Review Article

Simplifying “target” intraocular pressure for different stages of primary

open‑angle glaucoma and primary angle‑closure glaucoma

Ramanjit Sihota, Dewang Angmo, Deepa Ramaswamy, Tanuj Dada

Lowering of intraocular pressure is currently the only therapeutic measure for Glaucoma management. Access this article online
Many longterm, randomized trials have shown the efficacy of lowering IOP, either by a percentage of Website:
baseline, or to a specified level. This has lead to the concept of ‘Target” IOP, a range of IOP on therapy, that www.ijo.in
would stabilize the Glaucoma/prevent further visual field loss, without significantly affecting a patient’s DOI:
quality of life. A clinical staging of Glaucoma by optic nerve head evaluation and perimetric parameters, 10.4103/ijo.IJO_1130_17
allows a patient’s eye to be categorized as having – mild, moderate or severe Glaucomatous damage. PMID:
***
An initial attempt should be made to achieve the following IOP range for both POAG or PACG after an
iridotomy. In mild glaucoma the initial target IOP range could be kept as 15-17 mmHg, for moderate Quick Response Code:
glaucoma 12-15 mmHg and in the severe stage of glaucomatous damage 10-12 mmHg. Factoring in baseline
IOP, age, vascular perfusion parameters, and change on perimetry or imaging during follow up, this
range may be reassessed over 6 months to a year. “Target” IOP requires further lowering when the patient
continues to progress or develops a systemic disease such as a TIA. Conversely, in the event of a very elderly
or sick patient with stable nerve and visual field over time, the target IOP could be raised and medications
reduced. An appropriate use of medications/laser/surgery to achieve such a “Target” IOP range in POAG
or PACG can maintain visual fields and quality of life, preventing Glaucoma blindness.

Key words: Advanced Glaucoma Intervention Study, Collaborative Initial Glaucoma Treatment Study,
Collaborative Normal‑Tension Glaucoma Study, Early Manifest Glaucoma Trial, glaucoma, long‑term
glaucoma, primary open‑angle glaucoma/primary angle‑closure glaucoma, randomized control trials,
success in glaucoma, target intraocular pressure

Glaucoma is commonly diagnosed and treated by all anatomically displaced or physiologically altered and therefore
ophthalmologists, not glaucoma specialists alone. It is therefore more prone to even moderately raised IOP [Fig. 1].
essential that guidelines for the management of primary adult
Target IOP is seen as a guesstimate that will stabilize
glaucomas  –  primary open‑angle glaucoma  (POAG) and
glaucoma, based on an evaluation of severity of glaucomatous
chronic primary angle‑closure glaucoma (PACG) – should be
damage in an individual patient, and other known risk factors.
easy to apply at any level of eye care.
In addition, a cost–benefit analysis of the therapy required to
In POAG and chronic PACG after iridotomy, the intraocular achieve that ‘target” IOP should be discussed with the patient.
pressure (IOP) is the primary risk factor for the development Current studies appear to favor a simple, threshold range
and progression of glaucoma, and studies have shown that approach to “target” IOP, based on structural and functional
IOP reduction can slow/prevent progression of glaucoma. changes due to optic nerve damage.[2]
Currently, lowering of IOP is the only therapy available to treat
A suggested range of initial target IOP for different stages
glaucoma, and most ophthalmologists are using the concept
of glaucomatous damage to prevent progression and therefore
of “target” IOP, in one form or the other. However, the extent
blindness are shown in Fig. 2. These are based on available
of IOP reduction is the common dilemma.[1,2]
long‑term studies discussed in this review.
The average IOP in a normal population without optic nerve
There are no uniformly accepted norms for determining
head changes has been reported as 14–17 mmHg, but this could
target IOP; therefore, this review will discuss:
be different in different races [Table 1]. Once raised IOP has
1. What is “normal” IOP?
damaged the optic nerve and ganglion cells, it is logical that
2. The concept of “target” IOP
such tissues would merit an IOP reduced to at least this level, if
not lower. This would maintain/improve function in damaged/
dysfunctional cells or the few remaining ones that have been This is an open access journal, and articles are distributed under the terms of
the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License,
which allows others to remix, tweak, and build upon the work non-commercially,
Glaucoma Research Facility & Clinical Services, Dr. Rajendra Prasad as long as appropriate credit is given and the new creations are licensed under
the identical terms.
Centre for Ophthalmic Sciences, All India Institute of Medical Sciences,
New Delhi, India
For reprints contact: [email protected]
Correspondence to: Prof. Ramanjit Sihota, Glaucoma Research and
Clinical Facility, Room No. 475, Fourth Floor, Dr. Rajendra Prasad Cite this article as: Sihota R, Angmo D, Ramaswamy D, Dada T. Simplifying
Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, “target” intraocular pressure for different stages of primary open-angle
Ansari Nagar, New Delhi ‑ 110029, India. E‑mail: [email protected] glaucoma and primary angle-closure glaucoma. Indian J Ophthalmol
2018;66:495-505.
Manuscript received: 16.11.17; Revision accepted: 10.02.18

