REVIEW ARTICLE

Ocular hypertension: an approach to assessment

and management
Pui Yi Boey, FRCSEd (Ophth),*,† Steven L. Mansberger, MD, MPH*
ABSTRACT ● RÉSUMÉ
Ocular hypertension is a common and important problem seen by eye care providers. This review presents a practical approach to
individuals with ocular hypertension. It describes the common functional and structural investigations used in evaluation, as well as
the advantages and disadvantages of each test. This review also discusses several landmark studies on ocular hypertension and
provides a practical guide to the management of this problem.

L’hypertension oculaire est un problème important et commun que voient les fournisseurs de soins oculaires. Cette revue présente
une approche pratique chez les personnes ayant une hypertension oculaire. Elle décrit les investigations fonctionnelles et
structurelles d’évaluation ainsi que les avantages et inconvénients de chaque test. Elle traite aussi des études historiques
concernant l’hypertension oculaire et présente un guide pratique de gestion de ce problème.

Eye care providers commonly encounter ocular hypertension
(OHT) in adult patients, occurring in 3.0% to 7.4% of
adults worldwide.1–3 Studies define OHT as intraocular
pressure (IOP) greater than 2 SDs from the mean of a
normal adult population, with normal visual fields, and no
evidence of glaucomatous optic disc changes.4 However,
studies differ in their definitions of “normal” visual fields and
“normal” optic disc structure. This review discusses the
expected results of evaluating visual fields in OHT with
standard achromatic automated perimetry (SAP), short-
wavelength automated perimetry (SWAP), or frequency-
doubling threshold (FDT) tests. We also examine optic disc
structure assessment using clinical disc photographs, con-
focal scanning laser ophthalmoscopy (CSLO), scanning laser
polarimetry (SLP), and optical coherence tomography
(OCT). Finally, the review uses data from structural testing,
functional testing, and clinical trials to efficiently and cost-
effectively detect progression from OHT to glaucoma.
IMPORTANCE OF OCULAR HYPERTENSION: FINDINGS
FROM RECENT LANDMARK STUDIES
to POAG, from 9.5% in untreated subjects to 4.4% in
treated subjects over 5 years. Other findings include the
determination of risk factors for progression from OHT to
POAG.7 These predictors include older age (hazard ratio
[HR] 1.22 per decade), higher baseline IOP levels (HR
1.1 per mm Hg), larger vertical (HR 1.32 per 0.1 larger) and
horizontal (HR 1.27 per 0.1 larger) cup/disc ratios, greater
pattern standard deviation (PSD; HR 1.27 per 0.2 dB
greater) on automated visual field perimetry, and thinner
central cornea thickness (CCT; HR 1.71 per 40 mm
thinner). In particular, CCT is a strong predictive factor,
where patients with CCT r 555 mm have a 3.4 times
greater risk for progression to POAG compared with those
with CCT greater than 588 mm, even after adjusting for age,
IOP levels, cup/disc ratio, and PSD. These findings are
corroborated in other studies.8–10 The European Glaucoma
Prevention Study (EGPS) Group is similar to OHTS and
also finds that older age (HR 1.32 per decade), higher
baseline IOP levels (HR 1.07 per mm Hg), larger vertical
cup/disc ratios (HR 1.34 per 0.1 larger), greater PSD (HR
1.66 per 0.2 dB greater), and thinner CCT (HR 1.32 per 40
mm thinner) are significant predictors of progression.8

The Ocular Hypertension Treatment Study (OHTS) is a

multicentre, randomized clinical study to evaluate the
efficacy of topical ocular hypotensive medications to delay
or prevent the development of primary open-angle glaucoma
(POAG) from OHT.5–7 The OHTS includes participants
with IOP between 24 and 32 mm Hg, with normal
and reliable visual fields on 2 consecutive visits and open
angles on gonioscopy. The study demonstrates that topical
ocular hypotensive agents reduce the progression of OHT
From the *Devers Eye Institute, Legacy Health System, Portland, Ore.;
and †Singapore National Eye Centre, Singapore
Risk assessment in ocular hypertension:
the use of risk calculators
One of the most important issues in the approach to an
individual with OHT is assessment of POAG risk. To
address this, several risk calculators are available that give
estimates of the 5-year probability of POAG onset. One of
these includes a prediction model that uses pooled data from
the OHTS and EGPS groups, coming up with a simple
Correspondence to: Steven L. Mansberger, MD, 1040 NW 22nd
Avenue, Suite 200, Portland, OR 97210; smansberger@deverseye.org

Presented in part at the Glaucoma Management Review Course, 53rd

Annual Walter Wright Day, Toronto, Ont., Dec. 6-7th, 2013. Can J Ophthalmol 2014;49:489–496
0008-4182/14/$-see front matter & 2014 Canadian Ophthalmological
Originally received Apr. 8, 2014. Final revision Jun. 24, 2014. Accepted Society. Published by Elsevier Inc. All rights reserved.
