Mundipharma Lecture Tools, Tips, Tricks CVV

Glaucoma Diagnosis and Progression:
Tools, Tips and Tricks
CYNTHIA V. VERZOSA, MD, DPBO, MSc

Disclaimer SHINE GLAUCOMA 2017
The contents presented in these slides and in the

speech are the opinions of the speaker and do not
necessarily reflect the opinion of Mundipharma.
They are for scientific discussions only and are not
intended to be off-label use recommendations.
Glaucoma causes progressive loss of vision
SHINE GLAUCOMA 2017
Normal vision
Normal vision Glaucoma
Glaucoma early
early stage
stage Glaucoma advanced
Glaucoma advanced stage
stage
Glaucoma is one of the leading causes of

irreversible blindness worldwide1
Image from: http://www.glaucoma.be/?lang=en (accessed February 2017)

1. World Health Organization. Glaucoma is second leading cause of blindness globally. Available at:
http://www.who.int/bulletin/volumes/82/11/feature1104/en/ (accessed January 2017).
Impact of glaucoma on quality of life SHINE GLAUCOMA 2017
Progressive
Progressive visual
visual field
field loss
loss
Difficulties with everyday tasks Disease burden
Reading
Reading Late
Late or
or misdiagnosis
misdiagnosis of
of glaucoma
glaucoma
Outdoor
Outdoor mobility
mobility (walking
(walking and
and driving)
driving) Intolerance
Intolerance and
and side
side effects
effects of
of medications
medications
Avoiding
Avoiding obstacles
obstacles Need
Need for
for long-term,
long-term, intensive
intensive monitoring
monitoring
Adaptability
Adaptability to
to different
different levels
levels of
of brightness
brightness
Labiris G, et al. Quality of life (QoL) in glaucoma patients. 2011. Available at: http://cdn.intechopen.com/pdfs-wm/23827.pdf (accessed March 2016).
Challenges in Diagnosis SHINE GLAUCOMA 2017
Comprehensive
Comprehensive diagnosis
diagnosis of
of glaucoma
glaucoma byby
detailed
detailed examination
examination of
of the
the optic
optic nerve
nerve is
is essential
essential11
Damage
Damage to
to the
the optic
optic nerve
nerve is
is characteristic
characteristic of
of glaucoma,
glaucoma,
irrespective
irrespective of
of the
the IOP
IOP
IOP
IOP is
is important,
important, but
but over-reliance
over-reliance on
on IOP
IOP may
may lead
lead to
to
under-diagnosis
under-diagnosis
IOP = intraocular pressure; POAG = primary open-angle glaucoma.
1. European Glaucoma Society. Terminology and guidelines for glaucoma (4th edition). 2014. Available at:
https://www.eugs.org/eng/guidelines.asp (accessed January 2017); 2. American Academy of Ophthalmology. Primary open-angle glaucoma
PPP - 2015. Available at: http://www.aao.org/preferred-practice-pattern/primary-open-angle-glaucoma-ppp-2015 (accessed January 2017).
Clinical Methods of Patient Assessment SHINE GLAUCOMA 2017
Three phases:
1. History
2. Examination
3. Investigations
Asia Pacific Glaucoma Society. Glaucoma guidelines. 2016.

SHINE GLAUCOMA 2017
1. History
• Ophthalmic history
• Medical history
• Socioeconomic factors
• Family history of glaucoma

Patient History SHINE GLAUCOMA 2017
Key points
Assess risk factors (age, gender, genetics, race, refractive error, presence of
comorbids)
Younger patients = longer exposures to disease and treatment
Consider previous medications (especially glaucoma medications, steroids,

sulfa-based)
Consider previous trauma or previous eye surgery or laser treatment
Asia Pacific
Glaucoma Society.
Glaucoma
guidelines. 2016.
Patient History SHINE GLAUCOMA 2017
Key points
Assess factors that might affect life expectancy and adherence to treatment
(musculoskeletal conditions, neuropsychiatric conditions)
Exclude history of nonprogressive systemic conditions such as

hemodynamic crises, anterior ischemic optic neuropathy that may cause
optic disc pallor and cupping or intracranial pathology
Asia Pacific
Glaucoma Society.
Glaucoma
guidelines. 2016.
SHINE GLAUCOMA 2017
2. Examination
• IOP measurement
• Gonioscopy
• ONH and RNFL examination
CCT = central corneal thickness; IOP = intraocular pressure; ONH = optic nerve head; RNFL = retinal nerve fiber layer; VF = visual field.

