What is the appropriate management for an adult patient with no prior medical history presenting with elevated intraocular pressure (IOP)?

Management of Elevated Intraocular Pressure

For an adult with no prior medical history presenting with elevated IOP, comprehensive evaluation is essential before deciding on treatment, as over 90% of patients with ocular hypertension alone will not develop glaucoma over 5 years—but treatment should be strongly considered if multiple risk factors are present or IOP is markedly elevated. 1

Initial Diagnostic Workup

Before initiating any treatment, the following assessments are mandatory to establish whether this represents isolated ocular hypertension versus early glaucoma:

• Gonioscopy to confirm open anterior chamber angles and exclude angle-closure mechanisms or secondary causes (pseudoexfoliation, pigment dispersion, traumatic recession) 1
• Pachymetry to measure central corneal thickness, as thin corneas (<555 μm) significantly increase risk of progression 1, 2
• Optic nerve head examination with stereoscopic photography and computerized imaging (OCT of optic nerve head, RNFL, and macula) to document baseline structure and detect any existing glaucomatous damage 1
• Visual field testing (automated perimetry with 30-2 or 24-2 protocols, consider 10-2 for central defects) to identify any functional loss 1
• Repeated IOP measurements to establish baseline pressure (single measurements are insufficient) 1

Risk Stratification Algorithm

High-Risk Patients Requiring Treatment

Treatment should be initiated if any of the following are present:

• IOP ≥26 mmHg with thin CCT (≤555 μm): 36% risk of developing optic nerve damage during long-term follow-up 2
• Very high IOP where optic nerve damage is imminent 1
• Evidence of optic nerve deterioration, RNFL loss, or visual field changes consistent with glaucomatous damage (this patient has converted to POAG and requires immediate treatment) 1
• Multiple additional risk factors including: older age, African or Latino/Hispanic ethnicity, family history of glaucoma, diabetes mellitus, myopia, low ocular perfusion pressure, disc hemorrhage, large cup-to-disc ratio, or high pattern standard deviation on visual field testing 1, 2

Lower-Risk Patients for Observation

Patients with IOP <24 mmHg and CCT >588 μm have only 2% risk of developing optic nerve damage and may be observed without treatment 2. However, long-term monitoring remains essential even without treatment 1, 2.

Treatment Recommendations When Indicated

Target IOP

Set target IOP at least 20% below baseline mean IOP based on the Ocular Hypertension Treatment Study, which demonstrated risk reduction from 9.5% to 4.4% over 5 years 1, 2, 3. For markedly elevated baseline pressures, a 20% reduction may be insufficient and more aggressive lowering is needed 1.

First-Line Pharmacotherapy

Prostaglandin analogs are the preferred initial medical therapy due to superior efficacy (20-35% IOP reduction), once-daily dosing improving adherence, and favorable side effect profile with minimal systemic effects 2, 4. This is particularly appropriate for patients with diabetes and hypertension as prostaglandins have minimal systemic effects 4.

Alternative first-line options include:

• Beta-blockers (timolol 0.5%): 15-25% IOP reduction, but contraindicated in asthma, COPD, or bradycardia 4, 5. Avoid nighttime dosing due to limited efficacy and potential nocturnal blood pressure reduction contributing to visual field progression 6
• Alpha-2 agonists (brimonidine 0.2%): 15-25% IOP reduction, but may cause ocular allergic reactions 4
• Laser trabeculoplasty: Can be considered as primary therapy for ocular hypertension as an alternative to medications 1

Monitoring Protocol

• Evaluate IOP and its relationship to target at each visit 1
• Serial optic nerve head and RNFL imaging, visual field testing, and regular IOP measurements are necessary for long-term monitoring 2
• Any evidence of structural or functional deterioration indicates conversion to POAG and requires treatment intensification with lower target IOP 1

Critical Pitfalls to Avoid

• Do not treat based on a single IOP measurement—establish baseline with multiple readings 1
• Do not ignore risk stratification—treatment decisions must incorporate CCT, age, ethnicity, family history, and other risk factors, not IOP alone 2
• Do not use beta-blockers in patients with respiratory or cardiac contraindications 4, 5
• Do not fail to establish baseline optic nerve documentation—without this, detecting future progression is impossible 1
• Poor medication adherence undermines treatment—once-daily prostaglandin analogs optimize compliance 4

When Initial Treatment is Inadequate

If target IOP is not achieved with monotherapy:

• Add a second medication from a different class or consider fixed-combination therapy 4
• Evaluate for laser trabeculoplasty as adjunctive therapy 4
• Reassess target IOP—definite deterioration suggests target pressure should be lower 1