Features of medical and surgical treatment of normal-tension glaucoma
https://doi.org/10.53432/2078-4104-2026-25-1-66-75
Abstract
Normal-tension glaucoma is a progressive optic neuropathy characterized by thinning of the peripapillary retinal nerve fiber layer and the development of typical visual field defects, open anterior chamber angle, and intraocular pressure levels that do not exceed the statistically normal range. The course of this disease differs from that of hypertensive glaucoma by the presence of more localized and deeper defects of light sensitivity, as well as by a higher rate of progression.
The management of normal-tension glaucoma (medical, laser, or surgical) is aimed at reducing intraocular pressure and achieving target levels at which further loss of visual function can be halted. A distinctive feature of the therapeutic approach to this form of glaucoma is the need for lower target intraocular pressure values, which, in combination with the high rate of disease progression, necessitates a more rapid transition to surgical treatment. The challenge of normal-tension glaucoma lies in its diagnostic features, clinical manifestations, and treatment strategies, all of which require a differentiated and personalized approach.
This literature review analyzes current data on the morphological and functional differences between normaltension glaucoma and typical primary open-angle glaucoma, evaluates the effectiveness of various pharmacological classes of hypotensive medications, and examines modern trends in the surgical management of this disease.
About the Authors
A. A. Vitkov
Krasnov Research Institute of Eye Diseases
Russian Federation
Russian Federation
Vitkov A.A., Cand. Sci. (Med), researcher at the Glaucoma Department
11A Rossolimo St., Moscow, 1190214
N. G. Glazko
Hospital for War Veterans No. 2 of the Moscow City Health Department
Russian Federation
Russian Federation
Glazko N.G., Cand. Sci. (Med), ophthalmologist
168 Volgogradsky Prospekt, Moscow, 109472
N. A. Bakunina
Peoples' Friendship University of Russia named after Patrice Lumumba; Сity Clinical Hospital № 1
Russian Federation
Russian Federation
Bakunina N.A., Dr. Sci. (Med.), Associate Professor at the Academic Department of Eye Diseases, ophthalmologist
6 Miklukho-Maklaya St., Moscow, 117198;
8 Leninskiy Prospekt, Moscow, 117049
A. V. Seleznev
Ivanovo State Medical University
Russian Federation
Russian Federation
Seleznev A.V., Cand. Sci. (Med.), Assistant Professor at the Academic Department of Otorhinolaryngology and Ophthalmology
8 Sheremetevskii Prospekt, Ivanovo, 153012
A. Yu. Brezhnev
Kursk State Medical University
Russian Federation
Russian Federation
Brezhnev A.Yu., Cand. Sci. (Med.), Associate Professor at the Academic Department of Ophthalmology
3 Karla Marksa St., Kursk, 305041
A. V. Kuroyedov
Clinical Medicine of the Pirogov Russian National Research Medical University; Mandryka Central Military Clinical Hospital
Russian Federation
Russian Federation
Kuroyedov A.V., Dr. Sci. (Med.), Professor, Head of the Academic Department of Ophthalmology, Head of the Ophthalmology Сenter
1 Ostrovityanova St., Moscow, 117997;
8A Bolshaya Olenya St., Moscow, 107014
References
1. Chen MJ. Normal tension glaucoma in Asia: Epidemiology, pathogenesis, diagnosis, and management. Taiwan J Ophthalmol 2020; 10(4):250-254. https://doi.org/10.4103/tjo.tjo_30_20.
2. Zhao J, Solano MM, Oldenburg CE, et al. Prevalence of normal-tension glaucoma in the Chinese population: A systematic review and meta-analysis. Am J Ophthalmol 2019; 199:101-110. https://doi.org/10.1016/j.ajo.2018.10.017.
3. Petrov S.Y. Modern view on normal-tension glaucoma. Russian Annals of Ophthalmology 2020; 136(6):57-64. https://doi.org/10.17116/oftalma202013606157.
4. L.C. Gutiérrez Martín. Update on the diagnosis and treatment of normotensive glaucoma. Archivos de la Sociedad Española de Oftalmología (English Edition) 2023; 98(6):344-350. https://doi.org/10.1016/j.oftale.2023.05.004.
5. Costagliola C, Agnifili L, Mastropasqua L, di Costanzo A. Low-Tension Glaucoma: An Oxymoron in Ophthalmology. Prev Chronic Dis 2019; 16:E10. https://doi.org/10.5888/pcd16.180534.
6. Traynis I, De Moraes CG, Raza AS, et al. Prevalence and nature of early glaucomatous defects in the central 10 degrees of the visual field. JAMA Ophthalmol 2014; 132(3):291-297. https://doi.org/10.1001/jamaophthalmol.2013.7656.