IOP Measurement SHINE GLAUCOMA 2017
Imbert-Fick principle Goldmann Applanation

Tonometry
P=F/A
Pressure inside an ideal dry thin-walled

sphere = Force needed to flatten an
Area
IOP = intraocular pressure.
1. Asia Pacific Glaucoma Society. Glaucoma guidelines. 2016.
Image adapted from: http://www.precisionophthalmicservices.com/images/AlphaTonopen.jpg (accessed January 2017).

Several factors influence IOP1:
• Circadian cycle • Blood pressure

• Age • Lifestyle
• Corneal parameters • Intra-abdominal pressure
• Exercise • Posture





 Thick vs thin corneas

• Circadian cycle • Corneal
 Blood pressure
hysteresis – lower
values associated with
• Exercise • greater
Posture risk of VF
progression
 Corneal/refractive surgery

• Circadian cycle • BloodIOP

 Decrease pressure
by 3 mmHg or
more, 1-2 hrs post exercise
• Exercise  Dehydration,
• Posture acidosis

• IOP – positive
Circadian cycle • Blood pressure
• Age
associated with BP • Lifestyle
• Reducing BP may not
Exercise • Posture
affect IOP

 Increase IOP – rapid

• Circadian cycle
intake of large volume of • Blood pressure
fluid
• Decrease IOP
Exercise • Posture
 Alcohol
 Marijuana



• Increased intra-
Age • Lifestyle
• Corneal parameters
abdominal pressure • Intra-abdominal pressure
-> increased IOP

 Increase IOP
•  Yoga – head
Age • Lifestyle
• Corneal
downparameters
position • Intra-abdominal pressure
 Supine or prone
position

Key Reminder SHINE GLAUCOMA 2017
Symptoms of acute IOP elevation in a patient
•• Intermittent/episodic
Intermittent/episodic blurring
blurring
•• Glare
Glare and
and colored
colored rings
rings around
around lights
lights
•• Eye
Eye pain
pain
•• Frontal
Frontal headache
headache with
with nausea
nausea and
and malaise
malaise
Acute IOP elevation has been misdiagnosed as

migraine, tension headaches, meningitis, acute
abdomen and psychosomatic disorders
IOP = intraocular
pressure.
Asia Pacific
Glaucoma Society.
Glaucoma
guidelines. 2016.
IOP Measurement: Tips and Tricks SHINE GLAUCOMA 2017
• Position the patient properly at the slit lamp. Instruct the patient
to loosen the tie and not to hold breath during IOP
measurement
• Adjust the gauge until the split tear meniscus just touches on
the inside
Tonometry mires: Correct endpoint corneal applanation

(IOP equals tonometer reading)
Adapted from Asia Pacific Glaucoma Society. Glaucoma guidelines. 2016.

IOP Measurement: Key Reminders SHINE GLAUCOMA 2017
Measurement errors associated with Goldmann-style applanation tonometry
Error Possible cause
IOP reading artificially low - Insufficient fluorescein in tear film

- Microcystic epithelial corneal edema
IOL = intraocular lens; IOP = intraocular pressure.

IOP reading artificially - Excessive fluorescein in tear film

high - Eyelid pressure on globe from blepharospasm
- Digital pressure on globe to hold lids apart
• The lid should be held against the orbit and not on the globe
- Obese patient
- Patient straining to reach chin/forehead rest
- Patient holding breath
- Patient wearing constricting clothing around neck (tight shirt collar
and tie for men)
- Hair lying across cornea distorting mires
- Lens-corneal (and IOL-cornea) apposition

Technical difficulties - Corneal abnormalities (scars, graft, edema, keratoconus)

(interpret results with - Marked corneal astigmatism
caution) - Small palpebral aperture
- Nystagmus
- Tremor

Anterior segment examination
and gonioscopy SHINE GLAUCOMA 2017
Indirect view
Gonioscopy allows the physician to determine the topography of

the anterior chamber angle and differentiate types of glaucoma
European Glaucoma Society. Terminology and guidelines for glaucoma (4th edition). 2014. Available at:
https://www.eugs.org/eng/guidelines.asp (accessed January 2017).
Gonioscopy: Steps SHINE GLAUCOMA 2017
Set slit lamp on upper cornea, beam off-center 30° to 45° nasally
Look through the upper mirror (inferior angle) as you place lens on
eye and stop pushing when you can see the iris. Examine opposite
(lower) mirror.
Turn beam 90° and move on axis
Move to nasal side (temporal angle) and then to temporal side

