86 Normal Low Tension Glaucoma PDF

Normal Tension Glaucoma: 50 year-old female with
progressive visual field loss, glaucomatous disc change and

normal IOP
Jordan Rixen, M3 and Young H. Kwon, MD, PhD
August 14, 2008 Unremarkable, OU
o Goniscopy: open angles to ciliary
Chief Complaint: 50 y.o. female with progressive body band for 360 degrees, OU
visual field loss, glaucomatous disc change and • Dilated fundus exam (DFE):
normal intraocular pressure (IOP). o OD: Optic nerve with 0.7 cup-to-
History of Present Illness: Patient was diagnosed disc ratio (CDR) with early notch
with glaucoma by her local optometrist one year ago. superior
She has been using latanoprost in both eyes (OU) at o OS: 0.8 CDR with inferior and
nighttime since her diagnosis. Recent follow up superior notches (see Figure 1)
detected progressive visual field changes in the left • Humphrey visual fields: OD -- Full; OS --
eye (OS) and the patient was referred for further inferior arcuate defect, superior and inferior
evaluation. nasal step (see Figure 2)
Past Ocular History: No previous ocular procedures • Optical Coherence Tomography (OCT):
or trauma. o OD: mean nerve fiber layer (NFL)
Past Medical History: Raynaud’s disease. thickness of 74 microns
Family History: No family history of glaucoma. o OS: mean NFL thickness of 62
Ocular Exam: microns (see Figure 3)
• Visual Acuity, with best correction: Right • Additional finding: change in hand color
eye (OD)--20/20; OS--20/20 consistent with Raynaud’s was observed
• Manifest Refraction: OD: -3.75 +0.75 x 050; bilaterally during exam (see Figure 4).
OS: -3.75 +0.25 x 020
• Motility: Full, OU Course: A 24 hour blood pressure monitoring ruled
• Intraocular pressure: OD -- 18 mmHg; OS -- out nocturnal hypotension (SBP: 110-138; DBP: 66-
16 mmHg 85. Lowest BP recorded was 110/66 at 4:10AM).
• Anterior segment examination: Based on the amount of cupping and corresponding
Figure 1: Optic nerve photographs, February 2007

Optic Disk, OD: 0.7 cup to disk ratio with early Optic Disk, OS: Left eye: 0.8 cup to disk ratio with
superior and inferior notches superior and inferior notches
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visual field damage, a target IOP range of 12-13 No features, other than IOP, can consistently
mmHg was chosen. Additional topical medication differentiate primary open glaucoma with elevated
was added (latanoprost OU and brimonidine OS). pressure (POAG) from NTG although some
Diurnal curve demonstrated IOP range 14-20 OD and differences have been described. Patients with NTG
12-18 OS with peak of 20 OD and 18 OS at are, on average, 10 years older than those who have
10:00AM . On subsequent follow-up, she was noted POAG. NTG optic discs are more likely to show
to have progression of visual field loss (see figure 5) focal notching, nerve fiber layer hemorrhage and
and a new disc hemorrhage OD (not shown). focal paracentral scotomas in the visual field.
Additional anti-glaucoma medication was prescribed. The pathogenesis of NTG remains unclear. One
potential mechanism is vasospasm. This idea is
Figure 2: Humphrey visual fields, February 2007
Visual Field OS: Inferior arcuate defect with superior and

Visual Field OD: Normal, full visual field
inferior nasal step
supported by studies which show an association

