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Editors Selection IGR 12-4

Examination methods: IOP fluctuation and progression

Comment by Kuldev Singh on:

21401 Long-term intraocular pressure fluctuations and risk of conversion from ocular hypertension to glaucoma, Medeiros FA; Weinreb RN; Zangwill LM et al., Ophthalmology, 2008; 115: 934-940

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Medeiros et al. (595), using data from the Diagnostic Innovations in Glaucoma Study (DIGS), provide the latest evidence assessing the importance of long-term IOP fluctuation or variation as a risk factor for glaucomatous optic nerve damage. A series of post-hoc analyses from the Advanced Glaucoma Intervention Study (AGIS) suggested that such variation of IOP between visits is an independent risk factor for visual field progression in glaucoma patients. An elegant post-hoc analysis from the Early Manifest Glaucoma Trial (EMGT) subsequently showed that mean IOP, but not IOP fluctuation, was an important risk factor for glaucoma progression.

At the present time, there is no Oxford Level I evidence that shortterm or long-term IOP fluctuation or variation is an independent risk factor for glaucoma progression

The EMGT was better suited for such an analysis than AGIS given that IOP-lowering therapy can induce fluctuation, and treatment was generally not advanced when IOP was not adequately controlled in the former study. The DIGS confirmed the findings of EMGT by following a cohort of untreated ocular hypertensive patients and noting that mean IOP correlated with progression, which in this case was the development of glaucoma, and that long-term IOP fluctuation or variation was not found to be an independent risk factor for progression.

There may be several reasons for the conflicting results with regard to the importance of IOP fluctuation in the various studies. Besides obvious methodological differences, the studies enrolled patients at different stages of the glaucoma continuum. Perhaps IOP fluctuation or variation is relatively more important in patients with more severe disease relative to those with earlier disease or ocular hypertension. This hypothesis, however, has not been confirmed and, at the present time, there is no Oxford Level I evidence that short-term or long-term IOP fluctuation or variation is an independent risk factor for glaucoma progression.

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