Jul. 15, 2014 http://dx.doi.org/10.1016/j.jcjo.2014.06.013

CAN J OPHTHALMOL — VOL. 49, NO. 6, DECEMBER 2014 489

Ocular hypertension—Boey and Mansberger
point-based risk calculator that takes into account the
predictors of age, IOP, CCT, vertical cup/disc ratio, and
PSD.9 These prediction models are helpful in management
of patients with OHT, where they provide individualized risk
estimates that are unique to a patient, which, in turn, may
provide a better understanding of their disease and motivate
compliance to treatment.11 We should note, however, that
there are caveats in the use of these calculators. These models
derive their data from a particular set of patients, which may
not be applicable to individuals with different characteristics
from the data set population. For uncommon combinations
of predictors in the OHTS, such as small cup/disc ratio
(o0.2), high IOP (429 mm Hg), and older age (470
years), individual estimates are likely to be less precise,
because of large confidence intervals around each estimate.
Ophthalmologists also show great variability of estimates in
prediction of POAG development from OHT, which differ
from the estimates from a risk calculator.12
INVESTIGATIONS RELEVANT IN THE ASSESSMENT OF
OCULAR HYPERTENSION
Structural testing in ocular hypertension: how does
this improve the detection of glaucoma from ocular
hypertension?
In the past few decades, new methods to evaluate the
structure and surrounding tissues of the optic disc have
improved our understanding of its anatomy in relation to
glaucoma. Stereoscopic optic disc photography is the tradi-
tional method of documenting the status of the optic nerve
head and its surrounding retinal nerve fibre layer, as well as
for detecting longitudinal change in these structures. Eye
care providers also use CSLO, OCT, and SLP to assess the
optic nerve head and retinal nerve fibre layer. This section
discusses the different types of structural tests available and
their use in detection of glaucoma from OHT.
Disc photography. Stereoscopic photography is a simple and
inexpensive method to assess the optic nerve. It gives a 3-
dimensional view of the optic nerve head, similar to clinical
slit-lamp examination, and is relatively easy to perform and
obtain. Features of glaucomatous change include vertical
elongation of the optic cup, thinning or notching of the
neuroretinal rim, undermining of the disc margin, disc
hemorrhage, and retinal nerve fibre layer defects.13–18 Com-
mon sites of thinning, which indicate progression of OHT to
POAG, are at the inferotemporal and superotemporal rim,
although diffuse structural losses are also frequently
observed.16,19,20 Studies show that optic disc changes are
good predictors of subsequent visual field damage, making
photographic examination a valuable tool in the early
detection of progression.21,22 This method, however, is highly
subjective and results in great variability between different
observers, even among glaucoma specialists, in discrimination
of normal versus glaucomatous discs.23–25 In summary, disc
490 CAN J OPHTHALMOL — VOL. 49, NO. 6, DECEMBER 2014
photography is easy and inexpensive to perform, but is
limited by subjectivity between observers.