© 2018 Indian Journal of Ophthalmology | Published by Wolters Kluwer - Medknow

496 Indian Journal of Ophthalmology Volume 66 Issue 4

Table 1: Some population based normal intraocular

in females. Two standard deviations above the mean, which is
pressure values from literature the 97.5th percentile, was calculated to be 21 mmHg and hence
the commonly held belief is that an IOP >21 mmHg should
Study Age Mean Population be considered as abnormal and that <21 mmHg as normal.
group IOP±SD Hollows and Graham themselves noted that >21 mmHg
Aravind Comprehensive Eye 40‑49 14.7 (3.3) Indians “should not be construed as meaning clinical abnormality, as
Study[3] 50‑59 14.5 (3.7) the distribution is skewed and physiological variables need not
60‑69 14.1 (3.7) necessarily follow a Gaussian distribution.”[12] It is therefore to
Central India Eye and Medical >40 13.6±3.4 Indians be understood that the so‑called cutoff of an IOP of 21 mmHg
Study[4] is not clinical or evidence‑based evidence of “normal,” but a
Rural South India[5,6] >40 14.29 3.32 Indians statistical construct.
Fukuoka et al.[7] >40 14.1±2.3 Japan There are known racial differences in measured IOP,
Tomoyose et al.[8] >40 15.1±3.1 Japan and as clearly stated, a statistical construct cannot reflect
Leske et al.[9] >40 Black: USA a physiological parameter, with its inherent variability.
18.7±5.2 Therefore, an IOP of < 21 mmHg should not be taken an
Mixed: appropriate “target” IOP or as normal.
18.2±3.8
White: Some population‑based normal IOP values from literature
16.5±3.0 are given in Table 1.
Gutenberg Eye Study[10] >35 14.0±2.6
mmHg The Concept of “Target” Intraocular
Beaver Dam Eye Study[11] >43 15.3/15.5 USA Pressure
mmHg
In 1977, Chandler reviewed patients seen by him over the
IOP: Intraocular pressure, SD: Standard deviation
years and noted that patients with increasing severity of
glaucomatous neuropathy did better with IOPs in the mid‑teens
or lower.[1] In the last few decades, many randomized studies
have provided evidence‑based data for the management
of different stages and types of POAG, and the American
Academy of Ophthalmology introduced the term “target” IOP
for appropriate management. Palmberg analyzed Advanced
Glaucoma Intervention Study (AGIS), data, and later surgical
data to suggest the practice of “target” IOPs that would prevent
progression.[13,14] There are also some long‑term studies on
PACG looking at long‑term prognosis with different severity
of damage.[15‑19]
Definitions of target intraocular pressure
1. The European Glaucoma Society guidelines define target
IOP as “an estimate of the mean IOP obtained with treatment
that is expected to prevent further glaucomatous damage”[20]
2. The American Academy of Ophthalmology defines target
Figure 1: A normal optic nerve head functions at an average intraocular IOP as “a range of IOP adequate to stop progressive
pressure of 14–17 mmHg (left), while an eye having glaucomatous pressure‑induced injury”[21]
optic neuropathy is damaged by high intraocular pressures, which 3. The World Glaucoma Association defines it as “an estimate
need to be lowered so that the remaining nerve fibers can function as of the mean IOP at which the risk of decreased vision‑related
best as possible (right) quality of life due to glaucoma exceeds the risk of the
treatment.”[22]
3. Parameters that influence progression and hence target IOP
The concept of “Target: IOP” is, therefore, that of an IOP that
4. Suggested methods to determine “target” IOP
prevent further progression of glaucomatous visual field (VF)
5. Limitations of using “target” IOP loss, without compromising a patient’s quality of life. Quality
6. Clinical determination and management to attain “target” IOP of life would be significantly and permanently affected by
7. Reassessing “target” IOP over time. progression of VF loss and stabilization of the VF is therefore
the major goal.[23,24]
What is “Normal” Intraocular Pressure?
It is important to know the IOP in people without glaucoma
Parameters that Influence Progression and
in a population, both for better diagnosis and also better Hence Target Intraocular Pressure
management of glaucoma patients from that population, as VF loss due to glaucoma is irreversible and therefore needs to
there are racial differences. Hollows and Graham conducted be prevented or slowed down so that the patient can continue
a survey in the UK in 1966, where they found the mean his daily activities without a problem. Over the years, many
applanation IOP to be 15.9 mmHg in males and 16.6 mmHg risk factors for progression have been studied and highlighted.
 Sihota, et al.: Simplifying “target” IOP
April 2018 497

