Initiating Hypotensive Therapy for Elevated Intraocular Pressure

Risk Assessment and Stratification

Patients with baseline intraocular pressure (IOP) ≥26 mmHg and thin central corneal thickness (CCT ≤555 μm) have a 36% risk of developing optic nerve damage during long-term follow-up, according to the American Academy of Ophthalmology 1, 2, 3
The Ocular Hypertension Treatment Study (OHTS) demonstrated that treatment reduced the 5-year risk of developing primary open-angle glaucoma (POAG) from 9.5% to 4.4%, as recommended by the American Academy of Ophthalmology 2
Patients with IOP <24 mmHg and CCT >588 μm have only a 2% risk of developing optic nerve damage, as reported by the American Academy of Ophthalmology 1, 3

Older age is a risk factor for developing POAG, as stated by the American Academy of Ophthalmology 4
Family history of glaucoma increases the risk of developing POAG, according to the American Academy of Ophthalmology 3
African-derived race or Latino/Hispanic ethnicity are risk factors for developing POAG, as reported by the American Academy of Ophthalmology 4
Thin central cornea (CCT <555 μm) is a risk factor for developing POAG, especially at IOP 26 mmHg, as stated by the American Academy of Ophthalmology 3
Large cup-to-disc ratio is a risk factor for developing POAG, according to the American Academy of Ophthalmology 6
Disc hemorrhage is a risk factor for developing POAG, as reported by the American Academy of Ophthalmology 6
Diabetes mellitus is a risk factor for developing POAG, as stated by the American Academy of Ophthalmology 4
Myopia is a risk factor for developing POAG, according to the American Academy of Ophthalmology 1
Low ocular perfusion pressure is a risk factor for developing POAG, as reported by the American Academy of Ophthalmology 6
Low systolic/diastolic blood pressure is a risk factor for developing POAG, as stated by the American Academy of Ophthalmology 6
High pattern standard deviation on visual field testing is a risk factor for developing POAG, according to the American Academy of Ophthalmology 1

The target IOP should be at least 20% lower than baseline measurements, as recommended by the American Academy of Ophthalmology 4, 6, 7
For an IOP of 26 mmHg, the target IOP should be approximately 21 mmHg or lower, according to the American Academy of Ophthalmology 4, 6, 7
Prostaglandin analogs are the preferred initial medical therapy for reducing IOP, as stated by the American Academy of Ophthalmology 4, 6, 8, 7
Alternative first-line options include topical beta-blockers, alpha-2 adrenergic agonists, and laser trabeculoplasty, as reported by the American Academy of Ophthalmology 4, 6, 1, 3, 2

Long-term monitoring for development of glaucoma is essential, even if treatment is not initiated, as recommended by the American Academy of Ophthalmology 1, 2, 5
Serial optic nerve head and RNFL imaging, visual field testing, and regular IOP measurements are necessary for monitoring, according to the American Academy of Ophthalmology 5, 1, 2
Any evidence of optic nerve deterioration, RNFL loss, or visual field changes consistent with glaucomatous damage requires immediate treatment, as stated by the American Academy of Ophthalmology 4, 2, 5