 Alright, really excited to be able to talk to you all today about a topic that's near and dear not only to my heart but to my eyes. We're talking about the ocular hazards of trumpet playing and the reason I talk about this is, this is me as you can see here and before residency I was a pretty active musician of the community here. The clip you're hearing is an old jazz standard that I was playing at a club and I had a really good opportunity to be able to work with a lot of different musicians, record with a lot of different musicians without ever thinking about that there were ocular consequences to playing an instrument and I don't think most of the musicians know about that either. There we know about the musculoskeletal consequences, we know about the pulmonary consequences but actually thinking about the ocular consequences is something that is not very well known. So thinking about this, we have the good fortune to work with people here like Dr. Orozco who never fails to remind us to think about outside the box, think about other things when we're looking at patients who don't seem to be responding to things the way we want them to or who are progressing despite our best treatments. And so today we're going to take a look at kind of a deeper look into some of the ocular consequences of playing the trumpet and how those can manifest in musicians as we go. So it's important to talk first about how brass instruments work. This is an important concept in looking at why there might be ocular consequences. So I give a lecture, I give a talk to elementary students every year and I tell them that the trumpet is basically a megaphone. It works to amplify what the musician puts into it. And what musicians put into it is vibrations and I'm going to show you just what those vibrations sound like here so you can see how we make sound on the trumpet. So you can see that the trumpet serves to amplify the vibrations that we make with our mouth. The way we make those vibrations has been such a bit of controversy in the literature here and it comes down to this idea of a valsalva. The valsalva is classically divided into four phases. I think we're all familiar with what a valsalva is. But a valsalva typically has a rise in blood pressure with inspiration due to compression of the thoracic aorta. It's subsequently followed by a fall in blood pressure with decreased venous return and closure of the glottis. When the glottis is released there's a drop in a thoracic pressure with restoration of venous return and there's subsequent increased cardiac output with reflex bradycardia. Graphically it looks like this. We can see as we go here we have that rise in blood pressure initially followed by the fall in blood pressure as the glottis opens. We see the change here with the subsequent rise in blood pressure, cardiac output and the subsequent reflex bradycardia. The reason why this is controversial in trumpet playing is because playing trumpet with a closed glottis results in poor tone, it results in decreased range, just poor sound overall. And so there's numerous articles, numerous books in the trumpet literature written about how to avoid playing with a closed glottis. And so when people would talk about that when you're playing a brass instrument that you're doing a valsalva, brass instrumentals don't really like to hear that because we don't like to think that we're playing with a closed glottis. It turns out though that when you actually look at the physiology of playing an instrument it seems that there probably is some physiology that's consistent with a valsalva when you're playing an instrument. So this is an article that took two of the players and had them play different tones and they looked at different hemodynamic properties that are shown here. I want to highlight just a few things here. You can see that when in the middle notes and higher notes these are very defined changes in blood pressure and heart rate. And when we compare it to our classic description of a valsalva we can see that the hemodynamics are actually very similar. And so while we may not be playing with a closed glottis the hemodynamics are very similar and there's likely some component of a valsalva when brass musicians are playing. And that's an important concept to understand here. Now we're going to talk about intraocular pressure changes in brass musicians because this isn't an important segue into what we need to know. So there have been multiple studies that have demonstrated increased intraocular pressure with valsalva maneuvers. But one of the first major studies to look at intraocular pressure changes in brass musicians was done in 2000 by Joel Schumann's group at Tufts. This is a multi-part study. We're going to talk about all the parts of the study as we go. But the first part of the study took three musicians with opening Google Oklahoma who underwent continuous intraocular pressure monitoring while playing as well as undergoing ultrasound to evaluate uveal thickness. Interocular pressure monitoring was done in both the supine and the sitting-up position. The patients were asked to play normally and then to play quite loud. You can see there's significant increase in intraocular pressure in all subjects actually quite dramatically. So you can see that in what they consider a high-resistance wind instrument, so the oboe and the trumpet, intraocular pressures rose into the 