T Nation

Eye Issues


#1

I was just diagnosed with something called Anterior Ischemic Optic Neuropathy. I have a swelling in the optic nerve of my dominant eye and have lost as a consequence approximately 25% of my vision in that eye. I am about to turn 54.

The neuro-ophthalmologist said I have to stop lifting heavy (and stop lifting altogether for a few months). I actually don't lift that heavy, but he said lifting has caused a buildup of pressure in the capillaries surrounding my optic nerve and caused a partial die-off.

He said some ignorant things about lifting in general ("the human body is not made to lift 300lbs when you are 55 years old...", etc.), so I am skeptical about this assessment. In any case, I am looking for comments, and should I decide to stop the heavier weights, looking for a program that makes sense to stay fit and moderately muscular as I age.


#2

Very sorry to hear this. AION is a tough condition to have.

Before I go further, I have to make one thing clear. I am an ophthalmologist, but I am not YOUR ophthalmologist. So the thoughts and info I share are not intended as medical advice, and shouldn’t be taken as such.

Dr. Sohan Hayreh of the Univ of Iowa is one of the world’s leading authorities on AION. The following is his list of systemic risk factors for NA-AION (‘NA’ designates the subtype of AION you have):

–arterial hypertension, nocturnal arterial hypotension
–diabetes mellitus
–ischemic heart disease
–hyperlipidemia
–atherosclerosis and arteriosclerosis in NA-AION patients compared to the general population
–sleep apnea
–arterial hypotension due to a variety of causes
–malignant arterial hypertension
–migraine

http://www.medicine.uiowa.edu/eye/AION-part2/

You will note that ‘weightlifting’ does not appear on this list. Now, does this mean weightlifting is in the clear? Unfortunately, no; Dr. Hayreh’s list of risk factors represents his compilation/distillation of the relevant medical literature, so all it means is there are no convincing studies in that literature implicating weightlifting as a cause of NA-AION. And while the absence of such studies might be due to the fact that no such relationship exists, it might also be because no researcher has looked for such a relationship (possibly because there are relatively few 50+ year-olds who lift weights). There’s an old saying: ‘The absence of evidence is not evidence of absence.’ It applies here.

You mention in the OP that you are “skeptical” regarding the assessment offered by the neuro-oph. Not surprisingly, this skepticism has left you reluctant to undergo the ‘treatment’ (= abstaining from heavy weightlifting) that was recommended. IMO, the appropriate response to such skepticism is to seek a second opinion. See another neuro-oph.

Let him/her know how important weightlifting is to you, and ask for an opinion concerning what level of increased risk weightlifting would pose vis a vis another ischemic event. (Bear in mind that having NA-AION in one eye means you run a 15-25% chance of it occurring in the fellow eye at some point in the next few years.) Don’t ‘doctor shop’; that is, don’t go from doctor to doctor until you find one who will tell you what you want to hear.

Rather, find another well-credentialed neuro-oph (those affiliated with university health centers are usually highly experienced and well-read), and see how his/her recommendations square with those of your first doc.

Sorry for the wall of text. Best of luck with all this.


#3

EyeDentist: extremely helpful. Thank you! Two other factors that he seemed to think important (I post just for general knowledge). I am on a lose dose (1ml) per week of Test Cyp, some anastrozolw, and HCG, as part of an HRT regimen. He, of course, wants me to stop this. And finally, because he is running a study on this, I have taken Cialis in the past. He believes that there may be a correlation between sildenafil and these events. Nothing about weightlifting there, but he indicated he has a couple other patients who lift, take sildenafil, and also have had ischemic optic nerve events.


#4

[quote]bjjnova wrote:
EyeDentist: extremely helpful. Thank you! Two other factors that he seemed to think important (I post just for general knowledge). I am on a lose dose (1ml) per week of Test Cyp, some anastrozolw, and HCG, as part of an HRT regimen. He, of course, wants me to stop this.
[/quote]

I can see why he would–HRT is known to affect certain parameters of the circulatory system, and NA-AION is a circulatory problem. He’s being cautious/conservative.

