How Your Sleeping Position Could Affect Glaucoma: Insights from Recent Clinical Research

Glaucoma is a leading cause of irreversible vision loss worldwide, affecting millions of people and posing a significant public health challenge. Elevated intraocular pressure (IOP) is the primary modifiable risk factor for glaucoma progression, making its management central to preserving vision. While medications and surgical interventions remain the standard approaches, emerging research suggests that even simple lifestyle adjustments, such as sleeping posture, may influence IOP. A recent clinical study by Tong Liu, Mengyuan Hu, Xin Liu, Zongrong Wang, Ke Yao, Min Chen, and Kaijun Wang provides new insights into how high-pillow sleeping positions may affect intraocular pressure in patients with glaucoma. This blog explores the study’s findings, their implications for glaucoma management, and practical considerations for patients.

Understanding Intraocular Pressure and Glaucoma

Intraocular pressure refers to the fluid pressure inside the eye. It is largely determined by the balance between aqueous humour production and its drainage through the eye’s trabecular meshwork into the venous system. Persistent elevation in IOP can damage the optic nerve, leading to vision loss, a hallmark of glaucoma.

There are several types of glaucoma, including primary open-angle glaucoma (POAG), normal-tension glaucoma (NTG), and ocular hypertension (OHT). POAG is characterized by increased IOP over 21 mm Hg with optic nerve damage, whereas NTG patients develop optic nerve changes despite normal IOP levels. OHT involves elevated IOP without associated optic nerve damage. Regardless of the type, fluctuations in IOP have been linked to glaucoma progression, highlighting the importance of both mean IOP and its variability.

The Role of Body Posture in Intraocular Pressure

Prior research has demonstrated that IOP is sensitive to body posture. IOP tends to be higher when lying down compared to sitting or standing, and it exhibits circadian variation, typically peaking at night. The transition from upright to supine positions during sleep is associated with nocturnal IOP elevation. Additionally, lateral decubitus and prone positions can further increase IOP by 1.5 to 5 mm Hg depending on the eye involved. These observations have sparked interest in whether postural modifications could serve as a non-pharmacological adjunct to conventional glaucoma therapy.

The Study on High-Pillow Sleeping Positions

The study conducted by Liu and colleagues investigated whether using two regular pillows to elevate the head by 20 to 35 degrees, referred to as the high-pillow position, affects IOP in patients with glaucoma. This approach differs from previous studies that used wedge-shaped pillows or adjustable beds to achieve semi-reclined positions, which may not be practical in everyday home settings.

Study Design

The researchers enrolled 144 patients with glaucoma, including those with POAG, NTG, and OHT. Patients underwent 24-hour IOP monitoring using a rebound tonometer, with measurements taken in both supine and high-pillow positions. To further explore potential mechanisms, the study also included ultrasonography of the internal and external jugular veins in 20 healthy volunteers to examine whether head elevation affects venous compression.

Key Findings

The study revealed several important findings:

1. Increased IOP in High-Pillow Position: On average, 96 out of 144 patients (66.7 percent) experienced an IOP increase when transitioning from the supine to the high-pillow position, with a mean rise of 1.61 mm Hg. The mean IOP in the high-pillow position was 17.42 mm Hg compared to 16.62 mm Hg in the supine position, demonstrating a statistically significant increase.
2. Greater 24-Hour IOP Fluctuations: Patients in the high-pillow position showed higher 24-hour IOP variability. The standard deviation of 24-hour IOP measurements was 2.60 mm Hg in the high-pillow position versus 2.26 mm Hg in the supine position.
3. Reduced Ocular Perfusion Pressure: Ocular perfusion pressure (OPP), a measure of the pressure driving blood flow to the optic nerve, was significantly reduced in the high-pillow position (54.57 mm Hg versus 58.71 mm Hg in the supine position). Reduced OPP may compromise optic nerve blood supply, increasing the risk of glaucomatous damage.
4. Influence of Age and Glaucoma Type: Younger patients exhibited greater postural IOP fluctuations compared to older adults, and patients with POAG had larger fluctuations than those with NTG. Multivariate analysis indicated that thicker central corneal thickness and the presence of POAG were positive predictors of greater postural IOP changes.
5. Jugular Venous Compression: Ultrasonography revealed that elevating the head with pillows significantly reduced the cross-sectional area of both internal and external jugular veins. The maximum blood flow velocity of the internal jugular vein increased, suggesting that mechanical compression of these veins could impede aqueous humour drainage, contributing to IOP elevation.