40s where in the clarinet and saxophone, some of the lower-resistance instruments, the intraocular pressure rose to a lesser degree. This is a tracing of the continuous pneumon tenometry that they did. And you can see here they asked the participants to begin playing here. There was a slow, kind of a very mild increase in pressure. And as we asked the participants to increase their volume in their pitch, we see a much greater increase to their maximum pressure here of around 40, okay? Now one of the critiques of this study was this. So this is how they tested the continuous pneumon tenometry. And this is not a physiologic way of playing. No one plays trumpet like this. And so the critique was that, well, we're not doing these measurements under normal conditions. We're changing the way the inner thoracic and the inner intradominal muscles work. We're probably increasing the back pressure because, I mean, it looks like he's working pretty hard here. And so, you know, these pressures may be falsely elevated in the setting of this kind of non-physiologic way of playing. So in 2010, a second study came out that looked to identify the pressure changes under more normal playing conditions. In this study, we took 37 professional brass players and 50 professional woodwind players and had them play under more normal conditions. So for the first part of this, we had them play tones of normal or low, middle, and high frequencies with increasing volumes. And then the second part, they played standard exercises, standard literature for 10 minutes followed by a high frequency note with maximal exertion. And what we see is this. So this bottom graph here shows the changes in intracular pressure, the mean changes in intracular pressure for each pitch that was played. Every pitch that was played showed an increase in about three to four millimeters of mercury for each pitch. And that was a significant difference. What's shown up top here, and I'm going to blow it up force right here, is the outliers. And so for each pitch that was played, they showed the maximum pressures for those different tones. And you can see that for these different pitches, even just playing a normal pitch at a normal frequency and a normal volume, this is a pretty significant increase in some of these participants, getting as high as 48 in playing a middle frequency note. You can see the percentage of participants who got into the ocular hypertension range raise these frequencies as well. Chris, how did they measure the pressure? So this was done with an eye care. This one with eye care. And one of the limitations here is that they didn't specify whether these participants for the different frequencies were the same participants who had these spikes or whether they were different participants, which would have been something good to know to analyze this data a little bit better. From the short-term playing results, when they had the participant play for 10 minutes, you can see a small increase in pressure with reduction in pressures as we continued. And then when they asked them to play with maximum adhesion after that 10 minutes, we saw a significant spike. And again, pretty significant spikes in these outliers here, going all the way up to nearly over 50. 50% of these musicians reached ocular hypertension level. One asked to play this high note here. They didn't see any difference in short-term playing versus high and low resistance instruments, but there was a significant difference for increases in intracular pressure in middle and high-frequency tones between higher resistance instruments and the lower resistance instruments. And so their conclusion was the sustained tones caused significant elevation and intracular pressure in brass players shown in this study. I want to mention one more study on intracular pressure. This was done in 2017. This is another two-part study. The first part, they evaluated intracular pressure after having musicians play for 20 minutes. They took 42 wind musicians, professional and amateur musicians, and nine subjects had existing diagnoses of glaucoma. The second part of their study looked at 24-hour intracular pressure monitoring with a trigger-fish contact lens. So we can see here the demographics of the professional and amateur musicians and the intracular pressure change 20 minutes after playing their instrument. Interestingly, there was a significant change with higher pressures noticed in professional musicians as opposed to amateurs. And there really wasn't a good explanation for why this happened. It's an interesting finding, and it needs to be looked at further, but just kind of something to note there. That was the only significant thing that they found here. Looking at differences between patients with glaucoma and no glaucoma, there wasn't any significant difference found in pressure changes between those two groups. And this brings up the question of auto-regulation. So the thought was that they measured intracular pressure after playing the instrument for 20 minutes. They didn't do any measurements during playing. And so the question was, as auto-regulation happens, is it bringing these pressures back down to the point where now we measure it after 20 minutes, the pressures are back to a more normal range. Falsely showing us that there wasn't any significant difference. Again, just something to think about there. The second part of their study