The link between phosphodiesterase type-5 (PDE-5) inhibitors (Viagra, Cialis, etc) and NA-AION is controversial; research is ongoing. Based on my understanding of the literature, I think it’s safe to say that if a causal relationship exists in the general population–ie, if PDE-5 inhibitor use does in fact increase the risk of NA-AION–the effect is fairly small. That said, it is important to recognize that you are NOT a member of the general population, in two respects:

  1. you are on a fairly aggressive HRT regimen (which is known to influence the status of the circulatory system, as mentioned above); and
  2. you are a weightlifter, and thus periodically subject the circulation of your optic nerve head to dramatic swings in perfusion pressure.

So in a nutshell, you are in uncharted waters–there’s simply no way to pin down to what extent (if any) your HRT, PDE-5I and/or weightlifting increase your risk of a second occurrence of NA-AION.

[quote]
Nothing about weightlifting there, but he indicated he has a couple other patients who lift, take sildenafil, and also have had ischemic optic nerve events.[/quote]

While anecdotal, that is worrisome. I hope he will write up a case series and publish it.


#5

Don’t want to thread jack OP, but couldn’t figure out how to PM Eye Dentist.

I have Keratoconus and am scheduled for cross linking in two weeks. Being that it is a trial procedure, I’m a bit nervous. Also, given my location there aren’t a lot of reasonably close places to get a second opinion. Especially, since the first doctor I saw, at a different practice, thought I had cataracts. The 3 doctors I spoke to, at the practice that I am scheduled to have the procedure, all independently said cross linking is my best option…

Just curious what your thoughts are on cross linking vs. alternatives (cornea transplant, etc).


#6

[quote]dchris wrote:
Don’t want to thread jack OP, but couldn’t figure out how to PM Eye Dentist.

I have Keratoconus and am scheduled for cross linking in two weeks. Being that it is a trial procedure, I’m a bit nervous. Also, given my location there aren’t a lot of reasonably close places to get a second opinion. Especially, since the first doctor I saw, at a different practice, thought I had cataracts. The 3 doctors I spoke to, at the practice that I am scheduled to have the procedure, all independently said cross linking is my best option…

Just curious what your thoughts are on cross linking vs. alternatives (cornea transplant, etc). [/quote]

Bearing in mind that I am speaking about corneal cross linking (CXL) and penetrating keratoplasty (PK) in general, and not about your case specifically…

IMO, CXL represents a significant advancement in our ability to manage keratoconus (KCN). CXL is one of the few procedures that has been demonstrated to slow or even stop the progression of KCN. And while CXL is not risk-free (there’s no such thing as a risk-free surgical procedure), I can tell you it is considered to have a good safety profile. If I had KCN and my cornea specialist thought I was a good candidate for CXL, I would undergo it. I would certainly have it done prior to PK. PK is a good procedure and can deliver excellent visual results, but it is far more invasive than CXL, and carries a much more significant complication profile.

And if CXL fails to prevent further progression of KCN, one can always proceed to PK.

As an aside, if your ophtho should ever decide you are in need of a transplant, ask whether you are a candidate for lamellar keratoplasty (eg, deep anterior lamellar keratoplasty, or DALK). Lamellar keratoplasty has the distinct advantage (over PK) of being a non-penetrating procedure; ie, only the diseased portion of the cornea is swapped out for a donor button, while the healthy layers are left intact. Very cool procedure.

Best of luck with whatever you decide to do.


#7

Again, thank you EyeDentist for your help. I haven’t found many doctors in general who are very sympathetic to choices made by the weightlifting community; that said I am seeking a second opinion just to hear what another specialist may have to say. Could you recommend any reading, even of a technical sort, on AION and on the kinds of pressure changes you mentioned that come about through lifting. I doubt there is much of the latter published with respect to eye concerns specifically, but I would be interested in any medical articles that discuss the impacts of lifting on areas in the head. Hope that makes some sense. Thank you again.


#8

What I am trying to do is put together a plan for some kind of workout that will not impact optic nerve pressure (for example, can I do bodyweight exercises); hence my interest in those articles. I also am trying to figure out whether working out (of any sort) now will have any impact on the swelling that has taken place in the optic nerve. And finally, trying to understand whether holding breath during exercise of any kind will have impact on that perfusion pressure.


