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Represented by :
Satya Hutama Pragnanda
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Glaucoma is amajor cause of
visual dysfunction
IOP is the riskfactor
progressive
structural &functional
damage to theoptic nerves
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Changes in body position can have
significant effects on IOP, with
elevations occurring in the supine and
head-down positions
The possible impact of theseelevations on glaucoma pathogenesisindicates a need to clearly understand
the effects of body position on IOP
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The magnitude of the
changes owing to body
position -> uncertain
differences between sitting
and supine IOP ranging from
0,3-5,6 mmHg
Previous studies
evaluating IOPand body position
have typically
utilized a fixed
measurement
sequence
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No previous studies have
investigated the effects ofbody position in a
randomized fashion to
eliminate the effects of
measurement sequence
In addition, the effect of
head position on IOP inhuman subjects is poorly
understood
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May beimportant
for:
Understanding
glaucomapathogenesis
Providing clinicalrecommendations
for glaucomapatients
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To investigate the effect of differenthead and body positions on intraocular
pressure (IOP) in a randomized study
Objective:
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IOPmeasurement*
Sitting
NeutralNeck
ExtensionNeck
FlexionNeck
Recumbent
SupineLeft
LateralDecubitus
RightLateral
Decubitus
* with the order of these sets of measurements randomized.All IOP measurements were performed with pneumatonometry.
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Prospective,comparative case
series
Design:
Twenty-fourhealthy volunteers
Participants:
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Healthy volunteers, male and female,
with refractive error between -4.00
and +2.00 diopters,were recruited
from students and employees ofMayo Clinic, and local area residents
Subjects were given a
complete dilated eye
examination
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systemic use of - blockers or steroids
Diabetes
Sitting IOP > 22 mmHg Any evidence of ocular pathology including
history of trauma or surgery, glaucoma,narrow angles, strabismus, infection, corneal
scarring, uveitis, or retinal tear ordetachment.
Subjects who could not tolerate neck flexion
or extension for 5 minutes duration
Exclusion criteria :
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Minimum 5 minwas allowed in eachposition before IOP
measurement STEADY STATE
Topicalanesthesia with
propacaine 0,5%
in both eyes
IOP wasmeasured usingpneumatometer
Averaged foreach eye from
three
measurements
Measurementsthat were > 3
mmHg than themean IOP were
rechecked
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Assuming sitting IOP to be 13.8+2.3 mmHg, the
necessary sample size was calculated to be 24 (
=0.05 and =0.2)
IOP measurements for right and left eyes in each
position were compared using paired t-tests
Statistical significance was assumed for P
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24
subjects*
Age
19 to
47years
7 men and 17 women
mean age of28.6+8.5 years
*All subjects were Caucasian (reflecting the ethnic makeup of the Olmsted County,
Minnesota, area) and low myopes, with a mean refractive error of -2.6+0.77 diopters(mean + standard deviation, spherical equivalent).
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Position
Intraocular Pressure (mmHg)
Right Left Bilateral
Sitting
Neck neutral
Neck extension
Neck flexion
15.0 2.1
16.5 2.6
20.2 4.1
14.6 2.0
16.3 2.8
19.4 3.7
14.8 2.0
16.4 2.7
19.8 3.8
Recumbent
Supine
RLD
LLD
17.3 3.1
18.8 2.9
17.6
2.6
17.3 2.9
17.7 3.1
18.3
2.8
17.3 2.9
18.3 3.0
17.9
2.7
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PositionPValues
Right VersusLeft
Sitting Neutral Supine
Sitting
Neck neutral
Neck extension
Neck flexion
0.24
0.45
0.15
-
< 0.0001
< 0.0001
-
0.010
< 0.0001
Recumbent
Supine
RLD
LLD
1.00
0.016
0.076
< 0.0001
< 0.0001
< 0.0001
-
0.006
0.058
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Previous studies : IOP is typically higher in
the supine position than the sitting position
The amount of increase in IOP from sitting to
supine position is greater in open-angle
glaucoma, ocular hypertension, or normaltension glaucoma compared with normal
subjects
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Most of studies performed measurements
in fixed sequence confounding factor,because the measurement sequence
affected the magnitude of the IOP change
that occurs with body position
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Other factors that may affect the IOP
change with body position are incompletely
understood
Axial length postural IOP change
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Mechanism for IOP change body position incompletely understood
Previous study
>>> EVP in recumbent position
choroidal vascular engorgement redistribution
of body fluid
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No previous study has reported the effect ofneck flexion on IOP
Klein,et.al.
>> IOP during neckhyperextention This study a significant >> neck extention
even greater >> on neck flexionhydrostatic pressure & increase of EVP
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Hwang et al alteration in IOP afterpositional change supine Lateral decubitus
2 mmHg >> IOP from supine tolat.decubitus 4 mmHg 30 minutes
This study1 mmHg after 5 on dependenteye hydrostatic effect & increase in EVP
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The observed increase in the dependent eye
may be due to the hydrostatic effects & >>
EVP
Differences in the magnitude of IOP elevation
in the dependent eye in the RLD compared
with LLD maybe caused by rightleft
differences in the cardiovascular system
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Only young, healthy subjects were included
Numerous factors -> positional changes in IOP ->
agingCircardian rhythms -> IOP changes -> unknown ->
aqueous humor dynamics variations
Further research -> to investigate the
positional changes in IOP in older subjects
and glaucoma patients
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In normal subjects, IOP is lowest whenmeasured while sitting with the neck in the
neutral position
Other head and body positions result IOP>> compared with the position used fortypical clinical measurements
RLD - LLD positions may result in a smallincrease in the IOP in the lower eye
Further research : determine whethersimilar elevations of IOP occur in glaucoma
patients
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PATIENT:24 healthy volunteers, male and female,
with refractive error between -4.00 and +2.00 diopters INTERVENTION:
IOP measurement in each sample with six differentpositions using pneumatometer
COMPARE:Comparing the IOP between sitting and recumbentposition
OUTCOME:Mean IOP is lowest when measured while sitting withthe neck in the neutral position
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TITLE
Too long / short ? Not more than 12 words, can illustratethe journal content generally
Illustrate the observedvariables ?