had them use a trigger-fish contact lens in 24-hour intracular pressure monitoring in patients with glaucoma. And you can see that there are atomic history here in medications that a couple of these patients were on. Just as an aside, this is what the trigger-fish contact lens looks like here. This is oftentimes attached to a base station that records the intracular pressure monitoring data. And interestingly, the trigger-fish lens doesn't measure intracular pressure directly. It measures strain differences, is how they describe it. So it measures changes in intracular pressure, changes in intracular volume, and changes in ocular elasticity. And so the trace things that you'll see here don't correlate with the intracular pressure directly. This study, unfortunately, has some problems. There were recording difficulties with the contact lens and over half of the participants here, which makes the data a little bit difficult to interpret. Interestingly, though, in a couple of these participants, you can see spikes when the participants were playing. But even in some of these participants, you can see higher spikes even when they were sleeping as opposed to when they were playing their instruments. So I guess there were some problems with the data here as opposed to how they recorded it and the recording methods of the trigger-fish lens. But this would be another interesting thing to look at as the technology for 24-hour continuous monitoring improves, repeating something like this to see if there are significant alterations in participants as we go along. So we've seen, though, that there are increases in intracular pressure. But are these increases clinically significant, meaning do these changes in intracular pressure cause changes in visual fields or cause risk of progression of glaucoma? So the second part of Schumann's study looked at 46 volunteer musicians stratified in the high and low resistance and non-wind instruments. All of these musicians underwent comprehensive exams with gonioscopy, dilation, and visual fields. This is showing how they graded visual fields and they reported the presence of abnormal fields and they reported the presence of pattern standard deviation of these fields. The results showed no difference in optic nerve-head appearance based on a clinical exam, but three of nine high resistance wind instruments musicians had abnormal visual fields compared to one of 11 in two of 23 non-wind instruments. The participants with abnormal visual fields had significantly increased pattern standard deviation scores, which I've shown here almost double their correct pattern standard deviation. Now, unfortunately, they didn't specify what kind of visual field defects. They didn't really give any additional information, just that there was an increase in these high wind resistance instruments in their level of abnormal visual fields. They also found in a regression analysis that life hours of playing showed significant relation with the development of an abnormal visual field. You can see here that they showed significant increases in significant relations rather with abnormal visual fields. And the numbers that they gave were, for every 1,000 hours of playing a high resistance wind instrument, it predicted a 0.009 increase in pattern standard deviation for these musicians. So the limitations here, obviously, this is a small sample size. They didn't specify any visual field defects. And kind of a common theme in a lot of these studies is that they're not taking into account other comorbidizignally devalcometer standards, such as sleep apnea, hypertension, and those other things that we know can be pretty significant influencers now. A second study came out in 2018 looking at visual field changes in players in a Philadelphia orchestra. So 51 musicians from the Philadelphia Orchestra, 21 wind musicians, 39 wind musicians, and six patients in this group with either self-reported glaucoma or glaucoma suspect. They did baseline screening exams on all 51 musicians, which included visual acuity, intracular pressure measurements, and dilated or undilated fundus photography. Mass specialists reviewed the imaging classified. The optic nerve is either glaucoma suspect or normal based on the criteria listed here. And the optic nerves are also graded according to the disc damage likelihood scale, with scores assigned from one to 10 to raise their risk of having comorbidizign damage. They identified 17 musicians with suspicious optic nerves, nine wind instrumentalists, and eight nano-wind instrumentalists. And of those 17, 12 came back for more comprehensive exams, which included picimetry, visual fields, goniascopy, and an undilated fundus exam. And from here, patients were diagnosed as either having glaucoma, being a glaucoma suspect, having ocular hypertension, or having no glaucoma disfeatures on their exam. So this is a table from the chart, and I'm gonna highlight just a couple of things. Number one, we see that the age of the wind instrumentalists compared to the nano-wind instrumentalists were significantly different. Wind instrumentalists had it more significantly older. We also see that the visual field defects here were significantly greater in wind instrumentalists as opposed to nano-wind instrumentalists. There are many deviations here. None of the other things, central conial thickness, the damage likelihood score, a couple of disc