Normal‐tension glaucoma: Current concepts and approaches‐A review

Abstract

Normal tension glaucoma (NTG) has remained a challenging disease. We review, from an epidemiological perspective, why we should redefine normality, act earlier at lower pre-treatment intraocular pressure (IOP) level, and the role of ocular perfusion pressures, noting that perfusion is affected by defective vascular bed autoregulation and endothelial dysfunction. The correlation of silent cerebral infarcts (SCI) and NTG may indicate that NTG belongs to a wider spectrum of small vessel diseases (SVD), with its main pathology being also on vascular endothelium. Epidemiological studies also suggested that vascular geometry, such as fractal dimension, may affect perfusion efficiency, occurrence of SCI, SVD and glaucoma. Artificial intelligence with deep learning, may help predicting NTG progression from vascular geometry. Finally, we review latest evidence on the role of minimally-invasive glaucoma surgery, lasers, and newer drugs. We conclude that IOP is not the only modifiable risk factors as, many vascular risk factors are readily modifiable.

Ischemic stroke of unclear aetiology: a case-by-case analysis and call for a multi-professional predictive, preventive and personalised approach

“…The correlation between SCI and NTG is considered indicative for small vessel diseases, a major contributor to the NTG pathology, microvascular dysregulation and endothelial dysfunction characteristic for the NTG patient cohort and NTGspecific type of nerve degeneration resulting in progressive visual field loss. Vascular geometry may affect perfusion efficiency and the functional link between SCI, small vessel disease and normal-tension glaucoma [40].…”

Perioperative Care of the Patient with Eye Pathologies Undergoing Nonocular Surgery

“…159 (2) Normal tension glaucoma is glaucoma occurring despite normal intraocular pressure. 160 Hypotheses concerning its origin include retinal ganglion cell or axonal hypersensitivity, restricted glymphatic flow, 161 activated microglia, 162 vasculopathy, or intermittent hypotension. 163 Alternatively, low intracranial pressure causes a pressure gradient across the lamina cribrosa.…”

Optical coherence tomography angiography metrics predict normal tension glaucoma progression

“…(Weinreb & Khaw 2004;Weinreb et al 2014;Lam et al 2019;Lee et al 2019) Although causes of NTG remain incompletely elucidated and are likely multifactorial, mounting evidence attests vascular dysfunction in its pathogenic process (Killer & Pircher 2018;Leung & Tham 2022). One of the hypotheses is that compared with high-tension forms of glaucoma, microcirculatory insufficiency may have a prominent role in NTG pathogenesis in the absence of elevated IOP (Mozaffarieh & Flammer 2013;Lin et al 2020;Leung & Tham 2022). Optical coherence tomography angiography (OCTA) enables noninvasive, objective and rapid evaluation of the retinal microvasculature at the level of the capillary network.…”

“…2019; Lee et al . 2019) Although causes of NTG remain incompletely elucidated and are likely multifactorial, mounting evidence attests vascular dysfunction in its pathogenic process (Killer & Pircher 2018; Leung & Tham 2022). One of the hypotheses is that compared with high‐tension forms of glaucoma, microcirculatory insufficiency may have a prominent role in NTG pathogenesis in the absence of elevated IOP (Mozaffarieh & Flammer 2013; Lin et al .…”

“…One of the hypotheses is that compared with high‐tension forms of glaucoma, microcirculatory insufficiency may have a prominent role in NTG pathogenesis in the absence of elevated IOP (Mozaffarieh & Flammer 2013; Lin et al . 2020; Leung & Tham 2022).…”