#9

[quote]bjjnova wrote:
Could you recommend any reading, even of a technical sort, on AION
[/quote]

Dr Hayreh’s work is a good place to start. The less-technical, pt-friendly version:

http://www.medicine.uiowa.edu/eye/AION-part1/

The more-technical version for ophthalmologists:

http://www.medicine.uiowa.edu/eye/AION-part2/

Note that you can skip all the material on arteritic AION (AAION), as it is a completely different condition that your neuro-oph is not treating you for.

There is very little extant medical literature concerning weightlifting and the eye. That said, in his technical review Hayreh discusses autoregulation of blood flow in the optic nerve head (ONH) circulation, and how this autoregulation fails at both low and high perfusion pressures (see Figure 2). During heavy weightlifting, perfusion pressure (equals mean arterial pressure minus intraocular pressure) spikes dramatically (especially if the Valsalva maneuver is employed). Fundamentally, NA-AION represents a failure of ONH autoregulation, resulting in hypoperfusion of the ONH. Like any tissue in the body, once the ONH is underperfused to a great enough extent, the affected cells die, resulting in vision loss.

Not related to NA-AION, but because you asked…

Weightlifting and Valsalva retinopathy:

(See Case 6)

Weightlifting and glaucoma:

http://abstracts.iovs.org/cgi/content/short/45/5/967

But see also:

Occupational lifting and retinal detachment:


#10

I posted the above comment prior to seeing this one.

[quote]bjjnova wrote:
I also am trying to figure out whether working out (of any sort) now will have any impact on the swelling that has taken place in the optic nerve.
[/quote]

I am unaware of any literature addressing this (very good) question, so any ophthalmologist will be flying blind on this (if you’ll pardon the expression). That said, I could see how a compelling argument could be made that swelling of the ONH in the acute post-NAAION period might compromise its circulation even further (ie, by physically compressing and thus narrowing its arterioles), and thereby render it more vulnerable to autoregulatory problems. This suggests that, in the acute post-event period, one should avoid any activity that might negatively impact ONH circulatory autoregulation (ie, don’t do anything that places the eye at either end of Figure 2 in the Hayreh review article).

[quote]
And finally, trying to understand whether holding breath during exercise of any kind will have impact on that perfusion pressure.[/quote]

It definitely does. The glaucoma links above are relevant in this regard.


#11

[quote]EyeDentist wrote:
If I had KCN and my cornea specialist thought I was a good candidate for CXL, I would undergo it.[/quote]

Thanks, I really appreciate it. Given that you know A) I have kerataconus. B) know Im approved for cross linking and C) would do it yourself given A & B helps ease my nerves a bit.

I dont feel that the ophtho was necessarily salesy, when it came to his recommendation, but the fact that he didnt offer other options felt slightly uneasy, mainly because it is a trial procedure.

My main concern has just been, at 24, will there be a better long term procedure, which doesnt require permanently freezing my oddly shaped eyeballs and hard contacts for the rest of my life. Although, my eyes have quickly gone from “not that big of a deal” to “crap, now I can’t drive”; I just can’t wait much longer to get it fixed.

[quote]EyeDentist wrote:
As an aside, if your ophtho should ever decide you are in need of a transplant, ask whether you are a candidate for lamellar keratoplasty (eg, deep anterior lamellar keratoplasty, or DALK). Lamellar keratoplasty has the distinct advantage (over PK) of being a non-penetrating procedure; ie, only the diseased portion of the cornea is swapped out for a donor button, while the healthy layers are left intact. Very cool procedure.

Best of luck with whatever you decide to do.
[/quote]

Sounds really Interesting, I definitely will. It’s crazy what can be done with eyes and very small blades.

Really appreciate everything, thanks!


#12

[quote]dchris wrote:

I dont feel that the ophtho was necessarily salesy, when it came to his recommendation, but the fact that he didnt offer other options felt slightly uneasy, mainly because it is a trial procedure.
[/quote]

CXL is currently undergoing Phase 3 clinical trials; with luck, it will be approved some time next year. One of the main reasons CXL has yet to be FDA-approved is that no manufacturer was willing to fund the clinical trials necessary to do so. Because the procedure relies on well-established materials (riboflavin and UV light), companies were concerned that they would be unable to establish proprietary control over the materials/procedure. Not surprisingly, no company was willing to spend millions of dollars on clinical trials to get the procedure approved when faced with the possibility their competitors would be able to start selling it immediately. In fact, it wasn’t until the FDA granted “orphan drug” status to one company’s riboflavin solution (which gives them some exclusivity rights) that the clinical trial process started proceeding again.