(nasal angle)
Record findings on goniogram

Gonioscopy: Tips SHINE GLAUCOMA 2017
• Minimal room illumination

• Avoid light entering the pupil
• Good anesthesia
• Shortest slit practicable
• High magnification
• Vary the slit light intensity

Gonioscopy: Dynamic SHINE GLAUCOMA 2017
Performed to look for peripheral anterior synechiae (PAS)
Tilt the mirror, or indent the cornea. Look for changes in angle
configuration.
Gonioscopy narrow angle Gonioscopy narrow angle

without indentation without indentation showing PAS

Gonioscopy: Flow Diagram SHINE GLAUCOMA 2017
Scleral spur visible?
Visible in 360° Visible < 180°

Grade Do indentation gonioscopy
Record findings Any synechiae?
Open angles
YES
NO
Grade
IOP raised?
Record findings
PAC (synechiae)
YES NO
Grade Grade
Record findings Record findings
PAC (apposition) PACS

PAC = primary angle closure.

Angle closure signs

• PAS
• Pigment patches over
trabecular meshwork
(TM) (evidence of
irido-trabecular
contact)
• Iris insertion above
scleral spur
Images courtesy of Prof Tin

PAS = peripheral anterior synechiae; PXF = pseudoexfoliation. Aung as part of the SHINE 2017
steering committee reviewing
Asia Pacific Glaucoma Society. Glaucoma guidelines. 2016. the modules. January 2017.
Abnormal open
angles
• TM with pigment,
PXF material, new
vessels, precipitates
or abnormal iris
processes
• Wide ciliary body
band or sclera (angle
recession,
cyclodialysis cleft)
• Schlemm’s canal
with blood reflux
PAS = peripheral anterior synechiae; PXF = pseudoexfoliation.

Optic nerve head and retinal nerve fiber layer
SHINE GLAUCOMA 2017
• Disc size, shape, tilt

• Cup shape, depth
• Vertical cup-disc ratio
• Peripapillary atrophy
• Neuroretinal rim (ISNT rule)
• Nerve fiber layer defect
• Disc hemorrhage
ISNT rule = normal eyes show a characteristic configuration for disc rim thickness of inferior > superior > nasal > temporal.

SHINE GLAUCOMA 2017
1.92 mm
• Disc size, shape,

tilt
• 1.2 mm to 2.5
mm (~1.8 mm)
diameter
• Cup shape, depth
1.76 mm

SHINE GLAUCOMA 2017
------------------------
----------------------
• Vertical cup-disc Disc Cup

ratio (VCDR)
---------------------
------------------------

SHINE GLAUCOMA 2017
• Peripapillary atrophy

SHINE GLAUCOMA 2017
• Neuroretinal rim
(ISNT rule)

SHINE GLAUCOMA 2017
• Nerve fiber layer

defect

SHINE GLAUCOMA 2017
• Disc hemorrhage

Clinical Assessment of the Optic Nerve SHINE GLAUCOMA 2017
Documentation of baseline optic nerve status at time of diagnosis

serves as a reference point for future glaucoma progression1
•• Stereo
Stereo disc
disc photos
photos22
•• Clinical
Clinical documentation
documentation in
in the
the
patient
patient record
record
•• Serial
Serial disc
disc photography
photography
interpretation
interpretation
−− Shown
Shown to to be
be subjective
subjective and
and
prone
prone toto variability
variability in
in
classification
classification of
of progression
progression22
1. Asia Pacific Glaucoma Society. Glaucoma guidelines. 2016; 2. Morgan JE, et al. Br J Ophthalmol 2005;89:879–884.
Optic nerve head and retinal nerve fiber layer:
Tips and Tricks SHINE GLAUCOMA 2017
• Use indirect slit-lamp lens (60-90D)

• It is important to gain a stereoscopic view (best when dilated ‒
recommended if safe)
• Red-free (green) illumination may help assessment of RNFL
Disc margin is INSIDE

INSIDE the
the peripapillary
peripapillary scleral
scleral ring
ring of
of Elschnig
Elschnig
Appropriate lens magnification correction for Volk lenses:

Superfield 1.5x, 90 D 1.3x, 78 D 1.1x, Super 66 D 1.0x
ISNT rule
Inferior > Superior > Nasal > Temporal (I>S>N>T)
D = diopter; ISNT = inferior superior nasal temporal; RNFL = retinal nerve fiber layer

.
Optic nerve head and retinal nerve fiber layer:
Tips and Tricks SHINE GLAUCOMA 2017
• Glaucomatous disc
• Neuroretinal rim
thinning
• Circumlinear baring
of blood vessel
• Bayoneting of blood
vessel
• PPA ß zone
D = diopter; ISNT = inferior superior nasal temporal; RNFL = retinal nerve fiber layer

.
SHINE GLAUCOMA 2017
3. Investigations • Optical Coherence Tomography

(OCT)
• Visual Field (VF) examination
examination
• Central Corneal Thickness (CCT)
measurement
CCT = central corneal thickness; IOP = intraocular pressure; ONH = optic nerve head; RNFL = retinal nerve fiber layer; VF = visual field.

Optic disc and RNFL investigation:
Optical Coherence Tomography SHINE GLAUCOMA 2017
To examine optic disc and RNFL:

“OCT measurement of
RNFL thickness may be
the best among the
currently available digital
imaging instruments for
detecting and tracking
optic nerve damage in
glaucoma.”
‒ 2016 WGA consensus on
glaucoma diagnosis
Glaucomatous eye has reduced RNFL (structure)
thickness and rim area, with increased
cup volume compared with healthy eye
OCT = optical coherence tomography; RNFL = retinal nerve fiber layer; WGA = World Glaucoma Association.

Image courtesy of Prof Tin Aung as part of the SHINE 2017 steering committee reviewing the modules. January 2017.
Retinal and Optic Nerve Imaging: More objective
method to identifying structural change SHINE GLAUCOMA 2017
OCT imaging: A common tool in Glaucoma Assessment
Changes can be detected in various retinal and optic nerve

parameters related to loss of retinal ganglion cells
RNFL thickness
Optic nerve
Cup/disc ratio
Neuroretinal rim width
Others
Macular GCC thickness
• Interpretation software developed to aid distinguishing measurement

variability from true change
• Imaging studies must be interpreted in context of clinical examination
GCC = ganglion cell complex; OCT = optical coherence tomography; RNFL = retinal nerve fiber layer.

VF investigation:
Standard Automated Perimetry SHINE GLAUCOMA 2017
Humphrey Field
Analyzer
Perimetry or VF testing defines:
• the limits of what can be seen in the peripheral
vision while looking straight ahead1
• the state of optic nerve function and whether

glaucoma is progressing or not1,2
VF testing should be performed

when glaucoma is suspected at examination 22
VF = visual field.
1. Spector H. Visual Fields in Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. 1990;
Characteristics of
glaucomatous VF defects SHINE GLAUCOMA 2017
• Follow pattern of the RNFL

• Rarely cross the horizontal midline/rarely extend
across the horizontal midline
• Located in midperiphery* (5°-25° from fixation)
• Reproducible
• Clustered in neighboring test points (localized)
• Not attributable to other pathology
• Defect(s) should correlate with the appearance
of the optic disc and the neighboring RNFL
* Early/moderate cases.
RNFL = retinal nerve fiber layer; VF = visual field

.
Types of glaucomatous VF defects SHINE GLAUCOMA 2017
Inferior Inferior
nasal step paracentral
defect, OD defect, OS

.
Superior &
Inferior inferior
arcuate arcuate
defect, OD defect, OS
.
Superior Temporal
altitudinal wedge
defects, defect, OD
* Early/moderate cases. OD
.
Visual Field: Tips and Tricks SHINE GLAUCOMA 2017
Help
Help patients
patients help
help you
you get
get better
better VF
VF results:
results:
•• Carefully
Carefully explain
explain the
the technique
technique and
and goal
goal of
of the
the test
test before
before starting
starting
•• Give
Give patients
patients feedback
feedback on on how
how well
well they
they performed
performed so so that
that they
they
can
can improve
improve in
in future
future tests
tests
•• VF
VF test
test performance
performance usually
usually improves
improves over
over the
the first
first two
two to
to three
three
tests
tests
•• Ensure
Ensure adequate
adequate rest
rest (30
(30 minutes)
minutes) for
for patient
patient ifif repeating
repeating test
test
Retinal diseases (detachment, retinal vein occlusion)

may also cause VF defects
VF = visual field.

