Ocular Hypertension

Ocular Hypertension
SYMPTOMS Typically asymptomatic
If IOP is too high (considered > 40mmHg), patient may experience Ocular pain, Pressure around the eye, Cloudy vision, Nausea, Vomiting, Headache, and Browache
SIGNS Typically bilateral
Open angles on Van Herick with no signs of secondary glaucomas
Healthy optic nerves with no evidence of glaucomatous damage
WORK-UP Pupils (normal), Color vision (normal), Slit lamp examination, IOP with GAT or ORA (> 21 mmHg on two or more visits), Dilated retinal exam, Post-dilated IOP with GAT or ORA, Fundus photos, Visual field with Humphrey 24-2/30-2/24-2C threshold (no glaucomatous misses), OCT analysis of the optic nerve/RNFL/GCC (normal RNFL and GCL thickness), OCT-Angiography (density of the radial peripapillary capillary plexus and superficial capillary plexus is normal), Gonioscopy (angles should be open with no anomalies), Pachymetry (thin corneas carry a higher risk of glaucoma), Corneal hysteresis (low hysteresis carries a higher risk of glaucoma), VEP/Pattern ERG (normal ganglion cell function)
TREATMENT Treatment is based on the risk of developing glaucoma over a 5 year period by looking at risk factors and IOP: If IOP is 22-25mmHg, the risk of developing glaucoma is 2.6-3% (observation), If IOP is 26-30mmHg, the risk of developing glaucoma is 12-26% (treatment should strongly be considered especially if there are other risk factors present), If IOP is >30mmHg, the risk of developing glaucoma is 42% (treatment should be initiated even if there are no other risk factors)
First-line of treatment would be a topical prostaglandin to be used 1 gtt QHS
If adjunct drop needed, consider a topical carbonic anhydrase inhibitor to be used 1 gtt BID
Rhopressa should be considered as the next adjunct drop to be used 1 gtt QHS
Alpha-2-agonists should be considered as the next adjunct drop to be used 1 gtt BID
Topical beta blockers should be considered as the next adjunct drop to be used 1 gtt once a day in the morning up to BID (the evening dose is thought to be minimally effective)
Consider using combo drops in order further lower IOP and improve compliance especially if patient is on multiple drops: Cosopt 1 gtt BID, Combigan 1 gtt BID, Simbrinza 1 gtt TID, Rocklatan 1 gtt QHS
Topical carbonic anhydrase inhibitors and alpha-2-agonists are to be used 1 gtt TID if utilized as stand-alone therapy
Topical apraclonidine and oral acetazolamide can be given in-office or on a short-term basis to quickly lower IOPs
Always keep in mind the contraindications and side effects before prescribing any glaucoma medications
SLT may be used as a first-line of treatment in lieu of glaucoma drops or as an adjunct treatment along with glaucoma drops
If using more than 2 different types of glaucoma drops in order to manage patient, co-management with a glaucoma specialist should be considered (highly unlikely with ocular hypertension)
If using more than 3 different types of glaucoma drops, refer to glaucoma specialist for co-management (highly unlikely with ocular hypertension)
FOLLOW-UP If observing, the patient should be seen back every 6-12 months for glaucoma testing in order to look for change or progression
Patients should be seen back in 2-4 weeks after initiation of treatment in order to assess IOP (SLT and prostaglandins typically show maximal effectiveness at 4 weeks)
After the initial assessment of IOP with treatment, patients are typically seen back every 4-6 months for glaucoma testing in order to look for progression
ADDITIONAL LAB | TESTS Typically additional lab testing is not needed
ETIOLOGY Elevated IOP secondary to a decrease in outflow and/or increase in production of aqueous. Strain and pressure on the optic nerve is not enough to cause damage on a cellular level.
DIFFERENTIAL DX Primary open angle glaucoma, Secondary open angle glaucoma, Chronic angle closure glaucoma
NOTES Five criteria must be met in order to diagnosis ocular hypertension: 1) IOP > 21 mmHg on two or more visits 2) No glaucomatous visual field defects 3) No glaucomatous optic nerve damage or RNFL loss 4) Open angles with no anomalies 5) No signs of secondary glaucomas
Risk factors to consider include the following: Race (African Americans have the highest risk of developing glaucoma due to ocular hypertension), Cardiovascular disease, Age (Younger patients have more risk of glaucomatous damage over time), High myopia, Family history of glaucoma especially on the maternal side, Diabetes, Poor vision in one eye, Presence of glaucoma in one eye, Sleep apnea, Steroid use, Thin corneas, Low hysteresis, Vertical cup to disc ratio > 0.30
Risk calculators such as STAR (Scoring Tool for Assessing Risk) can help clinicians decide whether or not to initiate treatment
Ocular Hypertension: OCT of a patient with ocular hypertension showing normal RNFL thickness in both eyes https://www.goodeyes.com/glaucoma/what-do-glaucoma-test-results-mean/

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