7. Cho HK, Lee J, Lee M, Kee C. Initial central scotomas vs peripheral scotomas in normal-tension glaucoma: clinical characteristics and progression rates. Eye (Lond) 2014; 28(3):303-311. https://doi.org/10.1038/eye.2013.285.
8. Kim KN, Jeoung JW, Park KH, et al. Relationship between preferred sleeping position and asymmetric visual field loss in open-angle glaucoma patients. Am J Ophthalmol 2014; 157(3):739-745. https://doi.org/10.1016/j.ajo.2013.12.016.
9. Esporcatte BL, Tavares IM. Normal-tension glaucoma: an update. Arq Bras Oftalmol 2016; 79(4):270-276. https://doi.org/10.5935/0004-2749.20160077.
10. Adlina AR, Alisa-Victoria K, Shatriah I, et al. Optic disc topography in Malay patients with normal-tension glaucoma and primary openangle glaucoma. Clin Ophthalmol 2014; 8:2533-2539. https://doi.org/10.2147/OPTH.S71136.
11. Park HY, Lee KI, Lee K, et al. Torsion of the optic nerve head is a prominent feature of normal-tension glaucoma. Invest Ophthalmol Vis Sci 2014; 56(1):156-163. https://doi.org/10.1167/iovs.13-12327.
12. Mallick J, Devi L, Malik PK, Mallick J. Update on Normal Tension Glaucoma. J Ophthalmic Vis Res 2016; 11(2):204-248. https://doi.org/10.4103/2008-322X.183914.
13. Killer HE, Pircher A. Normal tension glaucoma: review of current understanding and mechanisms of the pathogenesis. Eye (Lond) 2018; 32(5):924-930. https://doi.org/10.1038/s41433-018-0042-2.
14. Furlanetto RL, De Moraes CG, Teng CC, et al. Low-Pressure Glaucoma Treatment Study Group. Risk factors for optic disc hemorrhage in the low-pressure glaucoma treatment study. Am J Ophthalmol 2014; 157(5):945-952. https://doi.org/10.1016/j.ajo.2014.02.009.
15. Lee EJ, Kim TW, Kim M, et al. Recent structural alteration of the peripheral lamina cribrosa near the location of disc hemorrhage in glaucoma. Invest Ophthalmol Vis Sci 2014; 55(4):2805-2815. https://doi.org/10.1167/iovs.13-12742.
16. Omodaka K, Horii T, Takahashi S, et al. 3D evaluation of the lamina cribrosa with swept-source optical coherence tomography in normal tension glaucoma. PLoS One 2015; 10(4):e0122347 https://doi.org/10.1371/journal.pone.0122347.
17. Kwun Y, Han JC, Kee C. Comparison of lamina cribrosa thickness in normal tension glaucoma patients with unilateral visual field defect. Am J Ophthalmol 2015; 159(3):512-8.e1. https://doi.org/10.1016/j.ajo.2014.11.034
18. Villarruel JM, Li XQ, Bach-Holm D, Hamann S. Anterior lamina cribrosa surface position in idiopathic intracranial hypertension and glaucoma. Eur J Ophthalmol 2017; 27(1):55-61. https://doi.org/10.5301/ejo.5000806.
19. Kim YW, Jeoung JW, Girard MJ, et al. Positional and Curvature Difference of Lamina Cribrosa According to the Baseline Intraocular Pressure in Primary Open-Angle Glaucoma: A Swept-Source Optical Coherence Tomography (SS-OCT) Study. PLoS One 2016; 11(9):e0162182. https://doi.org/10.1371/journal.pone
20. Kim M, Bojikian KD, Slabaugh MA, et al. Lamina depth and thickness correlate with glaucoma severity. Indian J Ophthalmol 2016; 64(5):358-363. https://doi.org/10.4103/0301-4738.185594.
21. Andrade JCF, Kanadani FN, Furlanetto RL, Lopes FS, Ritch R, Prata TS. Elucidation of the role of the lamina cribrosa in glaucoma using optical coherence tomography. Surv Ophthalmol 2022; 67(1):197-216. https://doi.org/10.1016/j.survophthal.2021.01.015.
22. Ko Eun Kim, Ki-Ho Park. Update on the Prevalence, Etiology, Diagnosis, and Monitoring of Normal-Tension Glaucoma. Asia-Pacific Journal of Ophthalmology 2016; 5(1):23-31. https://doi.org/10.1097/APO.0000000000000177.
23. Betzler BK, Siat DJY, Agrawal R, et al. Comparison of Peripapillary Choroidal Thickness Between Primary Open-angle Glaucoma, Normal Tension Glaucoma, and Normal Eyes: A Systematic Review and Metaanalysis. Ophthalmol Glaucoma 2024; S2589-4196(24)00035-8. https://doi.org/10.1016/j.ogla.2024.02.008.
