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Signs ⬇

Critical

Generally defined as IOP >21 on two or more visits. Normal-appearing, open anterior chamber angle with normal anatomy on gonioscopy. Apparently normal optic nerve, retinal nerve fiber layer, and visual field.

Differential Diagnosis ⬆ ⬇

Reference(s) ⬆ ⬇

Kass MA, Heuer DK, Higginbotham EJ, et al. The Ocular Hypertension Treatment Study: a randomized trial determines that topical ocular hypotensive medication delays or prevents the onset of POAG. Arch Ophthalmol. 2002;120:701-713.

Work Up ⬆ ⬇

Workup
  1. See 9.1, PRIMARY OPEN-ANGLE GLAUCOMA.
  2. If any abnormalities are present on formal visual field testing, consider repeat testing in 2 to 4 weeks to exclude the possibility of learning curve artifacts. If the defects are judged to be real, the diagnosis is glaucoma or ocular hypertension along with another pathology accounting for the field loss.
  3. OCT and HRT may reveal glaucomatous optic nerve defects. These objective structural tests may show pathology earlier than functional testing (visual fields).

Treatment ⬆ ⬇

  1. If there are no suggestive optic nerve or visual field changes and IOP is ≥24 mm Hg, no treatment other than close observation is usually necessary.
  2. Patients with an IOP >24 to 30 mm Hg but with normal examinations are candidates for IOP-lowering therapy (threshold varies per glaucoma specialist). A decision to treat a patient should be based on the patient’s choice to elect therapy and baseline risk factors such as age, CCT, initial IOP, optic nerve appearance, and family history. The results of the Ocular Hypertension Treatment Study showed that treatment reduced the development of visual field loss from 9.5% to 4.4% at 5 years, with a 20% average reduction of IOP. If treatment is elected, a therapeutic trial in one eye, as described for treatment of POAG, should be used. Some clinicians may elect to monitor these patients with close observation. Risk calculators have been developed to approximate the level of risk progression to glaucoma if left untreated. These may help guide clinicians and patients as to whether treatment should be initiated. See 9.1, PRIMARY OPEN-ANGLE GLAUCOMA.

Follow Up ⬆

Close follow up is required for patients being treated and observed. All patients should initially be followed similarly to POAG; see 9.1, PRIMARY OPEN-ANGLE GLAUCOMA. If there is no progression in the first few years, monitoring frequency can be decreased to every 6 to 12 months. Stopping medication may be considered in patients who have been stable for several years to reassess the need for continued treatment.