Figure 2: Suggested “target” range of intraocular pressures at three stages of glaucomatous damage as determined by optic nerve head and
perimetric evaluation

Certain important risk factors need to be assessed before progression of VF loss over time; rate of progression on
an objective plan to prevent/stabilize glaucoma progression glaucoma progression analysis of Humphrey field analyzer
in POAG and PACG can be formulated. should also be noted, as it will indicate the need for a more
or less aggressive therapy
1. Examination of the optic nerve head, looking especially at the
4. Age – Collaborative Initial Glaucoma Treatment
inferior and superior poles as pointed out by Chandler, helps
Study  (CIGTS) found that patients who were a decade
identify thinning/notching/pallor of the neuroretinal rim and
older had a 40% risk of perimetric loss.[26] Early Manifest
associated retinal nerve fiber layer defects. This provides a
Glaucoma Trial (EMGT) reported that those > 68 years old
measure of the amount of structural damage to the nerve
were more likely to progress.[27] On analysis, AGIS also noted
2. IOP – At least three IOP measurements, taken at different
that an older patient was more likely to progress.[28] Similar
times of the day, ideally with an applanation tonometer,
association with age has been seen in PACG eyes as well[15]
help determine baseline IOP, the pressure at which optic
5. Additional risk factors such as a family history of glaucoma,
nerve damage can be taken to have occurred. Any single
thinner central pachymetry, pseudoexfoliation, history of an
IOP measurement taken between 7 am and 9 pm has a > 75%
acute PACG attack,[17] cardiovascular disease, patient’s life
chance of missing the highest point of a diurnal curve.[25]
expectancy, steroid use, transient ischemic attacks (TIAs),
Therefore, IOP should be measured at different times, to
and other systemic problems should be recorded.[27,29]
have the best chance of observing the maximal value. In
PACG, it is important that the baseline IOP be recorded
Staging of Glaucomatous Damage
after iridotomy. On review, the IOP should be rechecked
at the point of peak baseline IOP, if available The extent of existing glaucomatous damage appears to
3. Perimetry – Reliable perimetry with reproducible VF significantly influence likely progression at a given IOP and
defects on at least two consecutive fields allows staging therefore is extremely important in determining “target”
of the functional visual loss in each patient. The speed of IOP. Staging of glaucomatous damage can be done on the
498 Indian Journal of Ophthalmology Volume 66 Issue 4

