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High Eye Pressure: Monitor Or Treat?

March 9, 2010

Adapted from the Washington University School Of Medicine

Most people at risk for developing glaucoma due to high eye pressure do not need treatment, according to a large, multi-center study. The Ocular Hypertension Treatment Study (OHTS) investigators, led by researchers at Washington University School of Medicine in St. Louis, report in the Archives of Ophthalmology that most patients with high eye pressure, but no glaucoma damage, can be carefully monitored rather than given eye drops.

The researchers say many patients at highest risk of developing glaucoma, such as those who have elevated pressure along with other symptoms—such as thin corneas or large cup/disc ratio (a measure of the part of the optic nerve visible inside the eye)—should be treated with pressure-lowering drops, but those without the additional symptoms probably don't need the therapy.

“It's clear that people with high eye pressure and high risk of developing glaucoma do benefit from early medical treatment,” says Michael A. Kass, M.D., lead investigator of the OHTS study. “But we have learned that not everyone with high pressure is at high risk.”

The OHTS study ran from 1994 until 2009. For the first seven years, half of the 1,636 subjects with elevated pressure, ages 40 to 80, received eye drops. The other half were closely monitored but received no medication. That first phase of the study determined that drops could reduce development of the potentially blinding disease by more than 50 percent.

After the first phase of the study, OHTS researchers put everyone on eye drops, and now they have determined that in patients at lower risk, there wasn't much difference between those who started using eye drops in 1994 and the original control group, who didn't get drops until more than seven years later. Among those with high pressure but otherwise at low risk, 7 percent in the early treatment group developed glaucoma, compared with 8 percent in the delayed treatment group who developed the disease.

By contrast, 28 percent of high-risk patients in the original treatment group went on to develop glaucoma, compared to 40 percent of the high-risk patients in the delayed treatment group. Fortunately, most people with modest elevations in eye pressure fall into the low-risk group.

“This study has determined that close monitoring is an appropriate option for large numbers of people with ocular hypertension but no damage from glaucoma,” says Paul A. Sieving, M.D., Ph.D., director of the National Eye Institute of the National Institutes of Health, which funded the OHTS study. “This is a strong example of research that can result in more appropriate treatment at a lower cost."

Elevated eye pressure is an important glaucoma risk factor, but it isn't the only one. A few years ago, Kass, the Bernard Becker Professor and head of the Department of Ophthalmology and Visual Sciences at Washington University, and Mae O. Gordon, Ph.D., professor of ophthalmology and visual sciences and of biostatistics, developed a model to quickly assess glaucoma risk in individual patients.

The model relies on five key risk factors: a patient's age, pressure in the eye, cup/disc ratio, corneal thickness and pattern standard deviation (a measurement derived from computerized visual field tests).

“When we consider these five risk factors and assign statistical values, it's possible to determine an individual's risk of developing glaucoma during the next five years,” says Gordon.

African-Americans as a group appear to have thinner corneas and a slightly different anatomical structure to the optic nerve than people from other ethnic backgrounds. Kass says because of the elevated risk, close monitoring may not be appropriate for many African-American patients. He says individual risk assessments should determine which patients receive treatment and which patients are followed.

“Glaucoma is about four times more common in African-Americans than in people of European ancestry, and blindness from glaucoma is about six times more common in African-Americans,” Kass says. “Treatment does help, but we know from our study that even when treatment is identical, the risk for African-Americans remains significantly greater."

“In low-risk patients, close observation looks to be an effective approach,” Kass says. “But it's important that all patients receive regular eye exams, to detect elevated pressure and to assess other risk factors for glaucoma. And if an individual has high eye pressure and no glaucoma damage, you should speak to your eye doctor about your risk for developing glaucoma and whether you might benefit from preventative treatment.”

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Some of the content in this section is adapted from other sources, which are clearly identified within each individual item of information.

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