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Low-Tension Glaucoma Clinical Presentation

  • Author: Mitchell V Gossman, MD; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Jun 16, 2016
 

History

The history of low-tension glaucoma (LTG) may include the following:

  • Ocular history
  • Steroid use
  • Trauma
  • Coagulopathies - Previous blood loss or shocklike episode
  • Systemic nocturnal hypotension (notably in older thin, white women)
  • Autoimmune disorders (evidence of other autoimmune diseases common)
  • Systemic vascular disease
  • Thyroid disease - Increased incidence of thyroid disease in patients with low-tension glaucoma (6 of 25 patients in 1 series)
  • Sleep apnea (particularly in heavy men)
  • Alzheimer disease - Associated with mild increase in cup-to-disc ratio
  • Family history of glaucoma or optic neuropathy
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Physical

Physical examination findings in low-tension glaucoma (LTG) may include the following:

  • Conduct general medical examination (eg, blood pressure, carotid arteries).
  • Exclude ocular hypertension and POAG
  • Refractive error - Myopia
  • Cornea (see below)
    • Central corneal thickness thinner in normal-tension glaucoma[3] in correlation with severity
    • Keratic precipitates indicating uveitis
    • Krukenberg spindle indicating pigment dispersion
  • Iris - Transillumination defects or pigment dusting indicating pigment dispersion
  • Anterior chamber (see below)
    • By definition, low-tension glaucoma has an open, normal-appearing angle.
    • Rule out angle closure and angle recession.
  • Lens - Glaucomflecken indicating previous IOP elevation, probably secondary to acute angle closure
  • Posterior synechiae
  • Peripheral anterior synechiae
  • Intraocular pressure (see below)
    • Perform diurnal curve (should be < 22 mm Hg).
    • May be asymmetric
    • Higher IOP in left eye (related to blood flow from carotid arteries)
      • IOP fluctuation leads to greater visual-field progression in normal-tension glaucoma[3]
      • Other - Corneal compensated IOP using the Ocular Response Analyzer[4]
  • Myopic - Greatest risk of progression
  • Senile sclerotic - Older with vascular disease
  • Focal ischemic - May be younger
  • Optic disc in low-tension glaucoma as compared to high-tension glaucoma (controversial)
  • Larger discs
  • Peripapillary disc atrophy (particularly beta zone)
  • Thin disc rims; more commonly shows notching, more sloping of cup
  • Narrow vessels in peripapillary area, independent of stage of the disease[5]
  • Disc hemorrhages[6]
  • Acquired pit
  • Retina - Arteriosclerotic changes indicating vascular disease
  • Visual fields in low-tension glaucoma as compared to high-tension glaucoma (controversial)
  • Focal
  • Closer to fixation
  • Deeper
  • Blood pressure - Nocturnal hypotension
  • Carotid bruit indicating carotid insufficiency
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Causes

Low-tension glaucoma is associated with the following:

  • Migraine
  • Peripheral vasospasm, Raynaud syndrome
  • Generalized peripheral vascular endothelial dysfunction[7]
  • Ocular circulation insufficiency (lower ocular pulse amplitude)[7]
  • Increased resistance index in the central retinal artery (role in progression of visual field defect)[8]
  • Impaired vascular autoregulation (prolonged arteriovenous venous passage time in relation to ocular perfusion)[9]
  • Autoimmune disorders
  • Systemic vascular disease (ie, atherosclerotic disease, cerebrovascular insufficiency)[10]
  • Systemic nocturnal hypotension
  • Sleep apnea (decreases oxygen saturation)
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Contributor Information and Disclosures
Author

Mitchell V Gossman, MD Partner and Vice President, Eye Surgeons and Physicians, PA; Medical Director, Central Minnesota Surgical Center; Clinical Associate Professor, University of Minnesota Medical School

Mitchell V Gossman, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Medical Association, American Society of Cataract and Refractive Surgery, Minnesota Medical Association, North American Neuro-Ophthalmology Society, Phi Beta Kappa

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Martin B Wax, MD Professor, Department of Ophthalmology, University of Texas Southwestern Medical School; Vice President, Research and Development, Head, Ophthalmology Discovery Research and Preclinical Sciences, Alcon Laboratories, Inc

Martin B Wax, MD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, Society for Neuroscience

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

Neil T Choplin, MD Adjunct Clinical Professor, Department of Surgery, Section of Ophthalmology, Uniformed Services University of Health Sciences

Neil T Choplin, MD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society, California Medical Association

Disclosure: Nothing to disclose.

Iqbal Ike K Ahmed, MD, FRCSC Clinical Assistant Professor, Department of Ophthalmology, University of Utah

Iqbal Ike K Ahmed, MD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Canadian Ophthalmological Society, Ontario Medical Association

Disclosure: Nothing to disclose.

Baseer U Khan, MD 

Baseer U Khan, MD is a member of the following medical societies: Canadian Ophthalmological Society

Disclosure: Nothing to disclose.

Khalid Hasanee, MD Glaucoma and Anterior Segment Fellow, Department of Ophthalmology, University of Toronto

Khalid Hasanee, MD is a member of the following medical societies: Canadian Medical Association, Canadian Ophthalmological Society, Ontario Medical Association

Disclosure: Nothing to disclose.

Jacqueline Freudenthal, MD Co-Investigator, Ophthalmic Consultants Centre, Toronto

Jacqueline Freudenthal, MD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, Canadian Ophthalmological Society

Disclosure: Nothing to disclose.

References
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