basis of either or both – structural optic nerve head damage be a significant risk factor for glaucomatous progression.
or functional loss on perimetry. Unfortunately, there is In advanced POAG, AGIS reported that patients with more
no universally accepted staging of either optic nerve head severe glaucomatous damage, as measured by larger C: D
abnormalities or VF changes, with regard to their relevance to ratio, 0.81 + 0.13, were at the great risk of progression.
progression [Fig. 3]. Sihota et  al. found baseline linear C: D on Heidelberg
retina tomography  (HRT) to be a significant risk factor for
Optic Nerve Head Examination progression at all stages of glaucomatous neuropathy in both
Chandler observed that “eyes with advanced cupping at both POAG and PACG eyes.[15,16]
ends of the disc worsened, if IOP was not consistently < 15 For example, a significant narrowing or loss of neuroretinal
mmHg… and require pressures below the average of the rim at both poles, with a C: D ratio of 0.8, would need a “target”
population.” However, “eyes with limited cupping, confined IOP below the population average, which in Indians would
to one pole of the disc, appear to withstand tension better, mean <14 mmHg.
mid to high teens.” Finally, “eyes with a normal disc appear to
withstand pressure < 30 mmHg well” for years.[3] Interindividual Spaeth et  al. described a disc damage likelihood score,
variability in disc size and shape make evaluation difficult; DDLS, based on the radial width of the narrowest neuroretinal
however, the extent of thinning of the neuroretinal rim needs rim, and divided into 10 stages, with stages 6–10 requiring
to be recorded. aggressive therapy.[31]
Cup: disc  (C:  D) ratio is more commonly employed in Perimetric Staging
clinical practice and recommended as a means of staging
glaucomatous damage into – mild with a C: D of < 0.65, There are many suggested classifications of the severity of
moderate 0.7–0.85, and severe > 0.9 [Table 2]. This is best glaucomatous damage –Hodapp Parrish Anderson,[32] Glaucoma
assessed by a 90/78 D examination for accurate delineation Severity Staging system  (GSS),[33] enhanced GSS,[34] etc. They
of the neuroretinal rim. Ocular Hypertension Treatment are based on the extent of damage and proximity to fixation,
Study (OHTS) found baseline C: D ratio to be a predictor of using global indices and number/percentage of significantly
further damage in Ocular hypertensives. However, in patients depressed loci, with multiple and varied stages. These need time
with early POAG, EMGT did not find baseline C: D ratio to and effort to analyze and stage a patient’s perimetric loss, are

Figure 3: Staging glaucoma by a careful examination of the neuroretinal rim. Rim loss generally starts inferiorly, and then superiorly, finally
extending around the disc. The inner edge of the neuroretinal rim should be identified by the bending of the blood vessels onto the surface of the
neuroretinal rim, as shown by the arrows

Table 2: Some simpler Glaucoma staging methods

Mild Moderate Severe
AAO[21] Optic disc cupping but no Glaucomatous neuropathy with Visual field loss in both
visual field loss visual field loss not within 5° of hemispheres or within 5° of
fixation fixation
Canadian guidelines[30] C: D ratio <0.65 or mild visual C: D ratio 0.7‑0.85 or visual field C: D ratio >0.9 or visual field
field defect not within 10° of defect not within 10° of fixation or defect within 10° of fixation or
fixation both both
International Classification Optic nerve abnormalities Optic nerve abnormalities Optic nerve abnormalities
of Diseases 10 consistent with glaucoma + consistent with glaucoma + one consistent with glaucoma + both
normal fields hemifield abnormality, not within 5° hemifield abnormality or within 5°
AAO: American Academy of Ophthalmology
 Sihota, et al.: Simplifying “target” IOP
April 2018 499

Figure 4: Representative visual field defects that could be classified as early, moderate, or severe glaucoma

largely used for research purposes at present, and are difficult Methods of Determining Target Intraocular
to apply clinically, by most ophthalmologists.
Pressure
EMGT found that a greater mean deviation (MD) loss at
baseline was a risk factor for greater progression.[27] CIGTS Having ascertained the degree of VF damage, baseline IOP,
reported that a unit increase in their baseline VF score was and risk factors, an IOP that would prevent further damage
associated with a 0.74‑unit progression.[26] In the AGIS, patients needs to be set. There needs to be a balance, between setting
with greater baseline damage, as evidenced by perimetric MD an appropriate target to prevent optic nerve damage and being
values of − 11.4 ± 5.5, were more likely to progress rapidly.[20] over aggressive in IOP lowering, to avoid side effects and an
The odds of VF progression increased by 11% for every 1‑dB economic burden.
worsening in baseline MD.[18] Baseline functional damage
determination requires any defect to be reproduced on at least Various approaches for setting a target IOP include as
two occasions, to obviate a learning curve, perimetric noise, etc. follows:
• Threshold/absolute cut off value
There is therefore a felt need for simple glaucoma staging • Percentage reduction
guidelines so that appropriate management algorithms can be
• Formula‑based values.
developed and validated. All perimeters with normative data
provide global indices and contain a plot highlighting localized An absolute/threshold target range is easiest for clinicians
loss in the VF that is definitive of glaucoma, similar to the pattern and is now most often used. Setting a ‘target” IOP by
deviation plot on HFA. These can be easily used to ascertain the percentage reduction or a threshold value has been used in
pattern of loss and stage glaucoma in each eye [Table 2 and Fig. 4]. many randomized control trials and studies. Formula‑based
Some simpler glaucoma staging methods are detailed in “target” IOP setting is more time‑consuming but appears to
Table 2. address risk factors in an individual patient.
500 Indian Journal of Ophthalmology Volume 66 Issue 4

