Medical Care

In low-tension glaucoma (LTG), the aim of IOP-lowering medications is for a reduction of at least 30%.

Also see the following clinical guideline summaries:

US Preventive Services Task Force - Screening for glaucoma: recommendation statement^[15]
American Academy of Ophthalmology - Primary open-angle glaucoma^[16]
American Optometric Association - Comprehensive adult eye and vision examination^[17]

Surgical Care

Argon laser trabeculoplasty (ALT): This procedure may have minimal effect because the intraocular pressure (IOP) is already in the reference range.

Selective laser trabeculoplasty (SLT): SLT targets pigment-producing cells in the trabecular meshwork with less tissue destruction and scarring compared with ALT.

Trabeculectomy: If medical therapy is ineffective, adjunctive antimetabolite therapy likely is needed for postoperative IOP to be in the single digits. A higher risk of hypotony and endophthalmitis exists when targeting extremely low pressures that may be needed to retard or prevent progression of field loss.

Consultations

Neurophthalmologist consultation can be ordered to rule out compressive optic neuropathy (as indicated).

Diet

An increase in salt intake may be recommended if the patient's diastolic blood pressure is significantly lower than the systolic blood pressure (ie, >70 mm Hg). However, controversy exists regarding this recommendation. Exercise caution in those patients with vascular or cardiac disease.

Activity

No restrictions on activity are indicated.

Long-Term Monitoring

After obtaining baseline optic disc photos and/or analysis and visual fields, patients should receive regular follow-up care (eg, at least every 6 months) to monitor for progression of field loss and optic nerve tissue in low-tension glaucoma (LTG).

Evaluate risk factors for defective visual-field progression linked to the following 4 independent predictive factors determined by the Canadian Glaucoma Study^[22]:

Abnormal anticardiolipin antibody level
Higher mean intraocular pressure (IOP) at follow up
Higher baseline age
Female sex

