Vascular Risk Factors in Normal-Tension Glaucoma

A practical approach to evaluating patients with progressive disease despite controlled IOP.

Ciera D. Johnson; Rachel Chapman, MD; Samantha Goldburg, MD; and Mary Qiu, MD

Glaucoma Today

Key Takeaways For patients with normal-tension glaucoma (NTG) whose disease continues to progress despite adequate IOP control, it is worth considering whether vascular risk factors are contributing to their optic nerve vulnerability. After confirming an NTG diagnosis, use a targeted vascular history to identify whether the patient may benefit from additional systemic evaluation, coordinate care with the patient's medical team, and continue to prioritize IOP reduction for NTG management. Evaluating vascular risk factors may improve understanding of disease progression and the overall health of patients with NTG. A familiar clinical scenario in glaucoma practice is the patient with normal-tension glaucoma (NTG) whose disease continues to progress despite seemingly adequate IOP control. The instinct is often to pursue an even lower target IOP. Although IOP reduction remains the only intervention proven to slow disease progression,1 it is worth considering whether another factor could be contributing to the patient’s optic nerve vulnerability. NTG accounts for a substantial proportion of primary open-angle glaucoma (POAG) cases worldwide, representing approximately 30% to 40% of POAG cases in Western populations and an even greater proportion in East Asian populations.2,3 The condition is characterized by progressive optic neuropathy despite untreated IOPs within a statistically normal range. Although IOP lowering remains the cornerstone of disease management, many patients continue to demonstrate structural or functional progression even after achieving their target pressures.4,5 This observation has prompted increasing interest in factors beyond IOP that may influence disease susceptibility and progression. Among these, vascular dysfunction has received considerable attention. Proposed contributors include nocturnal hypotension, impaired vascular autoregulation, obstructive sleep apnea (OSA), vasospastic disorders, and other systemic conditions that may reduce optic nerve perfusion.6,7 Although these associations are supported by a growing body of observational evidence, it remains unclear whether identifying or treating these conditions alters the course of NTG.

Corneal Graft Rejection Versus Failure

Failure to differentiate the two could result in an irreversible loss of the graft.

Kianna Swanson, OD, Jacob Lang, OD, FAAO

Modern Optometry

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