ratios, none of these other things really had any significance aside from these two findings here. And what they did here was a multi-variable regression, similar to what Schumann did that showed a significant increase in practice time and a significant correlation with practice time and visual field defects. I've written it out here for us, but they showed that there's a 0.7, a 0.07 increase in visual field mean defect for an hour, a thousand hours increase in cumulative practice time. So it looks like there's something there. Again, this is a small sample size. There's no discussion over the medical comorbidities. Most of these participants were first-time visual fieldtakers, and there was really a lack of OCT data. They did clinical exams, but didn't look at any OCT data. So what are some possible mechanisms for visual field loss? Obviously, the easy answer is elevated intracular pressure. So there's multiple proposed mechanisms for elevated intracular pressure in musicians, and it all goes back to this idea of the Valsalva. Valsalva's cause elevated intracurricular pressure, which reduces venous return and increases venous backflow. This can cause elevated episcleral venous pressures and can lead to pervodal engorgement leading to expansion and subsequent rises in intracular pressure. And this was demonstrated in Schumann's study where they looked at the anterior uveal thickness in the musicians as they played. Prior to playing, you can see the anterior uveal thickness right here as 0.371 millimeters as they played that uveal thickness increased here. And the thought was due to engorgement of the uvea from elevated episcleral venous pressure. There's also the thought that intermittent angle closure may have a role in these changes as well. There were multiple studies that have showed reductions in anterior chamber depth and narrowing of the angles during Valsalva maneuvers. And this is an anterior segment OCT to show the different measurements that can be taken for these studies. Patal in 2016 published a study of 22 professional Indian wind musicians. They did comprehensive exams on all these patients with intracular pressure measurements and gonioscopy. And none of these patients had narrow angles. They all were documented as open. But what they found in these, what 72% of these wind musicians had pigment clumps and multiple pigment clumps in the angle compared to 9% of age match controls. And this picture doesn't project very well, but they're trying to demonstrate the pigment clumping that they found. And their conclusion was that these pigment clumps are records or evidence of prior episodes of intermittent angle closure. And the thought was that as these wind musicians are doing these Valsalvas, are they having increased episodes of intermittent angle closure leading to these elevated pressures? Elevated central retinal venous pressure is also something that needs to be considered. So CRVP has been shown to be elevated in patients with glaucoma. And this study that was done in 2014, 96% of normal controls showed spontaneous venous pulsations compared to 46% of early glaucoma and absent venous pulsations in those with advanced glaucoma. There is significantly elevated CRVP in these patients with glaucoma. Here they use contact dynamometry to determine the retinal venous pressure. And what they found was that in controls without glaucoma, their retinal venous pressure was around 14 millimeters of mercury as a mean value. In those with intermediate to advanced glaucoma, their retinal venous pressure was significantly elevated almost to 40 millimeters of mercury. And this resulted in significantly reduced ocular perfusion pressure with controls having ocular perfusion pressures right around 50 millimeters of mercury. And those with intermediate to advanced glaucoma having a nearly half reduction in their ocular perfusion pressure. In trumpet players, this is a study that just was published this year also showing that central retinal venous pressure can be elevated in trumpet playing. Here, they took 20 amateur trumpet players who underwent measurements of interocular pressure in retinal venous pressure with dynamometry while playing a standard kind of middle frequency tone in the trumpet. You can see their setup for what they did here. It looks a lot nicer, more physiologic than what the previous studies looked like. And this study actually did a really good job of taking out people with systemic comorbidities like sleep apnea, like hypertension and ocular comorbidities that could influence the results of the study. And so what they found was that central retinal venous pressure became significantly elevated during trumpet playing and became much more elevated than interocular pressure actually. So the baseline mean value for retinal venous pressure in these participants was around 21 millimeters of mercury. And when they played trumpet, retinal venous pressure increased to 56 millimeters of mercury with a max and one participant of 80 millimeters of mercury. This showed that again, that there's a decreased ocular perfusion pressure which can have impacts not only retinal circulation but also on the abdomen nerve as well. And this has been potentially implicated, elevated CRVP in brass playing associated recurrent CRVOs. There's a case report, literature of a 50 year old man who was a professional trombonist who suffered three retinal venous