Central Corneal Thickness SHINE GLAUCOMA 2017
Population-based studies have shown that

thinner CCT is a risk factor for POAG
Central corneal thickness obtained
by Visante OCT pachymetry
Variations
Variations in
in CCT
CCT can
can influence
influence
measured
measured IOPIOP
•• Thickness
Thickness andand steepness
steepness ofof
cornea
cornea1,2
1,2
 Thicker
Thicker corneas
corneas cause
cause IOP
IOP
over-estimation
over-estimation
 Thinner
Thinner corneas
corneas cause
cause IOP
IOP
under-estimation
under-estimation
•• Corneal
Corneal edema
edema33
CCT = central corneal thickness; IOP = intraocular pressure; OCT = optical coherence tomography; POAG = primary open-angle glaucoma.
1. Glaucoma Research Foundation. The Importance of Corneal Thickness. 2011. Available at

https://www.glaucoma.org/glaucoma/the-importance-of-corneal-thickness.php (accessed January 2017); 2. Kotecha A. Surv Ophthalmol
2007;52:Suppl2:S109-114; 3. Asia Pacific Glaucoma Society. Glaucoma guidelines. 2016. Image courtesy of Prof Aung Tin as part of the
SHINE 2017 steering committee reviewing the modules. January 2017.
Evaluation of Diagnostic Test Results:
Key Reminders SHINE GLAUCOMA 2017
Accurate diagnosis requires a comprehensive evaluation of the following:
IOP
Gonioscopy
Optic disc
OCT
VF
CCT
CCT = central corneal thickness; IOP = intraocular pressure; RNFL = retinal nerve fiber layer; VF = visual field.

Recommendations:
Treatment decision with IOP Target SHINE GLAUCOMA 2017
Appropriate IOP target
Not met Met
Confirm stability through

Advise advance / follow-up assessment:1,2
switch therapy1,2 1. VF testing
2. Optic nerve clinical assessment
3. Imaging of :
a) Optic nerve
b) RNFL thickness
c) Macular GCC thickness
GCC = ganglion cell complex; IOP = intraocular pressure; RNFL = retinal nerve fiber layer; VF = visual field.
1. Adapted from Asia Pacific Glaucoma Society. Glaucoma guidelines. 2016; 2. European Glaucoma Society. Terminology and guidelines for
glaucoma (4th edition). 2014. Available at: https://www.eugs.org/eng/guidelines.asp (accessed January 2017).
Assess Progression with other factors SHINE GLAUCOMA 2017
Limitation of IOP measurement alone
Uncertainty in Measurement IOP

susceptibility to error2 fluctuations2
visual damage1
1. Musch DC, et al. Ophthalmology 2011;118(9):1766–1773; 2. Asia Pacific Glaucoma Society. Glaucoma guidelines. 2016.
Assessment of Visual Field Progression (1)
SHINE GLAUCOMA 2017
True progression must be distinguished from random fluctuation1
• Repeat testing is generally needed to confirm progression 2
• Statistical tools incorporated into VF interpretation software

can be very useful in distinguishing true change from
random variability1
• Clinical correlation of change in VF with the clinic exam is

always necessary to ensure change is due to glaucoma 2
VF = visual field.
Assessment of Visual Field Progression (2)
SHINE GLAUCOMA 2017
True progression must be distinguished from random fluctuation1
Baseline for comparison of subsequent VF tests needs to

be updated according to patient’s circumstances: 2
Following improvement in vision from cataract

or other ocular surgery
After occurrence of permanent vision loss due

to other ocular pathology
After confirmation of glaucoma progression,

a new baseline should be set once a new, lower target IOP is achieved2
VF = visual field.
Importance of tailored assessment
of rate of change SHINE GLAUCOMA 2017
Assessment of rate of change
In context of…
Patient’s age Baseline severity of
glaucomatous VF loss
VF = visual field.
European Glaucoma Society. Terminology and guidelines for glaucoma (4th edition). 2014. Available at:
https://www.eugs.org/eng/guidelines.asp (accessed January 2017).
Progression: Tips and tricks SHINE GLAUCOMA 2017
Careful assessment of patient and results of ancillary

can provide clues indicative of progression
Structure/function correlation:
Help distinguish random variation from true
progression1
Suspicious, but non-definitive findings in VF

and imaging studies that correspond
can heighten suspicion of progression
before severe change develops1
VF = visual field.
1. Medeiros FA, et al. Arch Ophthalmol 2012;130:1107–1116.