Confocal scanning laser ophthalmoscopy. CSLO uses a diode
laser to create 3-dimensional high-resolution images of the
optic nerve head. One instrument is the Heidelberg Retina
Tomograph (HRT; Heidelberg Engineering, Heidelberg,
Germany). The laser scans the optic nerve head in the
horizontal and vertical planes, generating 2-dimensional
images, which then are successively stacked to produce a
3-dimensional optic nerve head image. An operator creates
a contour at the margin of the optic nerve head, and the
software creates a reference plane 50 mm posterior to the
retinal surface height at the papillomacular bundle 4 to 10
degrees below the horizontal meridian. Structures within
the contour line above the reference plane are taken as the
neuroretinal rim, and those below the reference plane are
considered the optic cup. The software creates various
stereometric parameters such as rim area, rim volume, cup
shape measure, and linear cup/disc ratio.
The Moorfields Regression Analysis (MRA) module of
the HRT divides the optic nerve head into 6 sectors and
compares each sector against normative database of
individuals without glaucoma. The individual sectors and
the overall optic nerve head are then classified as being
within normal limits (Z5th percentile of the normal
distribution), borderline (1st–5th percentile), or outside
normal limits (o1st percentile). The MRA shows good
diagnostic accuracy in differentiating between normal and
glaucomatous eyes diagnosed from photography, showing
relatively high levels of sensitivity and specificity.26–28
These range from 74% to 84% for sensitivity and 65%
to 96% for specificity.27,28
The OHTS study shows that several CLSO-derived
assessments of the optic disc are associated with develop-
ment of glaucoma. These include larger cup/disc area
ratio, larger mean cup depth, larger mean height contour,
higher cup volume below reference, and higher reference
plane height, as well as smaller rim area, smaller ratio of
rim area to disc area, and smaller rim volumes above
reference.29 The MRA “outside normal limits,” for HRT
parameters and MRA global and regional measurements,
are also associated with progression to POAG, with HRs
from 2.5 to 5.8.29 This indicates that patients with OHT
with a result of “outside normal limits” for these param-
eters are 2.5 to 5.8 times more likely to experience
development of glaucoma, compared with those with a
result of “within normal limits” during the same time
period. In a recent article, Zangwill et al.30 report that the
rate of neuroretinal rim area loss on HRT was about
5 times faster in OHT eyes that developed glaucoma
compared with those that did not.
A newer classification system present in HRT3 software
is the Glaucoma Probability Score (GPS), which discrim-
inates between normal and glaucomatous optic nerve head
using Zernike polynomials to estimate the shape of the

optic nerve head. The sensitivities and specificities of GPS
and MRA in differentiation of normal and glaucomatous
discs are comparable,31–33 although some report that the
GPS has marginally higher sensitivity and lower specific-
ity.31,34 The advantages of the GPS are that it is contour
line independent, because it does not require manual
demarcation of the contour line, and is derived independ-
ently of the reference plane. An MRA classification of
outside normal limits is useful to confirm a glaucomatous
disc, whereas a GPS classification of within normal limits
is useful to confirm a normal disc.34 A study reports that
patients with OHT with “outside normal limits” baseline
MRA and GPS are 3 to 10 times and 3 to 4 times,
respectively, more likely to experience development of
glaucoma compared with those “within normal limits.”35
The diagnostic ability of HRT is generally comparable
with stereophotography36,37; although in some studies,
where glaucoma specialists graded disc photographs to
assess for glaucoma, a better discriminatory ability is
reported with stereophotography.38,39 Optic disc progres-
sion detected by HRT compared with expert assessment of
serial stereophotographs shows poor agreement.40
An advantage of the HRT is that images can be taken
without the need for pupillary dilation in most eyes with
clear media. Also, continuous development and upgrades of
the software allow longitudinal information to be collected,
and the newest software includes a larger database of a wider
range of ethnicities, including European, African, and Indian
individuals in addition to the original group of white
individuals. Limitations include requiring an operator to
create a contour line for parameters such as the MRA, and
that the calculation of stereometric parameters is based on the
reference plane. The reference plane is automatically placed at
50 mm posterior to the retinal surface to divide between
neuroretinal rim and cup in all eyes, which is arbitrary and
may not be accurate. Overall, HRT has the disadvantage of
using surface topography to estimate measures of the optic
disc even those deeper than the surface. This limitation
makes it unclear how researchers will use this technology in
the future when ocular coherence tomography is available.
