Low-Tension Glaucoma Clinical Presentation

Updated: Sep 20, 2018
  • Author: Mitchell V Gossman, MD; Chief Editor: Hampton Roy, Sr, MD  more...
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Presentation

History

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

  • Ocular history

  • Steroid use

  • Trauma

  • Vasospasm (see below)

  • 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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Complications

Permanent loss of vision can occur if low-tension glaucoma is not detected early.

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