Management of the glaucoma patient progressing at low normal intraocular pressure

Abstract

Purpose of review Patients with glaucoma with disease progression despite low or normal intraocular pressure (IOP) present special challenges to the treating clinician. Treatment goals may depend on whether patients have apparent low IOP with concurrent treatment or have low IOP at baseline without treatment. We review the diagnostic and therapeutic approaches to these patients. Recent findings Apparent progression at low IOP should start with confirmation of IOP, made easier by devices enabling patient home self-tonometry. Suspected visual field progression should be confirmed by repeat testing prior to advancement of therapy. Trabeculectomy remains the most effective surgical method of achieving long-term success, particularly when there is a low starting IOP. Drainage tube implantation or the use of novel micro-incisional non-bleb-forming procedures are less likely to be successful in achieving low IOP goals. Summary Diagnostic testing is important in confirming progressive glaucomatous disease at low IOP levels. The most effective way of slowing the progression of glaucoma in a patient with low IOP is to lower the IOP further, sometimes to single digit levels, which is most often achievable with trabeculectomy.

Long-Term Surgical Outcomes of Glaucoma Drainage Implants in Eyes with Preoperative Intraocular Pressure Less than 19 mmHg

“…Several previous studies have reported reduced visual field progression following a 30% reduction of IOP [ 9 , 11 , 12 , 19 , 20 ]. Notably, the Collaborative Normal-Tension Glaucoma Study group demonstrated that lowering IOP, either through medications or trabeculectomy, significantly slowed down the progression rate of visual field loss in a dose-dependent manner [ 21 ].…”

Long-Term Effectiveness and Safety of Tafluprost, Travoprost, and Latanoprost in Korean Patients with Primary Open-Angle Glaucoma or Normal-Tension Glaucoma: A Multicenter Retrospective Cohort Study (LOTUS Study)

“…In a study of NTG patients receiving topical medical treatments [ 25 ], patients with a higher mean IOP reduction from baseline (i.e., percentage IOP reduction > 22.1%) experienced less progression than patients who achieved a lower mean IOP reduction (i.e., percentage IOP reduction < 13.3%). Wang and Singh suggested lowering IOP further as the most effective way of slowing the progression of glaucoma in patients with low IOP [ 26 ]. In the present study, the mean IOP reduction from baseline in NTG patients for the three PGAs, tafluprost, travoprost, latanoprost, was −2.20, −2.11, −1.86 mmHg, respectively, which translates to a rate of IOP reduction of 14.03%, 14.70%, and 12.28%, respectively.…”

Therapeutic Potential of Cannabinoids in Glaucoma

“…Although several anti-glaucoma medications and surgical procedures are currently available to lower IOP, a considerable number of patients progress despite adequate treatment [ 20 ]. Therefore, therapy aimed at more than just lowering IOP would be required [ 17 ].…”

“…Two months of systemic treatment with Δ 9 -THC resulted in toxic effects on photoreceptor cells in mice through functional loss in electroretinography and apoptosis [ 148 ]. For a detailed overview of other studies on neuroprotection in ocular diseases, the reader is referred to more extensive reviews [ 9 , 20 , 60 ]. An excellent overview on in vivo animal glaucoma models is provided by Gallo Afflitto et al [ 60 ].…”