Mechanistic Insights

The study proposes a physiological explanation for the observed findings. Neck flexion associated with the high-pillow position may compress the jugular veins, which are critical for venous drainage of aqueous humour. When these veins are constricted, fluid outflow from the eye is impeded, leading to higher IOP. This mechanism aligns with previous studies showing that neck rotation or direct jugular vein compression can significantly increase intraocular pressure.

Clinical Implications

These findings have practical implications for patients with glaucoma:

1. Sleeping Position as an Adjunctive Strategy: While medications remain the primary intervention for IOP management, modifying sleeping posture could serve as an additional, low-cost approach. Avoiding high-pillow sleeping positions that compress the jugular veins may help reduce nocturnal IOP elevations.
2. Patient Education: Clinicians should consider discussing sleeping posture during routine glaucoma consultations. Awareness of posture-induced IOP changes can empower patients to make simple behavioral adjustments that may benefit long-term ocular health.
3. Tailoring Interventions to Individual Risk: Subgroup analyses indicated that younger patients and those with POAG are more susceptible to postural IOP fluctuations. Personalized guidance on sleep posture could be particularly important for these populations.
4. Non-Invasive Monitoring: The use of ultrasonography to assess jugular vein compression provides a non-invasive method to explore the relationship between head posture and ocular pressure, offering potential for individualized assessment and risk stratification.

Limitations and Future Directions

Despite its valuable insights, the study has some limitations. The high-pillow position was defined with a 15-degree range of elevation, introducing variability. The study population for jugular vein ultrasonography was separate from the glaucoma cohort, and OPP estimates were approximations rather than direct measurements. Additionally, long-term outcomes of sleep posture modification on glaucoma progression remain untested.

Future research could focus on:

• Investigating postural IOP changes across a wider range of pillow elevations
• Evaluating the long-term effects of sleep posture modifications on glaucoma progression
• Exploring additional non-pharmacological interventions to optimize nocturnal IOP management

Practical Recommendations for Patients

Based on the study findings, patients with glaucoma may consider the following practical tips:

• Avoid using multiple pillows that elevate the head excessively during sleep.
• Maintain a neutral neck posture while sleeping, keeping the cervical spine aligned.
• Consider consulting with an ophthalmologist about individualized strategies for nocturnal IOP control.
• Monitor IOP regularly to assess potential effects of lifestyle adjustments.

While these strategies are not a replacement for medical therapy, they offer a simple and non-invasive way to support overall glaucoma management.

Conclusion

The study by Liu and colleagues highlights a previously underappreciated factor in glaucoma management: sleeping posture. The high-pillow position, defined as using two regular pillows to elevate the head by 20 to 35 degrees, was associated with elevated intraocular pressure, increased 24-hour IOP fluctuation, and reduced ocular perfusion pressure. These effects are likely linked to mechanical compression of the jugular veins, which impedes aqueous humour drainage.

Patients with glaucoma, particularly younger adults and those with primary open-angle glaucoma, may benefit from avoiding sleeping postures that cause jugular venous compression. While further studies are needed to validate these findings and explore long-term outcomes, this research underscores the potential of simple behavioral modifications to complement standard glaucoma therapies.

Sources

1. Liu T, Hu M, Liu X, Wang Z, Yao K, Chen M, Wang K. Association of high-pillow sleeping posture with intraocular pressure in patients with glaucoma. British Journal of Ophthalmology. 2026. doi:10.1136/bjo-2025-328037. Open Access
2. Weinreb RN, Aung T, Medeiros FA. The pathophysiology and treatment of glaucoma: a review. JAMA. 2014;311(18):1901–1911.
3. Liu JH, Zhang X, Kripke DF, Weinreb RN. Twenty-four-hour intraocular pressure pattern associated with optic nerve damage in glaucoma. Arch Ophthalmol. 2003;121(1):61–66.
4. Jonas JB, Berenshtein E, Holbach L. Anterior chamber angle and supine IOP. Ophthalmology. 2002;109:1895–1900.
5. Asrani S, Zeimer R, Wilensky J, Gieser D, Vitale S, Lindenmuth K. Large diurnal fluctuations in intraocular pressure are an independent risk factor in patients with glaucoma. J Glaucoma. 2000;9(2):134–142.
6. Weinreb RN, Garway-Heath DF, Leung CK-S, et al. The pathophysiology and treatment of glaucoma: a review. Lancet. 2014;383:171–181.

Disclaimer

This blog is intended for educational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. Always consult a qualified ophthalmologist or healthcare provider regarding any questions or concerns about glaucoma or intraocular pressure management. Changes to sleeping posture or other lifestyle interventions should be discussed with a healthcare professional before implementation