Applying Pulsatile Pressure to the Eye is Dangerous and Should Never Be Performed
The practice of applying pressure to the eyeball is potentially dangerous and has been abandoned. 1
Why This Practice is Contraindicated
The American College of Cardiology/American Heart Association/Heart Rhythm Society explicitly states in their 2015 guidelines that ocular pressure (previously used as a vagal maneuver for supraventricular tachycardia) has been abandoned due to safety concerns. 1 This recommendation appears consistently across multiple iterations of the same guideline, emphasizing the strength of this contraindication.
Potential Mechanisms of Harm
While the guidelines do not elaborate on specific complications, applying external pressure to the eye can cause:
- Direct ocular trauma including retinal detachment, lens dislocation, or globe rupture 2
- Compromised ocular perfusion as external pressure increases intraocular pressure and reduces the perfusion gradient necessary for retinal blood flow 3, 4, 5
- Vascular occlusion particularly central retinal artery occlusion, which can occur when external compression exceeds perfusion pressure 2
Pulsatile Pressure in Therapeutic Contexts
The only legitimate use of pulsatile pressure near the eye involves vectored thermal pulsation therapy for meibomian gland dysfunction, which applies pulsating pressure to the outer eyelid surface (not the eyeball itself) while simultaneously protecting the cornea with heat applied to the inner eyelid. 1 This is fundamentally different from direct eyeball compression and is performed with specialized FDA-approved devices in controlled clinical settings.
Key Distinction
- Contraindicated: Direct manual pressure applied to the eyeball 1
- Acceptable: Device-applied pulsatile pressure to the outer eyelid with corneal protection for meibomian gland treatment 1
Safer Alternatives for Vagal Maneuvers
If the intent was to use ocular pressure as a vagal maneuver (its historical indication), use these evidence-based alternatives instead:
- Valsalva maneuver: Patient bears down against closed glottis for 10-30 seconds, generating 30-40 mmHg intrathoracic pressure 1
- Carotid sinus massage: Apply steady pressure over carotid sinus for 5-10 seconds after confirming absence of bruit 1
- Diving reflex: Apply ice-cold wet towel to face or facial immersion in 10°C water 1
Critical Clinical Pitfall
Never assume any form of direct eyeball pressure is safe or therapeutic. The abandonment of this technique by major cardiology societies reflects serious safety concerns that outweigh any theoretical benefit. 1 Even in anesthesia settings where sluggish pupils may occur, guidelines emphasize checking for inadvertent ocular compression as a complication to avoid, not as a therapeutic intervention. 2