Abstract
The case of a 78-year-old man with progressive glaucoma despite seemingly adequate control of his intraocular eye pressure is presented. On further questioning he was discovered to have played the trumpet for up to 4 h per day for 60 years. Significant increases in intraocular pressure were subsequently recorded during trumpet playing.
BACKGROUND
Glaucoma is a neurodegenerative disease of the optic nerve. Elevated intraocular pressure, increase in age, reduced central corneal thickness and vasospasm are established risk factors for glaucoma. Risk factor analysis is important in predicting the likelihood and rate of glaucoma progression.1 We report a case where progressive glaucomatous optic neuropathy was evident in the absence of overt risk factors for glaucoma.
CASE PRESENTATION
A 78-year-old man was referred with progressive reduction in visual function in the right eye over recent months. He had been diagnosed with having primary open angle glaucoma 2 years earlier. Topical ocular medications used to lower his intraocular pressure included a prostaglandin analogue and a β-blocker. His medical history included a transient ischaemic attack, hypertension and hypercholesterolaemia. There was no history of migraines, Raynaud phenomenon, diabetes or systemic corticosteroid use. He had no family history of glaucoma. A CT scan of the orbits and brain was normal.
On examination his best corrected visual acuity was 6/12 in the right eye (OD) and 6/7.5 left eye (OS). His intraocular pressures (IOP) were 16 mm Hg OD and 14 mm Hg OS. Anterior segment examination was unremarkable with no evidence of pigment dispersion or pseudoexfoliation syndrome. Gonioscopy revealed open iridotrabecular drainage angles. Central corneal thicknesses were in the normal range at 525 μm (both eyes). Fundoscopy showed advanced loss of the neuroretinal rim in both optic nerves with corresponding loss of the retinal nerve fibre layer indicative of advanced glaucoma. Visual field analysis showed corresponding loss to the visual field (fig 1)
Figure 1.
Progression of visual field in both eyes between 2005 and 2008.
On subsequent questioning it became apparent that the patient had been a wind instrument player for over for over 60 years. He played the trumpet, cornet or trombone between 1 and 4 h per day. His intraocular pressures (IOP) were subsequently found to increase significantly while playing. Using a handheld tonometer (Icare, Helsinki, Finland; fig 2) his baseline IOP increased from 14 mm Hg to 36 mm Hg with trumpet playing a high C, 26 mm Hg with cornet and 21 mm Hg with trombone. At 10 min after playing, the IOP returned to baseline.
Figure 2.
Intraocular pressures (IOP) being measured during trumpet playing.
DISCUSSION
Wind instrument musicians experience transient elevation in their IOP while playing.2 Schuman and colleagues reported a small but significant increase in the prevalence of visual field loss and greater IOP elevation in players of high-resistance wind instruments (eg, the trumpet) compared to low-resistance instrument players (eg trombone). The same study reported increased uveal engorgement on forced exhalation, via a Valsalva manoeuvre, providing a mechanism for IOP elevation. A further study3 measured IOP in members of an orchestra before and after a 90 min rehearsal. Wind instrument playing significantly increased the mean IOP by 9.6% (p=0.0149). Wind instrument playing has also been linked to other ocular complications such as recurrent retinal vein occlusion, again the Valsalva manoeuvre the likely catalyst.4
Intermittent IOP elevation due to many hours of playing wind instruments likely led to progressive glaucomatous optic neuropathy in this patient. Management options included a reduction in playing or glaucoma surgery. The patient elected to discontinue playing the trumpet and reduce the amount of time that he played the trombone. Glaucoma progression has since abated.
LEARNING POINTS
This case demonstrates that cumulative effects of long-term intermittent intraocular pressure (IOP) elevation that occurs during high-resistance wind instrument playing may result in glaucomatous damage.
Obtaining a thorough history for high-resistance wind instrument playing in cases of presumed normal tension glaucoma may provide a helpful clue in identifying the aetiology.
Footnotes
Competing interests: none.
Patient consent: Patient/guardian consent was obtained for publication.
REFERENCES
- 1.Bron A, Chaine G, Villian M, et al. Risk Factors for primary open-angle glaucoma. J Fr Ophtalmol 2008; 31: 435–44 [DOI] [PubMed] [Google Scholar]
- 2.Shuman JS, Massicotte EC, Connolly S, et al. Increased intraocular pressure and visual field defects in high resistance wind instrument players. Ophthalmology 2000; 107: 127–33 [DOI] [PubMed] [Google Scholar]
- 3.Aydin P, et al. Effect of wind instrument playing on intraocular pressure. J Glaucoma 2000; 9: 322–4 [DOI] [PubMed] [Google Scholar]
- 4.Sbeity ZH, Mansour AM. Recurrent retinal vein occlusion after playing a wind instrument. Graefe Arch Clin Exp Opthalmol 2004; 242: 428–31 [DOI] [PubMed] [Google Scholar]