24. Jung YH, Park HY, Jung KI, Park CK. Comparison of prelaminar thickness between primary open angle glaucoma and normal tension glaucoma patients. PLoS One 2015; 10(3):e0120634. https://doi.org/10.1371/journal.pone.0120634.
25. Lopilly Park HY, Lee NY, Choi JA, Park CK. Measurement of scleral thickness using swept-source optical coherence tomography in patients with open-angle glaucoma and myopia. Am J Ophthalmol 2014; 157(4):876-84. https://doi.org/10.1016/j.ajo.2014.01.007.
26. Wang YM, Shen R, Lin TPH, et al. Optical coherence tomography angiography metrics predict normal tension glaucoma progression. Acta Ophthalmol 2022; 100(7):e1455-e1462. https://doi.org/10.1111/aos.15117.
27. Aznabaev B.M., Zagidullina A.Sh., Aleksandrov A.A. et al. Optic nerve head microcirculation and morphometry in normal-tension glaucoma. RMJ Clinical ophthalmology 2017; 17(1):17-20. https://doi.org/10.21689/2311-7729-2017-17-1-17-20
28. van Eijgen J, Heintz A, van der Pluijm C, et al. Normal tension glaucoma: A dynamic optical coherence tomography angiography study. Front Med (Lausanne) 2023; 9:1037471. https://doi.org/10.3389/fmed.2022.1037471.
29. Cvenkel B, Kolko M. Current Medical Therapy and Future Trends in the Management of Glaucoma Treatment. J Ophthalmol 2020; 2020:6138132. https://doi.org/10.1155/2020/6138132.
30. Wang T, Cao L, Jiang Q, Zhang T. Topical Medication Therapy for Glaucoma and Ocular Hypertension. Front Pharmacol 2021; 12:749858. https://doi.org/10.3389/fphar.2021.749858
31. Takagi Y, Santo K, Hashimoto M, Fukuchi T. Ocular hypotensive effects of prostaglandin analogs in Japanese patients with normal-tension glaucoma: a literature review. Clin Ophthalmol 2018; 12:1837-1844. https://doi.org/10.2147/OPTH.S166657
32. Kim JM, Sung KR, Kim HK, et al. Long-Term Effectiveness and Safety of Tafluprost, Travoprost, and Latanoprost in Korean Patients with Primary Open-Angle Glaucoma or Normal-Tension Glaucoma: A Multicenter Retrospective Cohort Study (LOTUS Study). J Clin Med 2021; 10(12):2717. https://doi.org/10.3390/jcm10122717
33. Kurysheva N.I., Kim V.E., Plieva H.M., Kim V.Yu. Normal-Tension Glaucoma: Epidemiology, Pathogenesis, Diagnosis and Treatment. Literature Review. Part 2. Role of Vascular Dysregulation in the Pathogenesis. Treatment of Normal Tension Glaucoma. Ophthalmology in Russia 2023; 20(4):585-592. https://doi.org/10.18008/1816-5095-2023-4-585-592
34. Salvetat ML, Pellegrini F, Spadea L, Salati C, Zeppieri M. Pharmaceutical Approaches to Normal Tension Glaucoma. Pharmaceuticals (Basel) 2023; 16(8):1172. https://doi.org/10.3390/ph16081172
35. Wang T, Cao L, Jiang Q, Zhang T. Topical Medication Therapy for Glaucoma and Ocular Hypertension. Front Pharmacol 2021; 12:749858. https://doi.org/10.3389/fphar.2021.749858
36. Lindsey JD, Duong-Polk KX, Hammond D, Chindasub P, Leung CK, Weinreb RN. Differential protection of injured retinal ganglion cell dendrites by brimonidine. Invest Ophthalmol Vis Sci 2015; 56(3):1789- 1804. https://doi.org/10.1167/iovs.14-13892.
37. Komori S, Ishida K, Yamamoto T. Results of long-term monitoring of normal-tension glaucoma patients receiving medical therapy: results of an 18-year follow-up. Graefes Arch Clin Exp Ophthalmol 2014; 252(12):1963-1970. https://doi.org/10.1007/s00417-014-2767-3.
38. Kim TW, Kim M, Lee EJ, Jeoung JW, Park KH. Intraocular pressurelowering efficacy of dorzolamide/timolol fixed combination in normal- tension glaucoma. J Glaucoma 2014; 23(5):329-332. https://doi.org/10.1097/IJG.0b013e3182741f4d.
39. Kim JM, Kim TW, Kim CY, Kim HK,Park KH. Comparison of the intraocular pressure-lowering effect and safety of brimonidine/timolol fixed combination and 0.5 % timolol in normal-tension glaucoma patients. Jpn J Ophthalmol 2016; 60(1):20-26. https://doi.org/10.1007/s10384-015-0420-2.