Ocular coherence tomography evaluates both surface and
deep structures, and should correlate better with actual optic
disc anatomy (see the following section).
In summary, important advantages of the HRT are that
changes correlate with progression to POAG as shown in
the OHTS study, and it is the only structural imaging
modality that predicts development of glaucoma from
OHT. Disadvantages are that some of the older modules
are operator dependent, although this is overcome by
newer updated software, and that correlation with stereo-
photographs in diagnosing or monitoring for progression
of glaucoma is variable.
Optical coherence tomography
Optical coherence tomography of retinal nerve fibre layer
thickness. OCT is a high-resolution cross-sectional
CAN J OPHTHALMOL — VOL. 49, NO. 6, DECEMBER 2014
Ocular hypertension—Boey and Mansberger
imaging technique that allows in vivo measurement of
tissue thickness, based on the principle of low coherence
interferometry. A superluminescent diode laser transmits
low coherence near-infrared light to the retina or optic
nerve head, which is reflected back by different structures
at different depths, and the resulting interference patterns
are used to construct a cross-sectional tomographic image
of the structure being imaged.41 The conventional time-
domain OCT produces scans with 8 to 10 mm axial
resolution, at 400 scans per second, but because of a
relatively longer acquisition time, it is subject to
movement artefacts. The newer spectral-domain OCT
performs 20,000 to 50,000 scans per second, is 50 to
100 times faster than time-domain OCT, and produces
minimal movement artefacts, and hence more stable
images. Currently, the spectral-domain OCT systems are
becoming the preferred modality of imaging because of
their higher speed and better-quality images.
Some case–control studies show significantly thinner
retinal nerve fibre layer thickness in OHT eyes compared
with normal controls,42–46 especially in OHT eyes with
thinner CCT,44 although others report no significant
difference.47 In the studies that show differences, retinal
nerve fibre layer is found to be thinner in the superior,44,45
inferior,43–45 and global retinal nerve fibre layer measure-
ments44–46 in OHT eyes compared with normal. In one
study, the difference is significant only with OHT eyes
that have thinner CCT r 555 mm, whereas those with
thicker CCT are comparable with normal.44
An advantage of the OCT is that databases are wide
ranging and include individuals from 20 to 80 years of age,
with refractive errors ranging from –12 to þ8 D. How-
ever, patients who fall out of these ranges should have their
results interpreted with caution. Thinner retinal nerve
fibre layer measurements in healthy eyes are associated
with increasing age, smaller disc size, and high myopia.48–50
A limitation is that pupillary dilation is generally required
for acquisition of good-quality scans, especially for time-
domain OCT. Software limitations of the time-domain
OCT are that some may be unable to reproduce subse-
quent scans at the exact location from the baseline scan,
although this is overcome with the newer spectral-domain
OCT technology where intervisit reproducibility is much
higher.
Optical coherence tomography of macular ganglion cell
complex. Clinicians and researchers may image the macula
to differentiate between glaucomatous and normal eyes.
