'Ocular Hypertension'
or
'Early Glaucoma'?
whose intraocular pressure is considerably but who have no other evidence of glaucoma has been solved in various ways at various times. Some decades ago, these patients' conditions were called "early glaucoma," and they were all treated and for a time even operated on. Then the pendulum swung back and there was a tendency to regard this condition as a benign one that would only rarely develop into a frank glaucoma. The acceptable position at the present time lies somewhere in the middle. A recent, unsolicited editorial opinion by Drs Chandler and Grantfrom Boston has put this problem into focus, and I have asked three other experts in the field to express their opinions. I hope that these four editorials will be of benefit to the readership.\p=n-\Ed. The
problem of what
higher than the
'Ocular
mean
term "ocular
is a
condition where the angle is open, and the disc and visual field are normal,
lut the tension is above the normal On the other hand, the term though not a descriptive
!;lllKe. glaucoma,"
erin, is nevertheless universally uner8tood by ophthalmologists to mean elevated intraocular pressure, or ^^racteristie changes in the optic disc and the visual field, or all three. There re> of course, different kinds of glau-
°uia-angle-closure glaucoma
and
illl.V kinds of "secondary" glaucoma,
nic'h may have elevated tension but
"t'nial discs and visual fields for some •bio. We do not call these conditions
ocular hypertension. In all 'j^ondary etie conditions where tension is
elovated,
even
though the disc
is
0l'mal, we consistently call the condi-
'
1011 glaucoma. Let us consider only a rtti of glaucoma commonly called Pen-angle glaucoma. If there is char-
glaucomatous-type cupping "juristic 'he disc and
"Us
optic
changes
patients
of the normal population
Hypertension' vs Open-Angle
hypertension" currently commonly applied to The
to do with
typical glaucoma-
in the visual field but >n-sion remains in the normal range, ° commonly call the condition "lowglaucoma." Aside from the Pasional case of low-tension glau-
^bsion
ma> open-angle glaucoma begins
with a somewhat elevated tension with the disc and field still normal. In the course of time, either because tension becomes higher or the eye is peculiarly susceptible to elevated tension, pathologic cupping and loss of field develop in many eyes. If the tension is at first only moderately elevated, say somewhere in the 20s, the ophthalmologist may elect to let the patient go without treatment as long as he detects no change in the optic disc and, of course, no defect in the visual field. If he detects a beginning change in the appearance of the optic disc, such as an asymmetry of the physiologic cups in the two eyes or a cup that is enlarging toward the disc margin either above or below or in both directions, or if the cup is physiologic but he detects saucerization of the disc, he will surely commence treatment with the hope of preventing glaucomatous damage to the eye. He regulates the intensity of treatment according to the level of tension, and especially to changes in the disc leading to loss of field. If tension without treatment rises into the 80s or higher, he usually starts treatment even though the disc may be completely normal. He certainly should start treatment if the tension is in the 40s
Glaucoma
if the disc is completely treatment in such cases and normal, should be intensive. We read in the literature about what percentage of cases of untreated so-called ocular hypertension go on to develop loss of field during a period of time, and what percentage of cases during the same period of time do not have loss of field. In most reports on ocular hypertension, we are not told the type and extent of field loss or the correlation of the appearance of the optic disc to the field loss. Is it a minimal loss of field, or is it an extensive loss? Is there pathologic cupping of the disc corresponding to the field loss? (It would not seem to be good
or
50s,
even
ophthalmological practice
to allow
a
substantial loss of field while withholding treatment, especially when such loss of field can be predicted and anticipated by studying the optic nervehead and starting treatment as soon as the nervehead begins to
appear abnormal, and before field loss
occurs.)
