Warning for glaucoma patients: Sleeping with head elevated raises IOP and lowers OPP

Investigators from China reported that the so-called “high-pillow sleeping position” can result in elevated intraocular pressure (IOP) values and decreased ocular perfusion pressure (OPP) in patients with glaucoma, according to first author Tong Liu, MD, PhD, and colleagues. He is from the Eye Center, Zhejiang University, Eye Center of Second Affiliated Hospital, School of Medicine; Zhejiang Provincial Key Laboratory of Ophthalmology; Zhejiang Provincial Clinical Research Center for Eye Diseases; and Zhejiang Provincial Engineering Institute on Eye Diseases, all in Hangzhou, Zhejiang, China.

The researchers reported their results in the British Journal of Ophthalmology.¹

Study methodology

They explained that elevated IOP is the “primary modifiable risk factor for glaucoma progression.² IOP typically follows a distinct circadian rhythm, with peak values occurring during nocturnal periods.³ This underscores the importance of nocturnal IOP management. IOP exhibits considerable fluctuations in response to postural changes.⁴ The transition from an upright to a supine position during sleep represents the primary contributor to nocturnal IOP elevation,⁵ the investigators explained.They theorized that postural changes may be an adjunctive strategy for IOP management in patients with glaucoma.

A total of 144 patients were included in the study. The investigators measured the IOP and then compared the values between the high-pillow position (head elevated 20^o to 35° using two pillows) and the supine position. The study also included 20 healthy volunteers, for whom the investigators used ultrasonography to evaluate the changes in the jugular venous lumen with postural variations.

What the analysis showed

When compared with the supine position, Liu and colleagues reported that when the head was elevated by 20^o to 35° using two regular pillows, the IOP was significantly elevated, 24-hour IOP fluctuations increased, and the OPP decreased in patients with glaucoma patients. The difference reached significance (P < 0.001).

They also reported observing greater postural IOP fluctuations (ΔIOP) in younger patients (P = 0.027) and in those with primary open-angle glaucoma (POAG) (P < 0.001).

When they conducted multiple regression analysis, the findings indicated that thicker central corneal thickness and POAG, in contrast to normal-tension glaucoma, independently predicted a greater ΔIOP (P < 0.05 for both comparisons).

The evaluation of the jugular venous lumen using ultrasonography in the healthy volunteers showed significant constriction of the internal and external jugular venous lumens (P < 0.001 for all comparisons) along with increased maximal internal jugular vein blood flow velocity (P = 0.013). The authors suggested that neck flexion was the possible mechanism. The findings suggested that head-elevating sleep positions likely to induce neck flexion and jugular venous compression may be counterproductive for nocturnal IOP control in patients with glaucoma; further validation is needed before this informs practice, they advised.

The key takeaway was that compared with the supine position, the high-pillow posture is associated with elevated IOP and reduced OPP, with potential adverse implications for long-term IOP control in patients with glaucoma.

“Preliminary evidence suggests that patients with glaucoma may benefit from avoiding postures inducing jugular venous compression to mitigate postural IOP elevation,” the investigators stated. They also pointed out the need for further studies to validate these preliminary associations.

References
1. Liu T, Hu M, Liu X, et al. Association of high-pillow sleeping posture with intraocular pressure in patients with glaucoma. Br J Ophthalmol. 2026;110:1051–1056. doi:10.1136/bjo-2025-328037
2. Jayaram H, Kolko M, Friedman DS, et al. Glaucoma: now and beyond. Lancet. 2023;402:1788–801.
3. Grippo TM, Liu JHK, Zebardast N, et al. Twenty-four-hour pattern of intraocular pressure in untreated patients with ocular hypertension. Invest Ophthalmol Vis Sci. 2013;54:512–7.
4. Liu T, Cai Y, Hu M, et al. The impact of intraocular pressure fluctuations on the progression of glaucoma and associated factors. Adv Ophthalmol Pract Res. 2025;5:142–8.
5. Kim JH, Caprioli CJ. Intraocular pressure fluctuation: is it important? J Ophthalmic Vis Res. 2018;13:170–4.