Retinal ganglion cells (RGCs), which are most densely
populated at the macula, are damaged early in glaucoma,
hence thinning of the macula may be a surrogate measure of
change.51 Time-domain OCT has demonstrated a thinner
macular thickness in glaucomatous eyes compared with
normal eyes,51,52 but the ability to differentiate between the
two is inferior to that of peripapillary nerve fibre layer
thickness.52,53 However, the ganglion cell complex (GCC)
consisting of the innermost retinal layers—retinal nerve
491
Ocular hypertension—Boey and Mansberger
fibre layer, ganglion cell layer, and inner plexiform layer—
may be preferentially damaged by glaucoma and is a focus of
research into its diagnostic efficacy.54 Spectral-domain OCT
of GCC thickness is a more sensitive test for glaucoma
compared with total macular thickness measurements,55 and
also has a similar or better ability than peripapillary retinal
nerve fibre layer analysis in discriminating between early
glaucoma and normal controls.56,57 In terms of correlation
to functional change, macular GCC thickness at baseline is
associated with visual field progression in glaucoma.58
However, currently, researchers have not determined the
diagnostic precision of macular GCC thickness to
differentiate between OHT and glaucoma.
Optical coherence tomography of optic nerve head: a new and
emerging field. Researchers and clinicians have used
spectral-domain OCT to evaluate the neuroretinal rim of
the optic nerve head.59–62 Recently, they have used
Bruch’s membrane opening (BMO)—the point where
Bruch’s membrane terminates at the optic nerve head—
to provide a stable and reproducible anatomic location to
measure the neural tissue of the neural canal. This is
advantageous over conventional assessment of the disc
margin, which is variable between observers because the
clinical disc margin is usually not a single anatomic
structure or readily identifiable junction.61,62 The BMO
serves as a reference point from which neuroretinal rim
measurements can be made, such as minimum rim width
(MRW). The MRW is defined as the minimal distance
from the BMO to the internal limiting membrane,
reflecting the thickness of RGC axons passing into the
neural canal. Initial reports show that MRW measure-
ments perform better than CSLO parameters in the
diagnosis of open-angle glaucoma,60,63 and more studies
are currently ongoing to further validate these new
parameters.
Regionalization of data. Traditionally, regional data of the
retinal nerve fibre layer and optic nerve head have been
based on superior, inferior, nasal, and temporal sectors,
which are relative to the vertical and horizontal axes of the
image. This may not be ideal in situations where there is
significant torsion of the eye or head rotation, resulting in
errors when acquiring sectoral data. Chauhan and
Burgoyne propose a new point of reference, the fovea-
BMO centre (Fo-BMO) axis, which is a line joining the
fovea and the centre of the BMO points.59 Taking the
horizontal axis of the image to be at 0 degrees,
interindividual variability in the Fo-BMO axis can result
in measurements from –17 to þ6 degrees, which would
make sectoral data based on the horizontal axis
erroneous.59 Regionalization according to Fo-BMO axis
may overcome these errors, and future studies are in
progress to further support this hypothesis.
Scanning laser polarimetry. The SLP measures retinal
nerve fibre layer thickness by measuring the retardance
of a polarized laser beam through the birefringent retinal
492 CAN J OPHTHALMOL — VOL. 49, NO. 6, DECEMBER 2014
nerve fibre layer. Birefringence retards the polarized light,
and the amount of retardation measured is proportional to
retinal nerve fibre layer thickness. Some instruments in use
are the GDx Nerve Fibre Analyzer (Laser Diagnostic
Technologies, Inc, San Diego, Calif.), which has a fixed
compensatory device that corrects for the effects of
birefringent structures in the anterior segment, namely,
the cornea and lens; the newer GDx-VCC (Zeiss Meditec,
Dublin, Calif.), which has a variable anterior segment
compensation that is individualized to each eye; and the
GDx-ECC (Zeiss Meditec) with enhanced cornea
compensation, which allows for more accurate retinal
nerve fibre layer measurements.