In the beginning of the observation of such patients when their nerveheads are normal, it has been stated that there is no way of predicting which patients will in time develop pathologic cupping and loss of field,
Downloaded From: http://archopht.jamanetwork.com/ by a Michigan State University User on 06/08/2015
after a period of time, perhaps only after several months, a rapid deterioration in the field, with optic atrophy, perhaps with still minimal pathologic cupping. In following up such patients with a relatively high tension and a normal disc, we have no clues as to when they will begin to lose field. By the time we recognize optic atrophy, they have already lost considerable field. In patients with a lower tension, we can
out damage, which it surely is. Yes, we may safely withhold treatment as
sion is referred to in other countries to some extent, we encounter the term most commonly in North America, and the term is relatively new in ophthalmologic literature. There is an implication that ocular hypertension is a relatively benign disease, whereas open-angle glaucoma is a serious disorder. Do we need the term ocular hypertension? In our opinion, we do not need this term. Let us call the condition early open-angle glaucoma with-
w^
we believe this is true. However, during a period of time, we often can make a prediction in these untreated patients as to which are more likely to develop loss of field and which are less likely to do so. If, in the period of our observation, we detect beginning glaucomatous changes in the disc, we can safely predict that these are the patients who are most likely to develop loss of field if we continue to
such
hand, if the disc remains completely normal and unchanged during our period of observation, we can conclude
recognize beginning glaucomatous changes in the disc before there is loss of field and we can treat the patient accordingly. Although the term ocular hyperten-
and
withhold treatment. On the other
that we can safely continue to withhold treatment for a further period, providing tension remains 30 or less. We believe treatment should not be withheld, even if the disc is completely normal, if tension is in the mid to high 30s. There may be some difference of opinion about this, but we believe there should be no difference of opinion if tension is in the 40s or higher. To be sure, one may see the disc remain normal and the field full for a period of time with tension in the 40s or higher, but we have seen in
'Ocular
cases
long
as
the disc remains
completely
normal, and the tension is not unduly elevated, but let us not withhold treatment when
we
have detected
a
begin'
ning glaucomatous change in the optic disc, even though there is as yet not the slightest defect in the visual field. and let
us
not withhold
treatment
if the disc is completely normal » the tension is considerably elevated. In cases where the disc is normal and the angle open, if tension is in the 20s, if one were to insist on using the term ocular hypertension, we mi)in call this a mild case of ocular hyper' tension. If tension is in the 30s, might call this a moderate case; » tension is in the 40s or higher, this should be called a severe case. But m all three instances, it is simply ope11' even
angle glaucoma. Regardless of terms. let us treat the case as we would an)' case of glaucoma with similar tension elevation. Paul A. Chandler, MD W. Morton Grant, MD Boston
Hypertension' vs Open-Angle
Glaucoma:
A Different View After reviewing the preceding editorial prior to publication, we find that we must disagree with much of the pessimistic thesis and many of the conclusions of the authors. We agree with the authors' definition of ocular hypertension as a "condition where the angle is open, and the disc and visual field are normal, but the tension is above the normal range." It is important to realize, however, that the "normal range" is purely a statistical definition\p=n-\itsrelationship to glaucoma is based on the fact that the
majority of patients with open\x=req-\ angle glaucoma have elevated intraocvast
ular pressures. In addition, the elevated intraocular pressure usually precedes glaucomatous damage to the optic nerve by a variable period of time. The fact that most patients with glaucoma have elevated intraocular pressure does not logically mean, however, that most patients with elevated intraocular pressure have
glaucomatous optic nerve damage, or will, in fact, ever develop such damage. On the contrary, available
Downloaded From: http://archopht.jamanetwork.com/ by a Michigan State University User on 06/08/2015
data indicate just the opposite to be true. Numerous studies from North America, as well as every other part the world, during the past decade ° demonstrate that the prevalence ocular hypertension in the genera population is at least ten to 15 times greater than the prevalence of glaucoof
matous
optic
nerve
damage (as
of
fined by visual field loss). Similarly.in studies in which patients with ,'1' vated intraocular pressure but wit"
optic nerve damage (ie, ocuia hypertension) are followed up witho11
out
or
'Early Glaucoma'?