Absolute/threshold values as “target” intraocular pressure progressed, 0% and 5% in POAG and PACG, respectively, with
Threshold or absolute values of target IOP are those that are an IOP of 10–12 mmHg. After that analysis, “target” IOPs in
relatively fixed and can be applied to a large number if not the same population were revised to < 15 mmHg, and a later
all patients having a similar degree of glaucomatous damage. evaluation of moderate POAG and PACG eyes over 10 years
showed a progression in only 11% of eyes, over double the
Target IOP in AGIS was <18 mmHg and eyes with a mean MD duration of review.[36]
of −10.5 dB had no average progression in 8 years of follow‑up
at pressures consistently reduced to <18 mmHg. However, a Quek et al. reported that a higher mean IOP and a history
post hoc analysis showed that in these eyes, the average IOP was of an acute attack in Chines eyes having PACG lead to poorer
12.3 mmHg. Eyes that had a mean IOP in the mid‑teens showed visual outcomes at 10 years. The mean IOP in eyes that
progression by 2.5 dB, and those with a mean of 20 mmHg had a progressed was 17.7 ± 2.6, as against 15.8 ± 2.1 mmHg in the
progression by 3.5 dB. Palmberg on analysis found a 30% chance eye that did not progress.[17]
of progression if the IOP remained in the mid‑teens and 70% at
In general, for mild‑moderate‑severe stage glaucoma, the
20 mmHg. Therefore, a target IOP of low teens should be set.[13]
initial target for absolute IOP cutoffs could be kept as IOP equal
A multicenter study in Japan reported that age and standard to or below 18 mmHg‑15 mmHg‑12 mmHg.
deviation of IOP were related to progression; however, in eyes
Percentage reduction in intraocular pressure
with an average IOP below 15 and also 13 mmHg, only age and
baseline VF total deviation were related to the progression rate.[35] The large RCTs aimed for either percentage reduction in IOP or
absolute values of IOP to gather information about long‑term
Many recent studies, especially surgical, have used results in different severities of POAG and have generally
designated “success” IOP levels as <18, <15, or even presented reviews with both evaluations.
<12 mmHg, as the importance of lower IOPs, especially in
moderate‑to‑advanced glaucoma where surgery is often The OHTS found that an IOP reduction of 20% or to an
performed, has become apparent. The World Glaucoma IOP of 24 mmHg leads to progression in 19% of high‑risk eyes
Association consensus on surgical success in glaucoma over 8–10 years, suggesting that a greater reduction was necessary.
stated that IOP success should be reported with a number of
Patients having early glaucoma, an MD < 5 dB, were studied
alternative upper limits (i.e., ≤21, 18, 15, and 12 mmHg) and
in EMGT, with a 72% progression off treatment, as compared
one lower limit (i.e., 6 mmHg).[22]
to 45% on therapy, when IOP was lowered by a mean of
Two‑hundred and forty‑five POAG and PACG eyes 5.1 mmHg or 25%. In CIGTS, similar patients had a calculated
were studied over  5  years in India, with a “target” IOP lowering of IOP based on damage, with a mean IOP around
of < 18 mmHg in all eyes, except severe glaucoma where the 17 mmHg a reduction by 38% and 46% in medical or surgically
“target” was 12–14 mmHg.[15] 12.1% and 15.5% of POAG and treated eyes, respectively. Fifteen percent of eyes were seen to
PACG eyes showed progression over 5 years, respectively. progress and 15% improve. Lichter et al. reported that those
Moderate glaucomas commonly progressed, 32/31.5% and with a peak IOP of 13 mmHg had more frequent improvement
26.6/25%, and hence, a target IOP of  <  18  mmHg was not than worsening of the VF.[37] With an IOP in the mid‑teens,
low enough in these eyes. Eyes with severe glaucoma rarely there was little improvement or progression; however, when