Thinner baseline retinal nerve fibre layer measurements
on GDx can predict future visual field damage in those
suspected of having glaucoma,64 but the relationship
between GDx retinal nerve fibre layer parameters and
OHT is not clear. Some authors demonstrate a significant
difference in SLP parameters between OHT and normal
eyes.65,66 In a case–control study examining retinal nerve
fibre layer thickness on GDx-VCC in OHT versus normal
eyes, OHT eyes with thinner CCT r 575 mm have
significantly thinner retinal nerve fibre layer compared
with OHT eyes with thicker CCT greater than 575 mm or
normal eyes.65 Pablo and associates66 report that in a
prospective cross-sectional study of 181 eyes with OHT,
those with retinal nerve fibre layer defects on disc photo-
graphs have significantly thinner retinal nerve fibre layer
measured by GDx-VCC in all quadrants, as well as in
average thickness. These findings suggest that SLP may
detect early retinal nerve fibre layer damage in OHT eyes,
especially in those with thin CCT. In contrast, Kanamori
et al.46 report no significant differences in SLP parameters
between OHT and normal eyes.
Issues with the SLP are that artefacts can be induced
with atypical retardation patterns, which can result from
light scatter in the eye.67 Another limitation includes the
fixed compensation module on the older versions of SLP,
which the newer GDx-VCC and GDx-ECC software
modules overcome. Various anterior and posterior seg-
ment diseases, especially those that affect the cornea and
lens, can also result in inaccurate measurements.68 Mac-
ular disease such as macular degeneration and cystoid
edema can disrupt baseline polarimetry and cause inaccu-
rate results as well.69
Functional testing in ocular hypertension:
alternatives to current standard
SAP is the current standard in many clinical trials for
functional assessment in glaucoma and OHT. It assesses
retinal sensitivity to light at different locations, using a
white-on-white stimulus. However, because of redundancy
in the visual system, a significant number of RGCs in the
order of more than 25% have to be lost before defects are
detected by SAP.70,71 Tatham and colleagues72 demon-
strate that visible retinal nerve fibre layer defects on

stereophotographs have an estimated 59% of RGC loss in
that sector. Moreover, in the early stages of RGC loss,
which is thought to be linear, the resultant decrease in
sensitivity is less obvious in SAP because the visual
thresholds are measured on a logarithmic scale.73 Also,
the variability between tests may pose difficulties with
determining whether true visual field progression has
taken place.74 Because of these issues with SAP, other
modalities of functional testing, such as SWAP and FDT,
have been suggested as alternatives to improve detection of
early glaucoma.
Short-wavelength automated perimetry. The currently avail-
able SWAP test is a modification of SAP using the
Humphrey Field Analyzer (Humphrey-Zeiss, Dublin,
Calif.), where it uses blue-on-yellow perimetry to isolate
the response of a subset of RGCs that process blue-yellow
colour vision.75,76 Several prospective longitudinal studies
on OHT eyes show that SWAP defects may occur
earlier,77–80 and that new defects on SWAP are more
prominent and persistent than SAP.77 In contrast, other
prospective longitudinal studies do not show benefits of
SWAP over SAP in OHT eyes,81,82 when compared with
the onset of SAP deficits.
Frequency-doubling technology. The FDT uses the principle
of frequency-doubling illusion, to isolate the function of a
subset of RGCs, the M cells. These cells are sensitive to
low-contrast, high-temporal-frequency stimuli, and have
low redundancy.83 Many studies report that FDT detects
functional losses earlier than SAP in patients with preperi-
metric and established glaucoma.84–86 In OHT eyes, 11%
to 46% of eyes with normal SAP show FDT deficits,87–90
suggesting that earlier change may be seen with FDT.
Mean deviations on FDT are worse in OHT compared
with normal eyes,85 as is the case with PSD.43 A report
suggests that sensitivity of FDT is higher than SAP in
patients with glaucoma, whereas specificity is compara-
ble.84 A main disadvantage of FDT is that cataracts
can result in unreliable test results.91,92 Also, the presence
of diabetes may be associated with abnormal FDT
results.93
To summarize, standard white-on-white perimetry
remains the standard functional test in the evaluation
and management of OHT. Other modalities such as
SWAP and FDT may be useful as additional tests, but
because of their limitations and lack of consistent data on
their benefit over SAP, they should not replace SAP as the
test of choice.