There’s always that chance, certainly. I for one am not aware of anything coming down the pipeline at the moment, however.

Yep. It’s hard to explain to people just how visually debilitating KCN is.


#13

You may not want to answer this, but if you, knowing what you know, were diagnosed with this, what would you do vis a vis working out? Would you quit load-bearing exercise altogether? change your weightlifting to bodyweight exercises only? change to aerobic exercise? What bothers me is that everything that I am reading seems very tangential a representative of potential problems that aren’t well-represented in the studies (possible raised arteriole pressure during exercise but no clear studies about that; raised perfusion pressure but no clear connection between that and AION because all studies are done on intraocular pressure with respect to glaucoma, etc). And while the stakes are very high - my vision - working out under loads is not just a pass time; at my age it’s kind of essential too (for maintaining mobility, for combating the eventual dissolution of posterior chain strength and the impact that would have on mobility, and not least for combating the other debilitating impacts on strength and mobility of growing older).

Sorry to sound petulant; I am frustrated: I haven’t found any other ophthalmologists in the area that take load-bearing exercise very seriously. And not many other doctors seem to know much about AION at all.


#14

[quote]bjjnova wrote:
You may not want to answer this, but if you, knowing what you know, were diagnosed with this, what would you do vis a vis working out? Would you quit load-bearing exercise altogether? change your weightlifting to bodyweight exercises only? change to aerobic exercise? What bothers me is that everything that I am reading seems very tangential a representative of potential problems that aren’t well-represented in the studies (possible raised arteriole pressure during exercise but no clear studies about that; raised perfusion pressure but no clear connection between that and AION because all studies are done on intraocular pressure with respect to glaucoma, etc). And while the stakes are very high - my vision - working out under loads is not just a pass time; at my age it’s kind of essential too (for maintaining mobility, for combating the eventual dissolution of posterior chain strength and the impact that would have on mobility, and not least for combating the other debilitating impacts on strength and mobility of growing older).

Sorry to sound petulant; I am frustrated: I haven’t found any other ophthalmologists in the area that take load-bearing exercise very seriously. And not many other doctors seem to know much about AION at all.[/quote]

Non-ophthalmologists generally know very little about the eye, and trust me when I say there’s a lot to know. (The medical literature in ophthalmology is second in size only to that of Internal Medicine.) This is why there are ophthalmologists in the world.

As for what I would do…The fundamental issue is one of risk stratification and amelioration. First, the risk factors for another event must be identified. Then it must be determined what intervention (if any) can potentially ameliorate each risk factor. Finally, a cost-benefit decision needs to be made re each potential intervention; ie, it must be decided whether the resulting risk reduction is worth the cost of the intervention itself.

From what you’ve shared here, your risk factors may include:

  1. History of NA-AION; ie, it’s already happened to you. This is the #1 factor putting you at risk for a second event. Unfortunately, until/unless a time machine is invented, this factor is not modifiable.
  2. Age; gender. (Ditto)

Then there are the modifiable ones:

  1. PGE-5I (Cialis) use
  2. TRT
  3. Weightlifting

Other potential modifiable risk factors include diabetes, hypertension, hypOtension, hyperlipidemia, sleep apnea, hyperviscosity, and others.

So here’s what I would do. I would create with my doc(s) an itemized list of my NA-AION risk factors. For each, we would come up with an estimate of how significant a risk factor it is. Then, for each modifiable factor we would determine what interventions might be undertaken to reduce the risk, and how much the risk would be reduced. Once this is done, a decision can be made regarding which interventions are worth undertaking.

Recall that the medical literature indicates the baseline risk of a second NA-AION event is 15% (at a minimum). So that’s your risk ‘floor,’ in that no intervention can take you below that number. The issue becomes, how high that number climbs when your other risk factors are tabulated.

This discussion is likely to require you to make some difficult, life-altering decisions. I hope it all works out for you.