Expert

Glaucoma and Eye Pressure

University of California, San Francisco, UCSF Medical Center
Illustration showing pressure developing inside the eye of someone who has glaucoma.

When people hear the word “glaucoma,” many of them connect the eye disease with elevated eye pressures. However, the relationship between glaucoma and eye pressure is complicated and has changed over time.

Historically, glaucoma was identified as a disease in which the eye was firm or hard due to high eye pressure. However, doctors gradually came to understand that glaucoma can occur even when eye pressure is normal, which sometimes makes it harder to diagnose. Today, eye pressure is considered a major risk factor for glaucoma but is not included in the definition of this eye disease. Eye pressure control also plays a major role in the treatment of glaucoma. Lowering eye pressure is the only treatment we currently have, whether through medications, laser, or surgery.

Illustration showing pressure building up in the eye for someone who has glaucoma

What is Considered High Eye Pressure?

In many forms of glaucoma, the eye pressure is high. What is considered “too high”? Patients ask me this all the time, and I tell them it depends.

First, we know that statistically speaking, having eye pressures over 21 mmHg (millimeters of mercury) is not very common in a generally healthy population. We also know that eye pressure tends to increase as we get older since the drainage system does not function as well.

Second, we know that an optic nerve that is healthy can withstand a higher eye pressure than an optic nerve that is unhealthy. For example, patients who have optic nerves with signs of more advanced disease likely need lower eye pressures to prevent worsening of glaucoma.

Third, the eye pressure that is “too high” for your optic nerve is sometimes determined over time. Let’s say you begin treatment with an eye drop to lower eye pressure, and it is successful in lowering your eye pressure by 20 percent. However, your glaucoma continues to progress slowly. In that case, despite the initial eye pressure lowering, your ophthalmologist may determine that this new lower eye pressure is still “too high” and your eyes need to have even lower eye pressures.

Finally, it is important to realize that most patients with the most common form of glaucoma, primary open-angle glaucoma, have elevated eye pressures but do not feel pain. Glaucoma is often called the “silent thief of sight” because patients do not have symptoms until late in the disease when they notice central vision loss.

Glaucoma with “Normal” Eye Pressure

Another form of glaucoma is called normal-tension glaucoma. If someone has normal-tension or normal-pressure glaucoma, their eye pressure has never been recorded above 21 mmHg, yet they still have optic nerve damage. Does this mean that their eye pressure has never been greater than 21 mmHg? That is difficult to say since a single eye pressure measurement at any given time on any given day in the ophthalmologist’s office is a tiny “snapshot” of what the eye pressure truly is.

Patients who have normal-tension glaucoma are thought to have more susceptible optic nerves, such that even at normal eye pressures the optic nerve slowly degenerates. Moreover, even though the eye pressure is “normal,” the treatment is the same: lowering the eye pressure through medications, laser, or surgery. Lowering eye pressure in normal tension glaucoma patients was found to slow glaucoma progression in well-designed randomized clinical trials including the Collaborative Normal Tension Glaucoma Study (CNTGS). The CNTGS was the first study of its kind to show that a 30 percent decrease in eye pressure reduced disease progression in patients with normal-tension glaucoma.

Aiming for the Target

One term you may hear your ophthalmologist discuss is your “target eye pressure.” This refers to a goal eye pressure your ophthalmologist believes will stop your glaucoma from worsening. There is no magic formula but it is based on the status of your optic nerve, the results of your visual field tests, and your ophthalmologist’s clinical judgment, among other factors. It is a good goal to have, but it is not the only factor to consider. And, even though you may have a target eye pressure, it is important to recognize that a single eye pressure measurement in the office is not truly reflective of what your eye pressure is on average, day to day, week to week, or month to month.

Finally, your target eye pressure may change over time depending on how stable your glaucoma is. For example, if you have been stable for a long time, your ophthalmologist may not be as concerned by an eye pressure measurement that is slightly above goal. Indeed, eye pressure can vary depending on the time of day, when you instilled your last dose of eye drops (if you are on medication), your stress level, and other factors. On the other hand, if you continue to demonstrate worsening glaucoma despite being at your target eye pressure, your ophthalmologist may decide to revise the target pressure to an even lower goal.

Resources:

This content was first posted on: August 13, 2018

The information provided here is a public service of the BrightFocus Foundation and should not in any way substitute for personalized advice of a qualified healthcare professional; it is not intended to constitute medical advice. Please consult your physician for personalized medical advice. BrightFocus Foundation does not endorse any medical product, therapy, or resources mentioned or listed in this article. All medications and supplements should only be taken under medical supervision. Also, although we make every effort to keep the medical information on our website updated, we cannot guarantee that the posted information reflects the most up-to-date research.

These articles do not imply an endorsement of BrightFocus by the author or their institution, nor do they imply an endorsement of the institution or author by BrightFocus.

Some of the content may be adapted from other sources, which will be clearly identified within the article.

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