Table 3: Literature regarding mean intraocular pressure, percentage reduction in intraocular pressure and progression in
different stages of primary open‑angle glaucoma and primary angle‑closure glaucoma
Study Type of Baseline Percentage IOP Progression Mean IOP level
glaucoma IOP reduction
Ocular Hypertension Treatment Study[29] Open angle 24.9 20% 4.4/9.5% 19.3
Early Manifest Glaucoma Trial[27] POAG 20.6 25% 45/62% Mean fall 5.2 mmHg
Collaborative Normal Tension Glaucoma NTG 30% 12/35%
Study[38]
Collaborative Initial Glaucoma Treatment POAG 27 38% 15% progressed 17‑18 mmHg
Study Medical[26] and 15% improved
Surgical[26] 27 46% 14‑15 mmHg
Advanced Glaucoma Intervention POAG 23.7‑24.8 IOP mean 12.3 mmHg Did not progress
Study[28]
Stewart et al.[39] POAG 19.5±3.8 0% <12 mmHg<17
6% mmHg≥18 mmHg
26%
Sihota et al.[15]
Early POAG and 24.9±8 32%‑43% 18.7% <18 mmHg
PACG
Moderate 28.3±5 44% 21.3% <18 mmHg
Advanced 27.7±9 50% 2.3% 12 mmHg
IOP: Intraocular pressure, POAG: Primary open‑angle glaucoma, PACG: Primary angle‑closure glaucoma
 Sihota, et al.: Simplifying “target” IOP
April 2018 501

peak IOP was > 16 mm Hg, progression was significant. Early For a patient with early POAG/PACG, an IOP in the
glaucoma therefore appears to need an IOP in the mid‑teens. mid‑teens, with a possible upper limit of 17 mmHg, should
be initially aimed for and modified after a review with at least
An Indian study[15] found perimetric progression in 21.3% of
6 monthly perimetric evaluations.
POAG and PACG eyes with moderate glaucomatous damage
over 5 years when the target IOP was <18 mmHg. For a patient In POAG and PACG eyes with moderate glaucomatous
with moderate glaucomatous optic neuropathy, it appears damage, it appears that lower IOPs, with an upper limit <15 mmHg,
that lower IOPs, with an upper limit of 15 mmHg, would be would be required to stabilize VFs in the long term.[15]
required to stabilize VFs.
In advanced POAG, there is an apparent correlation
The AGIS had an average reduction in IOP of 40% with between peak IOP, IOP recorded over time, and progression.[28]
significant rates of progression.[28] An Indian study recorded Similarly, in advanced PACG, an IOP in the low teens was
progression in just 2.3% of POAG and PACG eyes with advanced found to reduce progression to 5%.[15] Advanced glaucomas
glaucoma over 5 years when the target IOP was 12–14 mmHg.[15] appear to need an IOP of <14 mmHg and preferably a mean
of 12 mmHg with minimal fluctuations over time.
Collaborative Normal‑Tension Glaucoma Study aimed to
lower IOP by 30% and found a 5‑year progression in 12% of For normal tension glaucoma, a fall in IOP of 30% from
treated patients as against 35% in untreated eyes. baseline has been shown to significantly reduce progression.