SHINE GLAUCOMA 2017
Summary
VF = visual field.
1. Medeiros FA, et al. Arch Ophthalmol 2012;130:1107–1116.

SHINE GLAUCOMA 2017
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Taguig, Metro Manila

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Glaucoma Diagnosis and Progression:

Tools, Tips and Tricks

CYNTHIA V. VERZOSA, MD, DPBO, MSc

The contents presented in these slides and in the

Glaucoma is one of the leading causes of

Image from: http://www.glaucoma.be/?lang=en (accessed February 2017)

Difficulties with everyday tasks Disease burden

IOP = intraocular pressure; POAG = primary open-angle glaucoma.

Asia Pacific Glaucoma Society. Glaucoma guidelines. 2016.

Asia Pacific Glaucoma Society. Glaucoma guidelines. 2016.

Younger patients = longer exposures to disease and treatment

Consider previous medications (especially glaucoma medications, steroids,

Consider previous trauma or previous eye surgery or laser treatment

Exclude history of nonprogressive systemic conditions such as

Asia Pacific Glaucoma Society. Glaucoma guidelines. 2016.

Imbert-Fick principle Goldmann Applanation

Pressure inside an ideal dry thin-walled

IOP = intraocular pressure.

1. Asia Pacific Glaucoma Society. Glaucoma guidelines. 2016.

Image adapted from: http://www.precisionophthalmicservices.com/images/AlphaTonopen.jpg (accessed January 2017).

Several factors influence IOP1:

• Circadian cycle • Blood pressure

IOP = intraocular pressure.

1. Asia Pacific Glaucoma Society. Glaucoma guidelines. 2016.

Image adapted from: http://www.precisionophthalmicservices.com/images/AlphaTonopen.jpg (accessed January 2017).

Several factors influence IOP1:

• Circadian cycle • Blood pressure

IOP = intraocular pressure.

1. Asia Pacific Glaucoma Society. Glaucoma guidelines. 2016.

Image adapted from: http://www.precisionophthalmicservices.com/images/AlphaTonopen.jpg (accessed January 2017).

Several factors influence IOP1:

• Circadian cycle • Blood pressure

IOP = intraocular pressure.

1. Asia Pacific Glaucoma Society. Glaucoma guidelines. 2016.

Image adapted from: http://www.precisionophthalmicservices.com/images/AlphaTonopen.jpg (accessed January 2017).

Several factors influence IOP1:

 Thick vs thin corneas

IOP = intraocular pressure.

1. Asia Pacific Glaucoma Society. Glaucoma guidelines. 2016.

Image adapted from: http://www.precisionophthalmicservices.com/images/AlphaTonopen.jpg (accessed January 2017).

Several factors influence IOP1:

• Circadian cycle • BloodIOP

IOP = intraocular pressure.

1. Asia Pacific Glaucoma Society. Glaucoma guidelines. 2016.

Image adapted from: http://www.precisionophthalmicservices.com/images/AlphaTonopen.jpg (accessed January 2017).

Several factors influence IOP1:

IOP = intraocular pressure.

1. Asia Pacific Glaucoma Society. Glaucoma guidelines. 2016.

Image adapted from: http://www.precisionophthalmicservices.com/images/AlphaTonopen.jpg (accessed January 2017).

Several factors influence IOP1:

 Increase IOP – rapid

IOP = intraocular pressure.

1. Asia Pacific Glaucoma Society. Glaucoma guidelines. 2016.

Image adapted from: http://www.precisionophthalmicservices.com/images/AlphaTonopen.jpg (accessed January 2017).

Several factors influence IOP1:

• Circadian cycle • Blood pressure

IOP = intraocular pressure.

1. Asia Pacific Glaucoma Society. Glaucoma guidelines. 2016.

Image adapted from: http://www.precisionophthalmicservices.com/images/AlphaTonopen.jpg (accessed January 2017).

Several factors influence IOP1:

IOP = intraocular pressure.

1. Asia Pacific Glaucoma Society. Glaucoma guidelines. 2016.

Image adapted from: http://www.precisionophthalmicservices.com/images/AlphaTonopen.jpg (accessed January 2017).