Medication

Kim M, Kim TW, Park KH, Kim JM. Risk factors for primary open-angle glaucoma in South Korea: the Namil study. Jpn J Ophthalmol. 2012 Jul. 56(4):324-9. [Medline].
Kim KCY, Ahn AMD, Seong SGJ. Does redefining of high intraocular pressure (IOP) according to IOP distribution change prevalence of normal tension glaucoma in Korea? [abstract]. World Glaucoma Congress, 2009. Available at http://www.worldglaucoma.org/WGC/WGC2009/index.php. Accessed: July 24, 2009.
Caprioli J, Coleman AL. Intraocular pressure fluctuation a risk factor for visual field progression at low intraocular pressures in the advanced glaucoma intervention study. Ophthalmology. 2008 Jul. 115(7):1123-1129.e3. [Medline].
Paul T, Radcliffe N, Shimmio M. Reclassification of normal and high tension glaucoma eyes using corneal compensated IOP [abstract]. World Glaucoma Congress, 2009. Available at http://www.worldglaucoma.org/WGC2009/. Accessed: July 28, 2009.
Akopov E, Astakhov Y, Nefedova D. Retinal vessels calibrometry in normal pressure glaucoma evaluation [abstract]. World Glaucoma Congress, 2009. Available at http://www.worldglaucoma.org/WGC/WGC2009/index.php. Accessed: July 28, 2009.
Furlanetto RL, De Moraes CG, Teng CC, Liebmann JM, Greenfield DS, Gardiner SK, et al. Risk factors for optic disc hemorrhage in the low-pressure glaucoma treatment study. Am J Ophthalmol. 2014 May. 157(5):945-52. [Medline].
Su WW, Cheng ST, Hsu TS, Ho WJ. Abnormal flow-mediated vasodilation in normal-tension glaucoma using a noninvasive determination for peripheral endothelial dysfunction. Invest Ophthalmol Vis Sci. 2006 Aug. 47(8):3390-4. [Medline].
Delaney Y, Walshe TE, O'Brien C. Vasospasm in glaucoma: clinical and laboratory aspects. Optom Vis Sci. 2006 Jul. 83(7):406-14. [Medline].
Plange N, Kaup M, Remky A, Arend KO. Prolonged retinal arteriovenous passage time is correlated to ocular perfusion pressure in normal tension glaucoma. Graefes Arch Clin Exp Ophthalmol. 2008 Aug. 246(8):1147-52. [Medline].
Harris A, Siesky B, Zarfati D, et al. Relationship of cerebral blood flow and central visual function in primary open-angle glaucoma. J Glaucoma. 2007 Jan. 16(1):159-63. [Medline].
Chauhan BC, Mikelberg FS, Balaszi AG, LeBlanc RP, Lesk MR, Trope GE. Canadian Glaucoma Study: 2. risk factors for the progression of open-angle glaucoma. Arch Ophthalmol. 2008 Aug. 126(8):1030-6. [Medline]. [Full Text].
Zhang YQ, Li J, Xu L, Zhang L, Wang ZC, Yang H, et al. Anterior visual pathway assessment by magnetic resonance imaging in normal-pressure glaucoma. Acta Ophthalmol. 2012 Jun. 90(4):e295-302. [Medline].
Asano E, Mochizuki K, Sawada A, Nagasaka E, Kondo Y, Yamamoto T. Decreased nasal-temporal asymmetry of the second-order kernel response of multifocal electroretinograms in eyes with normal-tension glaucoma. Jpn J Ophthalmol. 2007 Sep-Oct. 51(5):379-89. [Medline].
Michelson G, Waerntges S, Engelhorn T, Doerfler A. Reduced optic radiation volume measured by DTI is correlated by arterial hypertension in normal tension glaucoma [abstract]. World Glaucoma Congress, 2009. Available at http://www.worldglaucoma.org/WGC/WGC2009/index.php. Accessed: July 28,2009.
[Guideline] Screening for glaucoma: recommendation statement. US Preventive Services Task Force. National Guideline Clearinghouse. 2005 Mar.
[Guideline] Primary open-angle glaucoma. American Academy of Ophthalmology. National Guideline Clearinghouse. 2005.
[Guideline] Comprehensive adult eye and vision examination. American Optometric Association. National Guideline Clearinghouse. 2005.
Orgul S, Zawinka C, Gugleta K, Flammer J. Therapeutic strategies for normal-tension glaucoma. Ophthalmologica. 2005 Nov-Dec. 219(6):317-23. [Medline].
Tarkkanen AH, Kivelä TT. Vascular comorbidity in patients with low-tension glaucoma. Eur J Ophthalmol. 2014 Jul 21. [Medline].
Cheng JW, Cai JP, Wei RL. Meta-analysis of medical intervention for normal tension glaucoma. Ophthalmology. 2009 Jul. 116(7):1243-9. [Medline].
Netland PA, Chaturvedi N, Dreyer EB. Calcium channel blockers in the management of low-tension and open-angle glaucoma. Am J Ophthalmol. 1993 May 15. 115(5):608-13. [Medline].
Takako Nakagami, Yoshio Yamazaki, Fukuko Hayamizu. Prognostic Factors for Progression of Visual Field Damage in Patients with Normal-Tension Glaucoma. Japanese Journal of Ophthalmology. January, 2006. Volume 50, Number 1:38-42.
Abedin S, Simmons RJ, Grant WM. Progressive low-tension glaucoma: treatment to stop glaucomatous cupping and field loss when these progress despite normal intraocular pressure. Ophthalmology. 1982 Jan. 89(1):1-6. [Medline].
Fraunfelder FT, Roy FH. Current Ocular Therapy. Philadelphia: WB Saunders; 2000. 488-9.
Hitchings RA. Low tension glaucoma--its place in modern glaucoma practice. Br J Ophthalmol. 1992 Aug. 76(8):494-6. [Medline]. [Full Text].
Kawabata K, Kimura T, Fujiki K, Murakami A. [Ocular pulse amplitude in patients with open-angle glaucoma, normal-tension glaucoma, and ocular hypertensionby dynamic observing tonometry]. Nippon Ganka Gakkai Zasshi. 2007 Dec. 111(12):946-52. [Medline].
Kurtz S, Haber I, Kesler A. Corneal Thickness Measurements in Normal-tension Glaucoma Workups: Is It Worth the Effort?. J Glaucoma. 2009 Apr 15 [Epub ahead of print].
Stewart WC, Reid KK. Incidence of systemic and ocular disease that may mimic low-tension glaucoma. J Glaucoma. 1992. 1:27-31.
Werner E. Progressive normal-tension glaucoma. I. Analysis. J Glaucoma. 1996 Dec. 5(6):422-6. [Medline].

Media Gallery

of 0

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, American Glaucoma Society, Association for Research in Vision and Ophthalmology, California Association of Ophthalmology, San Diego County Ophthalmological Society, Society of Military Ophthalmologists

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.