Literature regarding mean IOP, percentage reduction in After acute PACG, 15% of patients developed PACG among
IOP, and progression in different stages of POAG and PACG Caucasians, when the IOP was high after resolution of the
are collated in Table 3.
Formulas for setting a “target” intraocular pressure Table 4: IOP recording in recent studies
Formulas attempt to incorporate baseline and risk factors into Study group Type of study IOP
determining “target” IOP. Jampel first calculated target IOP criteria (mmHg)
by taking into account several attributes of the patient – initial
AVB[43] Multicenter, Primary : 5‑18
pretreatment IOP, Z score (an indicator of disease severity), randomized trial Secondary :
and Y factor (burden of therapy).[40] 5‑21 and 5‑15
Target IOP =  (Initial IOP ×  [1  –  initial pressure/100] − ABC Ahmed Multicenter, Primary: 6‑21
Z + Y ± 1 mmHg) Baerveldt randomized trial Secondary:
Comparison 6‑18, 6‑15
Modified equations increased the range of Z score, 0–7.[41,42] Study[44,45]
The CIGTS formula for target IOP was based on a patient’s Cillino et al.[46] Collagen IOP ≤21,17,15
baseline IOP (mean of six IOP measurements taken over two implant‑RCT
visits) and their reference VF score (the mean of VF scores from Lopes et al.[47] Prostaglandin IOP ≤18
at least two Humphrey 24‑2 VF tests).[18] efficacy open‑label
Recent studies can be seen to have predetermined target/ Sugimoto et al.[48] Surgery ‑ IOP
success IOPs as shown in Table 4. observational <22,19,16,13
Pakravan et al.[49] AGV ‑ RCT IOP ≤15
Clinical Recommendations of Absolute/ Akkan and Trabectome ‑ RCT IOP
Threshold “Target” Intraocular Pressure Cilsim[50] <21,18,15,12

Range in Different Stages of Primary Miki et al.[51] Trabeculectomy ‑

retrospective
IOP ≤15

Open‑Angle Glaucoma and Primary Al‑Mugheiry MIGS ‑observational IOP ≤18, 15

Angle‑Closure Glaucoma et al.[52] cohort
Perez et al.[53] Trabeculectomy ‑ IOP ≤18
Setting and achieving a “target” IOP range provide an
retrospective
algorithm for management. Quality of life may be affected
Khandelwal Trabeculectomy ‑ IOP ≤18,15,12
by the medications used, but how much more is it affected by
et al.[54] retrospective
progressive glaucomatous optic neuropathy because it is not
Nguyen et al.[55] Trabeculectomy IOP ≤18,15,12
VF defects only, but contrast sensitivity, mobility, night vision,
‑ retrospective
driving, etc., that are significantly affected. After an iridotomy,
case‑control study
PACD eyes appear to respond similarly to IOP control, as in
Takihara et al.[56] Trabeculectomy ‑ IOP <21,18,15
POAG.[15]
prospective cohort
In ocular hypertension or primary angle closure with ocular Ahuja et al.[57] Trabectome ‑ IOP <21,18
hypertension, the decision to treat should depend on high‑risk retrospective
factors such as – a family history, high baseline C: D ratio, high Sihota et al.[15,58] POAG/PACG IOP <18, <14
baseline IOP, low central corneal thickness (CCT), and older Sihota et al.[15,58] POAG/PACG IOP <16, <14,
age. The suggested upper limit of the initial IOP range should <12
be less than 18 mmHg in patients at high risk of progression, AVB: Ahmed Versus Baerveldt, RCT: Randomized control trials,
older age, thinner CCT, males, cardiovascular disease, greater AGV: Ahmed glaucoma valve, MIGS: Microinvasive glaucoma stent,
baseline C: D ratio, IOP, and pattern standard deviation.[29] POAG: Primary open‑angle glaucoma, PACG: Primary angle‑closure glaucoma
502 Indian Journal of Ophthalmology Volume 66 Issue 4

