'Glaucoma

Suspect' or 'Ocular Hypertension'?

More than 15 years ago, various studies made it clear that many eyes tolerated pressures far above the statistical normal for long periods of time. Until these studies were done, it would have been considered close to malpractice if hypertensive eyes were not treated. Yet we knew that undesirable side effects were present with all the antiglaucomatous medications. The term ocular hypertension was coined to describe eyes with increased intraocular pressure, but with undamaged optic discs and normal fields of vision. The older ophthalmologists

Ocular

angle glaucoma for patients with high

intraocular pressures, open angles, normal

optic discs, and normal visual They also advocate early treat-

ment of these patients to prevent glaucomatous loss of vision. Should we label these patients early glaucoma? Many of them will never lose vision. In addition, the word glaucoma has connotations of prospective blindness that frighten the patient and hamper his ability to obtain employment or insurance. Ocular hy-

pertension is

a useful term that the condition describes accurately without implying an unduly dire prognosis. It does not, of course, imply a totally benign condition offering no risk to the patient's vision. Obviously, some patients with ocular hypertension will in the future develop glaucomatous optic nerve damage, and all must be carefully watched for this

possibility.

medical students, residents, and ophthalmologists have been lulled into a false sense of security. In their minds, the term ocular hypertension some

implies a benign process. As a result, patients have suffered serious visual loss because they were not carefully followed up. For this reason, the term "glaucoma suspect" is preferable. It includes patients with insome

Hypertension:

Chandler and Grant urge us to discard the diagnosis ocular hypertension and use in its stead early open\x=req-\

fields.

then became psychologically more willing to follow up (but not treat) such patients when the condition was called "ocular hypertension" rather than "possible glaucoma." A problem has since arisen because

To Treat

or

The

important issue raised by the editorial, however, is not the question of terminology. Rather, it is the question of whether the ocular hypertensive patient should be treated with

pressure-lowering

medication. This

question is of great importance to the practicing ophthalmologist who faces

the decision several times each week. Experts certainly disagree about indications for treatment. Some, like Chandler and Grant, emphasize the danger of visual loss in the ocular hypertensive patient and are inclined

begin treatment early. Others, impressed by the side effects of treatment and the relative infrequency of visual loss in ocular hypertensives, prefer to carefully follow up these patients, withholding treatment to

more

until subtle signs of damage appear.

optic

nerve

The reason for these divergent opinions about the risks and benefits of therapy becomes clear when we examine the factual information available to the ophthalmologist as he

creased intraocular pressures, or large

(presumably physiologic) optic cups>

angles. Both the physicia" and the patient are more likely t0 remain interested in adequate folio*' or narrow

up

care.

There will continue to be some usefulness for the term ocular hyper' tension, eg, for the nervous patien1 who might be badly frightened by tne term glaucoma suspect. It may perm'1 employment and insurance opportun!' ties that could be lost if the term glaucoma suspect is used. Robert Shaffer, MD San Francisco

Not to Treat? decides whether or not to treat a patient with ocular hypertension' When making this decision the op"'

thalmologist, explicitly

or

implicite'1

asks himself three questions. (1) What is the risk to the with high intraocular pressures ° losing vision from glaucoma? In tw recent population surveys, the prevalence of ocular hypertension (pressUi more than 20 mm Hg) was nine and ¿ times, respectively, the prevalence °

patient

primary open-angle glaucoma.1' suming that all patients with g»aU' coma go first through a phase ° ocular hypertension, these figi"'0' suggest that the lifetime risk of gla"' coma developing in a patient wit ocular hypertension is, on the averaf?f' "

somewhere around 1:20 to 1:1). T"' estimate of average risk is encouraf. ingly low. Unfortunately, it is n° particularly useful in dealing wit" young patient with ocular hyperte" sion or a patient with severe ocUl» hypertension. Both of these patiefl will probably have a higher-tha"

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