occlusions in a 10 month period after playing strenuous orchestral pieces. Systemic workouts were negative, there were no medical comorbidities and after he retired from playing, he had no recurrence of venous occlusions in 10 years, which suggests that potentially there is a role of elevated retinal venous pressure. So next steps, we've identified that there are pressure changes certainly in musicians who play brass instruments. We've shown that there appears at least to be some sort of association with visual field defense. And we've looked at mechanisms for why this might happen. So a couple questions that I think deserve a little bit of time. Number one, most studies showed no change in optical nerve head appearance, but are there differences that could be detected on OCT? This is a study that just hasn't been done yet and hasn't been performed in the literature. The second question is one that is a little bit tougher to answer and should we be pre-treating or treating rather, when musicians to prevent glaucoma and its damage? And it comes into the question of which musicians would be kind of our targets for therapy? Not every musician obviously who plays a brass instrument has glaucoma, but are there risk factors that can be identified that would warrant treatment? Perhaps those with more narrow angles if we're considering intermittent angle closure as a potential mechanism, or targeting those with systemic morbidities like hypertension, sleep apnea, and those things that could impact blood flow to the optic nerve in the red. Again, these are just foods for thought. These answers are not in the literature yet, but as we continue to look at this, hopefully we'll be able to identify and better able to target our therapy as we move forward in this arena. So, it's just some references here and hopefully you don't feel like this girl right here. But thanks again for your attention and happy to take any questions that might be. Yeah, Dr. Penny. First, I assume the Philadelphia study did numbers for the age difference and then also having the visual field difference in the comment on whether just the age difference a little bit. Yeah, that's a great question because we know glaucoma is more prevalent in older individuals and that can certainly be a contributing factor. That was one of the things that they said was something they had to take into account in their study and that is kind of a confounding factor to their study, absolutely. Thanks for bringing that up. Dr. St. Clair. Beautiful, Chris. There's a parallel here. Anesthesiologists are very concerned about cases now of reported monocular or binocular ischemic hoppy neuropathy immediately following anesthesia and it could even be local MAC but with additional ventilation for head down positioning for spinal surgery on the back when the patient is placed head down in a sling and what we have recorded back when I was in Philadelphia we recorded elevated central venous and cavernous sinus elevated pressure secondary. We only measured central venous pressures and so anesthesiologists are now starting to become very concerned about this and we thought about developing maybe a VEP binoculars that we would measure the patient while they were being anesthetized and doing surgery on so we could try to detect if this was starting and perhaps what was causing it that is suggested by your trumpet and high resistance playing instruments here when they're doing a modified valsalva it's the elevated perhaps central venous and secondary carotid cavernous sinus venous pressure is reducing the perfusion pressure to the sensitive optic nerve. The optic nerve is much more sensitive than the retina to these changes and maybe these are the cause of these visual field effects but the whole problem with this is if the anesthesiologist says, oh shit we're starting to see reduced function of the optic nerve, what do you do? Can you tell the spine surgeon, gotta quit, gotta stop? We're at an impasse here but this is a big concern now in the anesthesia world. Right, that's a great point. Did I just say? So Chris, you're a trumpet player, does this review change what you're gonna do? No, actually, I don't think so just because there's definite changes that have been shown, there's definite increases in tracking the pressure but not everyone who plays a brass instrument has a glaucoma and until we know what the risk factors until we know what patients are more susceptible to developing complications it's not really gonna change the way that I play. So no, personally, it's not gonna, I'm not gonna stop playing because of this. Do you talk to your musician friends about it? I'm going to start I think, yeah, just because we know about the musculoskeletal complications, we know about the pulmonary complications but I'd never heard of ocular complications till I got to residency and I guarantee most people who play don't know that this is potentially a thing either and so just having regular exams and I think it hopefully prompt more people to just have regular routine exams because it seems like a risk factor for developing complications in the eye, yeah. Would you recommend woodwinds for your children then? No, no, I definitely wouldn't recommend woodwinds. Rass instruments are clearly superior. Woodwinds are superior. String instruments. String instruments, there we go, there we go. All right, thanks everybody, have a great day.