attack. About 11%–16% were blind or visually impaired.[18,59] therapeutic modalities. Liang et  al. reported the initial use of
It is therefore apparent that patients with acute angle‑closure trabeculectomy in PACG and an iridotomy and medications in
glaucoma need a long‑term control of IOP, to at least the PAC eyes.[58] Trabeculectomy is effective in significantly reducing
population normal. IOP in the long term in both POAG and PACG eyes.[61‑63]
Determination of a target IOP is an important step in the The question frequently raised is whether such low IOPs
management of glaucoma, but it cannot be determined with should be aimed for as soon as therapy is instituted or whether
any certainty, and achieving the set target IOP does not give a graded lowering of IOP should be done. van Gestel et  al.
complete assurance that disease progression will be prevented, studied a mathematical model of stepped reduction of IOP
as many other factors also play a part in glaucoma progression. 21–18 mmHg, then further to 15 mmHg, or directly < 15 mmHg,
and found that an initially low target IOP gave better‑quality
EMGT concluded that mean elevated IOP is a major risk
adjusted life years  (QALYs), as compared to a gradual
factor for progression in POAG, while fluctuations are not.
reduction over time.[64] A low initial target pressure (15 mmHg)
A change of IOP by 1 mmHg resulted in about a 10% change
resulted in 0.115 QALYs gained and €1550  (approximately
in risk of progression.[60] De Moraes et al. found mean IOP,
Indian Rupees 116,777/‑) saved compared to a gradual
peak IOP, and IOP fluctuation to be significant risk factors
decrease from 21 to 15 mmHg upon progression. These
for progression in POAG. Sihota et al. found that an intervisit
lower target IOPs, however, required more medications, laser
fluctuation in IOP of > 4 mmHg over a median of three visits
trabeculoplasty, trabeculectomies, and drainage implants.
was associated with progression in POAG and chronic PACG
From a cost‑effectiveness and quality‑of‑life point of view,
eyes.[15]
it seems advantageous to aim for a low IOP in all glaucoma
Achieving “Target” Intraocular Pressure patients [Fig. 5].

Lowering an IOP to such levels may need medications, lasers, Limitations of target intraocular pressure
and even surgery in some patients. In a cross‑sectional study IOP recording, even by applanation, is imprecise, with known
from India, 92.2% POAG and 98.4% CPACG eyes were on ≤ 2 diurnal and physiological variations, which could confound
glaucoma medications at 5 years. 15.5% POAG eyes underwent IOP measurements on long‑term review. Corneal thickness
trabeculectomy and 14.6% argon laser trabeculoplasty, while and hysteresis changes can influence IOP measurements
among CPACG eyes, 16.3% underwent trabeculectomy to so that a baseline IOP and later IOPs should be evaluated
achieve target pressure. [15] Thus, achieving target IOP in keeping these fallacies in mind. For example, a review
glaucoma patients is not difficult but requires the use of all IOP of 16 mmHg in a patient with moderate damage and a

Figure 5: Achieving target intraocular pressure based on initial baseline intraocular pressure
 Sihota, et al.: Simplifying “target” IOP
April 2018 503

CCT of 420 µ would have a higher corrected IOP that is not should not be “written in stone.” Long‑term serial objective
appropriate for this eye. recording of the optic disc and retinal nerve fiber layer and
VFs can highlight early progression and therefore modification
Aiming for low IOPs in all glaucoma patients needs
of glaucoma therapy when required. There is significant
aggressive IOP reduction and may lead to a reduction in
individual variability in anatomical and physiological
quality of life due to the medications necessary to achieve
parameters and numerous other coexisting systemic diseases
this or the risks of glaucoma surgery. Adherence to therapy is
and medications. However, it is apparent that with an
difficult to ascertain on review and may lead to unnecessary
appropriate target IOP range and continuous reassessment,
increases in therapy when an IOP appears to be above the
glaucoma progression can be considerably slowed down so
target. In addition, once a “target” IOP is set, patients could be
that at most, only a few loci show a change.
stressed and unhappy if it is not achieved at every visit. There
may be possible medicolegal consequences if “target” IOP is For both POAG and PACG after an iridotomy, in mild
considered the standard of care and progression continues. glaucoma, the initial target IOP range could be kept as
15–17 mmHg, for moderate glaucoma 12–15 mmHg, and in the
To date, there are inadequate data available to show
severe stage of glaucomatous damage 10–12 mmHg.
that if an individual patient exceeds this target, he/she will
progress, and there are not enough evidence‑based studies Appropriate use of medications/laser/surgery to achieve
to determine absolute IOP levels in each individual. It is also such a “target” IOP range in POAG or PACG can maintain VFs
difficult to definitively diagnose early progression by perimetry and quality of life, preventing glaucoma blindness.
or objective monitoring so that resetting target IOP may be
delayed, allowing some loss of VF. Financial support and sponsorship
Nil.
However, “target” IOP range has been shown to help
prevent progression and should be discussed thoroughly with Conflicts of interest
the patient. There are no conflicts of interest.

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