1958 reported four cases of acute angle-closure glaucoma occurring postoperatively in a series of 3437 surgical pa- tients who received either general or spinal anes- thesia, None of the patient had a history of eye disease. The authors suggested that causative factors included the patients’ shallow anterior chambers, premedication with atropine or sco- polamine, pupillary dilation in deep anesthesia, and anxiety. In a controlled study of the events preceding the onset of acute closed-angle glaucoma, Cohen and Hajoff’® studied 52 consecutive unselected patients. Their life history preceding the attack was compared with that of 52 control subjects868 AM J OPTOM & PHYSIOL OPTICS matched for age, sex, social class, visual impair- ment, and threat to sight. A full history was taken from both the patients and the control subjects. Particular attention was paid to ac- quiring data on major and easily identifiable changes in life situations during the preceding 3 months—such as early bereavement or anniver- saries of major bereavements. Also analyzed was each patient's history of illnesses and accidents. ‘The information was assessed independently by two psychiatrists who were unaware of the ocu- lar condition of the patients. There were signif- icant emotional events in the histories of 13 glaucoma patients and 6 control subjects. Cohen and Hajoff concluded that stress plays a part in the precipitation of acute closed-angle glaucoma, though not as great a part as earlier literature had suggested. Once the acute attack has oc- curred, treatment is usually surgical. Cohen and Hajoff did not agree with Schoenberg that psy- chotherapy at this stage proves efficacious. In addition to increasing the size of the pupil, stress can increase engorgement of the ciliary body, resulting in a thrusting forward of the iris- lens diaphragm, further narrowing the angle and leading to acute closed-angle glaucoma in pa- tients with an anatomically narrow chamber angle. Fazio et al.”* reviewed the records of all in-patients of UCLA Medical Center from 1955 to 1980 with the discharge diagnosis of glau- coma. Nine cases of acute closed-angle glaucoma occurring after spinal or general anesthesia were identified among the 913 records reviewed. The authors concluded that drug-induced mydriasis may have contributed to this complication. Psy- chological stress in the surgical patient. may increase the risk of glaucoma by causing my- driasis ASSOCIATION OF STRESS AND ELEVATED 1oP An association between environmental stres- sors and acute closed-angle glaucoma has been reported,'* * but far fewer ophthalmologists are convinced that stress is implicated in open-angle glaucoma. Researchers have produced sugges- tive evidence of such an association.” ** In 1948, Ripley and Wolff’ looked for a rela- tion between emotional reactions and the level of IOP. Kighteen patients with open-angle glau- coma who were considered sufficiently coopera- tive to tolerate intensive study were selected, ‘The study group consisted of 13 women and 5 men, ranging in age from 27 to 75 years. Over periods ranging from 10 months to 7 years, data were collected concerning life history, eye symp- toms, and IOP. The relations between person- ality, emotional reactions, and the occurrence of eye symptoms or changes in IOP were deter- Vol. 64, No. 11 mined by correlating daily life situations and emotional changes with the eye findings. During interviews, observations were made on three independent variables—behavior, thought con- tent, and feeling states—and on the dependent variable IOP. Tonometer readings were taken, using the McLean scale." Blood pressure levels were recorded. In three of the patients, experi- ments were carried out after the intravenous administration of sodium amytal. In all patients there was a history of anxiety, anger, or depres- sion associated with a frustrating life situation at the time of the onset of glaucoma symptoms. It was found that both increased severity of eye symptoms and elevation of IOP coincided with accentuation of previously existing frustrations, or the development of new threats to the pa- tient’s security. In 9 of the 18 patients, corre- sponding elevations of systemic blood pressure were also found. Changes in IOP were associated with changes in emotional reaction or preoccu- pation with frustrating personal problems. Ele- vations of IOP were found to be associated with anxiety, anger, or depression. At times, when the patient was relatively happy and relaxed, IOP was lower. Ripley concluded that the association between relatively untroubled periods and low levels of IOP, and the fact that in several patients there was a decrease in pressure subsequent to ps: chotherapy, indicate that treatment of the emo- tional reactions of those with glaucoma is of value in some cases. Gringnolo et al.” studied the behavior of IOP in normal and glaucomatous subjects when sub- mitted to a variety of stresses. Their data showed that prolonged stress tended to increase IOP in normal subjects—unlike shorter stress, which ordinarily caused only an increase of IOP subjects. Weinstein and Dobossy”’ reported that anxiety conditions and stress can lead to glaucoma. A glaucoma personality“'—characterized by the tense, nervous, or emotional patient, or by all three—has been described. People with this personality exhibit mood fluctuations, excessive anxiety, and hypochondriacal tendencies and such compulsive traits as conscientiousness, me- ticulousness, and perfectionism.” in glaucomatous DISCUSSION There is suggestive evidence that precipita tion of angle-closure glaucoma is associated with “McLean scale measurements are made with an indentation tonometer, similar in construction to the Schiotz tonometer. A weighted plunger is placed on the cornea, and ocular tension is read directly from an attached seale calibrated in millimeters of mercuryNovember 1987 psychophysiological stress." In eyes with an open angle elevated IOP might be associated with stress." However, what is less often recognized is the potential role of stress reduc- tion techniques in preventing acute closed-angle glaucoma and lowering elevated IOP. Stress-reduction treatment modalities may be useful in the treatment of acute closed-angle glaucoma and perniciously elevated IOP, in view of the reported association of these conditions with stress. Because of uncertainties concerning the as- sociation of environmental stress, acute closed- angle glaucoma, and elevated IOP additional retrospective case-control studies—more care- fully designed than those reported to date—need to be performed. Potential confounding vari- ables should be controlled, and more sensitive measures of stress and other independent vari- ables should be developed. Additional poten- ally relevant variables requiring investigation include the possible prophylactic role of alcohol asa moderator of ocular tension; the association of previous nonocular surgery, income, and stress; and recent life history, current life sit- uation, and bereavements."” Studies should uti- lize a sufficient number of subjects, that more id extrapolations may be made to the popu- Finally, in view of the reported efficacy of biofeedback, mediation, and relaxation tech- niques in treating other psychosomatic disor- ders," investigations should be performed to see if these techniques will be useful in reduc- ing the risk of acute closed-angle glaucoma in at-risk patients and for lowering high IOP in persons with open-angle glaucoma. Stress-re~ duction techniques should not be expected to provide the sole or sufficient treatment regimen, but rather their efficacy as supplementary treat- ments should be investigated. ACKNOWLEDGMENT The late Dr. L. M. 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New York: Atheneum, 1985 AUTHOR'S ADDRESS: B.G.Shily 612 South Barrington Avenue, Suite 210 Los Angeles, California 90049