whose intraocular pressure is considerably but who have no other evidence of glaucoma has been solved in various ways at various times. Some decades ago, these patients' conditions were called "early glaucoma," and they were all treated and for a time even operated on. Then the pendulum swung back and there was a tendency to regard this condition as a benign one that would only rarely develop into a frank glaucoma. The acceptable position at the present time lies somewhere in the middle. A recent, unsolicited editorial opinion by Drs Chandler and Grantfrom Boston has put this problem into focus, and I have asked three other experts in the field to express their opinions. I hope that these four editorials will be of benefit to the readership.\p=n-\Ed. The
problem of what
higher than the
'Ocular
mean
term "ocular
is a
condition where the angle is open, and the disc and visual field are normal,
lut the tension is above the normal On the other hand, the term though not a descriptive
!;lllKe. glaucoma,"
erin, is nevertheless universally uner8tood by ophthalmologists to mean elevated intraocular pressure, or ^^racteristie changes in the optic disc and the visual field, or all three. There re> of course, different kinds of glau-
°uia-angle-closure glaucoma
and
illl.V kinds of "secondary" glaucoma,
nic'h may have elevated tension but
"t'nial discs and visual fields for some •bio. We do not call these conditions
ocular hypertension. In all 'j^ondary etie conditions where tension is
elovated,
even
though the disc
is
0l'mal, we consistently call the condi-
'
1011 glaucoma. Let us consider only a rtti of glaucoma commonly called Pen-angle glaucoma. If there is char-
glaucomatous-type cupping "juristic 'he disc and
"Us
optic
changes
patients
of the normal population
Hypertension' vs Open-Angle
hypertension" currently commonly applied to The
to do with
typical glaucoma-
in the visual field but >n-sion remains in the normal range, ° commonly call the condition "lowglaucoma." Aside from the Pasional case of low-tension glau-
^bsion
ma> open-angle glaucoma begins
with a somewhat elevated tension with the disc and field still normal. In the course of time, either because tension becomes higher or the eye is peculiarly susceptible to elevated tension, pathologic cupping and loss of field develop in many eyes. If the tension is at first only moderately elevated, say somewhere in the 20s, the ophthalmologist may elect to let the patient go without treatment as long as he detects no change in the optic disc and, of course, no defect in the visual field. If he detects a beginning change in the appearance of the optic disc, such as an asymmetry of the physiologic cups in the two eyes or a cup that is enlarging toward the disc margin either above or below or in both directions, or if the cup is physiologic but he detects saucerization of the disc, he will surely commence treatment with the hope of preventing glaucomatous damage to the eye. He regulates the intensity of treatment according to the level of tension, and especially to changes in the disc leading to loss of field. If tension without treatment rises into the 80s or higher, he usually starts treatment even though the disc may be completely normal. He certainly should start treatment if the tension is in the 40s
Glaucoma
if the disc is completely treatment in such cases and normal, should be intensive. We read in the literature about what percentage of cases of untreated so-called ocular hypertension go on to develop loss of field during a period of time, and what percentage of cases during the same period of time do not have loss of field. In most reports on ocular hypertension, we are not told the type and extent of field loss or the correlation of the appearance of the optic disc to the field loss. Is it a minimal loss of field, or is it an extensive loss? Is there pathologic cupping of the disc corresponding to the field loss? (It would not seem to be good
or
50s,
even
ophthalmological practice
to allow
a
substantial loss of field while withholding treatment, especially when such loss of field can be predicted and anticipated by studying the optic nervehead and starting treatment as soon as the nervehead begins to
appear abnormal, and before field loss
occurs.)