Discussion: Normal Tension Glaucoma (NTG)
between NTG and conditions of vasospasm or
In summary, this patient is a 50 year-old woman with vasoconstriction such as Raynaud’s syndrome and
cupped optic nerves with corresponding visual field migraine headaches. In addition to vasospasm, it has
loss and nerve fiber layer thinning on OCT, and been shown that some glaucoma patients (and normal
normal IOP on diurnal curve measurement. Past individuals) have blood pressures which decrease
medical history is significant for Raynaud’s disease significantly at night during sleep. At the same time,
and 24 hour blood pressure monitoring ruled out there is evidence that the IOP increases in a supine
nocturnal hypotension. She subsequently developed position which is typical during sleep. The decrease
visual field progression and a disc hemorrhage. This in systemic perfusion pressure coupled with increase
constellation of findings is consistent with the in IOP could lead to a compromise in blood flow to
diagnosis of normal tension glaucoma. the optic nerve in NTG. For this reason, patients
Normal tension glaucoma is characterized by open should be questioned on the use of systemic
angles, glaucomatous optic discs, progressive visual antihypertensives at night and may benefit from a 24-
field changes and thinning nerve fiber layers in hour BP monitoring to rule out nocturnal
individuals with normal IOPs. In the United States, hypotension.
15-25% of people with signs of open-angle glaucoma
will have a single IOP measurement within the
normal range. Because IOP can vary from hour to
hour, a diurnal curve is helpful to confirm single
readings in making the diagnosis.
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Figure 3: Ocular coherence tomography (OCT), February 2007.
OCT demonstrates thinning of the nerve fiber layer in the superior Figure 4: Image of patient’s hand
and inferior portion of the both optic nerves. A) Right eye shows during exam. Erythema demonstrates
loss of nerve fiber layer with an average thickness of 74.43 hyperemic phase of Raynaud’s,
microns. B) Left eye shows more substantial loss of nerve fiber which usually follows vasospasm
layer with an average thickness of 62.05 microns. Larger portions and reversible ischemia of peripheral
of the superior and inferior optic nerve head are affected. This arterioles.
correlates with the appearance of the optic nerves on photography.
The Collaborative NTG Study showed that a 25-30% and uncommon because of their potential for
reduction in IOP can slow or prevent progression in systemic hypotension.
NTG patients. This can be achieved through the same
medical or surgical treatments utilized in POAG. A Diagnosis: Normal Tension Glaucoma (NTG)
few studies from Japan showed calcium channel
blockers may be beneficial in NTG associated with
vasospasm. However, their use remains controversial
EPIDEMIOLOGY SIGNS
• 15-25% of patients with open angle • IOP within normal range
glaucoma in the US have normal range IOP • Progressive glaucomatous cupping
on single measurement • Visual field loss
• On average, older than POAG patients • Decreased nerve fiber layer on OCT
• Increased prevalence in Japan • Recurrent optic disc hemorrhage
SYMPTOMS TREATMENT
• Progressive vision loss • Reduce IOP by at least 25% using
• May be associated with migraines and glaucoma medications or surgery
peripheral vasospasm (Raynaud’s) • Avoid drug induced nocturnal systemic
hypotension
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Figure 5: Subsequent Humphrey visual fields, February 2008
Visual Field OS: Paracentral scotoma with superior and
Visual Field OD: Small inferior nasal step has
inferior nasal step. Field now shows development of
developed.
superior arcuate defect.
Differential Diagnoses for what appears to be hypotension and its role in optic nerve head
glaucomatous optic neuropathy with a normal and ocular ischemic disorders. Am J
IOP reading: Ophthalmol 1994; 117:603-624.
• Normal-tension glaucoma 4. Kiuchi T, Motoyama Y, Oshika T :
• Primary open-angle glaucoma with Relationship of progression of visual field
episodic normal IOP damage to postural changes in intraocular
• Secondary open-angle glaucoma from pressure in patients with normal-tension
previous elevated IOP (eg. glaucoma. Ophthalmology 2006
Corticosteroid-induced glaucoma) Dec;113(12):2150-5.
• Nonglaucomatous optic neuropathy 5. The effectiveness of intraocular pressure
reduction in the treatment of normal-tension
REFERENCES: glaucoma. Collaborative Normal-Tension
Glaucoma Study Group. Am J
1. Hitchings, R. Normal Tension Glaucoma.
Ophthalmology 1998; 126(4):498-505.
Chapter 221. Yanoff: Ophthalmology, 2nd
6. Sawada A, Kitazawa Y, Yamamoto T, et al:
ed. Mosby Inc. 2004.
Prevention of visual field defect progression
2. Ahmed, Iqbal. Glaucoma, Low Tension.
with brovincamine in eyes with normal-
eMedicine.com. 2006 [cited May 5, 2008 ];
tension glaucoma.
Available from
Ophthalmology 1996; 103:283-288.
http://www.emedicine.com/oph/topic133.ht
Additional Resource:
m
3. Hayreh SS, Zimmerman MB , Podhajsky 1. Gonioscopy.org
P, Alward WL: Nocturnal arterial
suggested citation format:

Rixen J, Kwon YH. Normal Tension Glaucoma: 50 year-old female with progressive visual field loss,
glaucomatous disc change and normal IOP. EyeRounds.org. August 14, 2008 [cited --insert today's date
here -- ]; Available from: http://webeye.ophth.uiowa.edu/eyeforum/cases/86-Normal-Low-Tension-
Glaucoma.pdf.
Copyright © 2008. The University of Iowa Department of Ophthalmology & Visual Sciences, 200 Hawkins Dr., Iowa
City, IA 52242-1091. Last updated: 08-27-2008
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Normal Tension Glaucoma: 50 year-old female with

progressive visual field loss, glaucomatous disc change and

Figure 1: Optic nerve photographs, February 2007

Visual Field OS: Inferior arcuate defect with superior and

supported by studies which show an association

suggested citation format:

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