APPROACH TO MANAGEMENT: WHEN TO TREAT AND
WHEN TO MONITOR?
The management of OHT in the last decade has
changed significantly, because of results of the OHTS
CAN J OPHTHALMOL — VOL. 49, NO. 6, DECEMBER 2014
Ocular hypertension—Boey and Mansberger
and EGPS as discussed earlier. Early topical hypotensive
treatment is effective in delaying or preventing POAG
onset,5 but if we were to treat all patients with OHT,
this would have significant financial and economic reper-
cussions.94 To get an idea of how effective treatment is, we
can use the number needed to treat (NNT) measure,
which is the average number of patients that need to be
treated to prevent 1 case of glaucoma. Based on the
OHTS, NNT calculations show that for every patient that
is prevented from developing glaucoma, 20 patients with
OHT (with IOP levels from 24 to 32 mm Hg) will have
to be treated.95 Kass and colleagues96 have stratified this
into low, moderate, and high risks, with respective NNTs
of 98, 16, and 7, respectively.
Delaying treatment in the OHTS may result in a
significant increase in the incidence of POAG.96 In this
study, the cumulative proportion of POAG development
after 13 years is 0.22 in the untreated cohort (with a
treatment delay of 7.5 years), compared with 0.16 in the
treated cohort. It also shows that the absolute effect of
early treatment in decreasing POAG incidence is the
greatest for high-risk OHT. Hence we recommend that
providers recognize those at moderate to high risk for
POAG, particularly individuals of older age, higher base-
line IOP greater than 25 mm Hg, CCT r 555 mm, larger
cup/disc ratio, and greater PSD on visual fields. These
individuals should be monitored at more frequent inter-
vals, so that early treatment may be started if necessary.
Chauhan and colleagues97 recommend that in the first
2 years, a minimum of 6 visual fields (with SAP) should be
performed to establish good baseline data, as well as to
pick up any rapid progression. Conversely, those at low
risk for POAG development may not require treatment
and may be safely monitored at less frequent intervals.
Individualized assessment of risk is important, as well as
the consideration of other factors such as age and life
expectancy, overall health, as well as patient preferences
before making a clinical decision for treatment.5,7,95,96
Other considerations include response to treatment, ability
to afford the cost of long-term medications, as well as
adherence to treatment.
In an ideal world, both structural and functional tests
would be performed at the baseline visit and at every
subsequent visit, which would be spaced at short intervals,
to monitor closely for progression. This would, however,
be extremely cost-ineffective and would put an enormous
strain on time and resources. We recommend that in a
routine practice, initial tests using SAP and optic disc
photography would be useful to establish a good baseline.
Additional baseline structural tests (e.g., OCT of retinal
nerve fibre layer) may be included in the baseline visit,
where available and if resources permit. For subsequent
visits, the same visual field strategy should be used so that
tests are comparable with baseline. Optic disc photography
may be repeated whenever appropriate to document
possible change, or when a disc hemorrhage is noted. If
493
Ocular hypertension—Boey and Mansberger
additional structural tests are available, we recommend
that the same modality should be used and repeated on an
annual or biennial basis in stable individuals, or earlier if
there is any suspicion of worsening.
CONCLUSIONS
OHT is an important clinical problem, and the main
goal of management is to prevent the progression to
POAG. The OHTS and EPGS are major clinical trials
that have shaped the way we approach this disease. Initial
assessments aided by both structural and functional tests,
as well as risk assessment, provide guidelines to manage-
ment. With these approaches, OHT can be managed in an
effective, safe, and cost-effective way.
Disclosure : The authors have no proprietary or commercial
interest in any materials discussed in this article.
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