In the beginning of the observation of such patients when their nerveheads are normal, it has been stated that there is no way of predicting which patients will in time develop pathologic cupping and loss of field,
Downloaded From: http://archopht.jamanetwork.com/ by a Michigan State University User on 06/08/2015
after a period of time, perhaps only after several months, a rapid deterioration in the field, with optic atrophy, perhaps with still minimal pathologic cupping. In following up such patients with a relatively high tension and a normal disc, we have no clues as to when they will begin to lose field. By the time we recognize optic atrophy, they have already lost considerable field. In patients with a lower tension, we can
out damage, which it surely is. Yes, we may safely withhold treatment as
sion is referred to in other countries to some extent, we encounter the term most commonly in North America, and the term is relatively new in ophthalmologic literature. There is an implication that ocular hypertension is a relatively benign disease, whereas open-angle glaucoma is a serious disorder. Do we need the term ocular hypertension? In our opinion, we do not need this term. Let us call the condition early open-angle glaucoma with-
w^
we believe this is true. However, during a period of time, we often can make a prediction in these untreated patients as to which are more likely to develop loss of field and which are less likely to do so. If, in the period of our observation, we detect beginning glaucomatous changes in the disc, we can safely predict that these are the patients who are most likely to develop loss of field if we continue to
such
hand, if the disc remains completely normal and unchanged during our period of observation, we can conclude
recognize beginning glaucomatous changes in the disc before there is loss of field and we can treat the patient accordingly. Although the term ocular hyperten-
and
withhold treatment. On the other
that we can safely continue to withhold treatment for a further period, providing tension remains 30 or less. We believe treatment should not be withheld, even if the disc is completely normal, if tension is in the mid to high 30s. There may be some difference of opinion about this, but we believe there should be no difference of opinion if tension is in the 40s or higher. To be sure, one may see the disc remain normal and the field full for a period of time with tension in the 40s or higher, but we have seen in
'Ocular
cases
long
as
the disc remains
completely
normal, and the tension is not unduly elevated, but let us not withhold treatment when
we
have detected
a
begin'
ning glaucomatous change in the optic disc, even though there is as yet not the slightest defect in the visual field. and let
us
not withhold
treatment
if the disc is completely normal » the tension is considerably elevated. In cases where the disc is normal and the angle open, if tension is in the 20s, if one were to insist on using the term ocular hypertension, we mi)in call this a mild case of ocular hyper' tension. If tension is in the 30s, might call this a moderate case; » tension is in the 40s or higher, this should be called a severe case. But m all three instances, it is simply ope11' even
angle glaucoma. Regardless of terms. let us treat the case as we would an)' case of glaucoma with similar tension elevation. Paul A. Chandler, MD W. Morton Grant, MD Boston
Hypertension' vs Open-Angle
Glaucoma:
A Different View After reviewing the preceding editorial prior to publication, we find that we must disagree with much of the pessimistic thesis and many of the conclusions of the authors. We agree with the authors' definition of ocular hypertension as a "condition where the angle is open, and the disc and visual field are normal, but the tension is above the normal range." It is important to realize, however, that the "normal range" is purely a statistical definition\p=n-\itsrelationship to glaucoma is based on the fact that the
majority of patients with open\x=req-\ angle glaucoma have elevated intraocvast
ular pressures. In addition, the elevated intraocular pressure usually precedes glaucomatous damage to the optic nerve by a variable period of time. The fact that most patients with glaucoma have elevated intraocular pressure does not logically mean, however, that most patients with elevated intraocular pressure have
glaucomatous optic nerve damage, or will, in fact, ever develop such damage. On the contrary, available
Downloaded From: http://archopht.jamanetwork.com/ by a Michigan State University User on 06/08/2015
data indicate just the opposite to be true. Numerous studies from North America, as well as every other part the world, during the past decade ° demonstrate that the prevalence ocular hypertension in the genera population is at least ten to 15 times greater than the prevalence of glaucoof
matous
optic
nerve
damage (as
of
fined by visual field loss). Similarly.in studies in which patients with ,'1' vated intraocular pressure but wit"
optic nerve damage (ie, ocuia hypertension) are followed up witho11
out