Yes
Non standard Abbreviation? None
Any corresponding author
and email ?
Obviously,Author : Mehrdad Malihi, MD ;
Corresponding Author : Arthur J.Sit,
SM,MD
E-mail : [email protected]
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ABSTRACT
Consists of 4 parts:
background, method, result,and conclusion ?
Yes, 4 parts: background, method,
result, and conclusion
Any keywords ? None
Do the abstract is wholly
appropriate ?Yes
AIM & BENEFIT OF THE RESEARCH
Does the aim explained ? Yes
oes the benefit explained ? Yes
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METHODS
Is there any research design ? Yes, it is explained
Population & samples Yes, it is explained
Inclusion-Exclusion Criteria Yes, it is explained
Sampling & Sample size
formulation
Yes, it is explained
Did the subject selection is
appropriate?
Is there any bias ?
Incorrect, because only young and
healthy subject involved
Treatment Yes, it is explained
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METHODS
Did the measurement blind ? NO
Is there any bias on
procedure, means, and
subject obedience ?
NO
Is there any explanation
about independent &
dependent variables ?
Yes, it is explained
Is there any operational
definition ?YES
Is there any ethical clearance
consent ?
Yes, by Institutional Review Board of
Mayo Clinic according to Declaration
of Helsinki (1989)
Data anal sis ? Yes usin aired t-tests
RESULTS
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RESULTS
Any Drop out ? None
Is there any subjectcharacteristic table ?
None
Is there any aim for the
results?Obviously
What is the main result of
the research ?
Averaged IOP in sitting with neutralneck position
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CONCLUSION
Could it be applied in
chosen sample, reachable
and target population ?
Yes, but it needs further research
Could this research be
applied for patients ?Applicable
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Source :
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Source :Liu JHK,et.al., Twenty-fourHour I ntraocular Pressure Pattern Associatedwith Ear ly Glaucomatous Changes, Investigative Ophthalmology & VisualScience. April 2003, Vol. 44, No. 4
Mean diurnal IOP (sitting/supine), glaucoma group>>>>> control group
Nocturnal supine IOP >>>> Diurnal sitting IOPDiurnal-to-nocturnal IOP increase
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IOP pattern from 5:30 7:30 AM
The two groups, the posture-independent IOPlevel changed in different : >>>> in the glaucomagroup,
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Body was tilted from standing to supine, HR > 29% (P 0.001)
The ocular perfusion pressure increases by purelyhydrostatic considerations
Longo, Antonio ,et.al., Posture Changes and Subfoveal Choroidal Blood Flow ,Investigative Ophthalmology & Visual Science. February 2004, Vol. 45, No. 2
Source :
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Source :
Longo, Antonio ,et.al., Posture Changes and Subfoveal Choroidal Blood Flow,
Investigative Ophthalmology & Visual Science. February 2004, Vol. 45, No. 2
Group Averaged Brachial Artery BP, IOP, and HR atthe Different Postures
PosturesBP Syst
(mmHg)
BP Diast
(mmHg)
BP mean
(mmHg)
IOP
(mmHg)
HR
(b/min)
Baseline 116 1581 7 96 10 13 1 82 13
Supine124 13 75 6 95 8 17 2 69 10
Recovery117 15 81 6 96 9 - 80 11
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Hydrostatic pressure occurs in the vascular system
because of the weight of the blood in the vessels.
The positional hydrostatic factor = p x g / 1360 x hmmHg
p : blood density (1.05 g/cm3)
g : acceleration due to gravity (980 cm/sec2)h : height from the reference point (cm)(- n ) for above the reference
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IOP >> from sitting to supine4,4 mmHg Control Group4,0 mmHg Ocular Hypertension
4,1 mmHg Low Tension Glaucoma
Pressure increase in Episcleral vein
Indicate that some glaucoma patient exhibit faultyregulation of central artery blood flow duringposture change
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Significant reduction in IOP, measured with CT80post Goldmann tonometer, 1 mmHg
Due to a decreased anterior chamber volume due toincreased aqueous outflow
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As eyes move from above heart level (sitting/standing position) to heart level (supine position)or even below heart level (inverted position), the
episcleral venous pressure increase -> resistance
That must be overcome for aqueous passage
through the trabecular pathway, and so it is the keydeterminant of steady state IOP
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Utilizes a pneumatic sensor (consisting of apiston floating on an air bearing).
Filtered air is pumped into the piston and travels
through a small (5-mm diameter) membrane atone end. This membrance is placed against the cornea.
The balance between the flow of air from themachine and the resistance to flow from the
cornea affect the movement of the piston andthis movement is used to calculate the intra-ocular pressure.
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The pressure inside an ideal dry, thin walledsphere equals the force necessary to flatten its
surface divided by area of the flattening
P = F / A
P = PressureF = ForceA = Area
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IOP in the undisturbed eye :
P0 = (F/C) + Pv
P0 = Intra Ocular Pressure in mmHgF = rate of aqueous formation in L/min
Pv = Episcleral Venous Pressure (mmHg)C = 1/R R = resistance to outflow
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Friedenwald(1948) found the average normalcoefficient ofocularrigidity to be K = 0.0245
Pt 1 : tonometric pressure V 1 : volume of the indentation caused by the
bar in the determination made with the first
weight Pt 2,V 2 : values as obtained with the second
weight; K : coefficient of ocular rigidity