40. Yoshikawa K, Mizoue S, Nitta K, et al. Stratification-Based Investigation of Adjunctive Brimonidine or Timolol to a Prostaglandin Analogue in Japanese Patients with Normal-Tension Glaucoma. Clin Ophthalmol 2021; 15:2875-2883. https://doi.org/10.2147/OPTH.S318392
41. Kuo CY, Liu CJ. Neuroprotection in Glaucoma: Basic Aspects and Clinical Relevance. J Pers Med 2022; 12(11):1884. https://doi.org/10.3390/jpm12111884.
42. Weinreb RN, Liebmann JM, Cioffi GA, Goldberg I, Brandt JD, Johnson CA, et al. Oral memantine for the treatment of glaucoma: Design and results of 2 randomized, placebo-controlled, phase 3 studies. Ophthalmology 2018; 125:1874-1885. https://doi.org/10.1016/j.ophtha.2018.06.017.
43. Malishevskaia TN, Dolgova IG. Options for correction of endothelial dysfunction and oxidative stress in patients with primary open-angle glaucoma. Russian Annals of Ophthalmology 2014; 130(5):6773.
44. Osborne A, Sanderson J, Martin KR. Neuroprotective effects of human mesenchymal stem cells and platelet-derived growth factor on human retinal ganglion cells. Stem Cells 2018; 36(1):65-78. https://doi.org/10.1002/stem.2722.
45. Vishwaraj CR, Kavitha S, Venkatesh R, Shukla AG, Chandran P, Tripathi S. Neuroprotection in glaucoma. Indian J Ophthalmol 2022; 70(2):380-385. https://doi.org/10.4103/ijo.IJO_1158_21.
46. Sena DF, Lindsley K. Neuroprotection for treatment of glaucoma in adults. Cochrane Database Syst Rev 2017; 1(1):CD006539. https://doi.org/10.1002/14651858.CD006539.pub4.
47. Song D., Wang L. Cost-utility analysis of treating mild stage normal tension glaucoma by surgery in China: a decision-analytic Markov model. Cost Eff Resour Alloc 2024; 22(1):13. https://doi.org/10.1186/s12962-024-00523-6.
48. Aoyama A., Ishida K., Sawada A., Yamamoto T. Target intraocular pressure for stability of visual field loss progression in normal-tension glaucoma. Jpn J Ophthalmol 2010; 54(2):117-123. https://doi.org/10.1007/s10384-009-0779-z.
49. Wang SY, Singh K. Management of the glaucoma patient progressing at low normal intraocular pressure. Curr Opin Ophthalmol 2020; 31(2):107-113. https://doi.org/10.1097/ICU.0000000000000640.
50. Vitkov A.A., Kuroyedov A.V., Makarova A.S., Poleva R.P., Dorofeev D.A., Asinovskova I.I. Repeat glaucoma surgery: modern view of the problem. National Journal glaucoma 2023; 22(4):80-88. https://doi.org/10.53432/2078-4104-2023-22-4-80-88
51. Jayaram H., Strouthidis N.G., Kamal D.S. Trabeculectomy for normal tension glaucoma: outcomes using the Moorfields Safer Surgery technique. Br J Ophthalmol 2016; 100(3):332-338. https://doi.org/10.1136/bjophthalmol-2015-306872.
52. Schultz SK, Iverson SM, Shi W, Greenfield DS. Safety and efficacy of achieving single-digit intraocular pressure targets with filtration surgery in eyes with progressive normal-tension glaucoma. J Glaucoma 2016; 25(2):217-222. https://doi.org/10.1097/IJG.0000000000000145.
53. Lai C., Shao S.C., Chen Y.H., Kuo Y.K., Lai C.C., Chuang L.H. Trabeculectomy With Antimetabolite Agents for Normal Tension Glaucoma: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2022; 9:932232. https://doi.org/10.3389/fmed.2022.932232.
54. Nakajima K., Sakata R., Ueda K., Fujita A., Fujishiro T., Honjo M., et al. Central visual field change after fornix-based trabeculectomy in Japanese normal-tension glaucoma patients managed under 15 mmHg. Graefes Arch Clin Exp Ophthalmol 2021; 259(8):2309-2316. https://doi.org/10.1007/s00417-021-05215-y.
55. Suominen S, Harju M, Kurvinen L, Vesti E. Deep sclerectomy in normal-tension glaucoma with and without mitomycin-c. Acta Ophthalmol 2014; 92(7):701-706. https://doi.org/10.1111/aos.12305.
56. Gabai A., Cimarosti R., Battistella C., Isola M., Lanzetta P. Efficacy and Safety of Trabeculectomy Versus Nonpenetrating Surgeries in Openangle Glaucoma: A Meta-analysis. J Glaucoma 2019; 28(9):823-833. https://doi.org/10.1097/IJG.0000000000001323.
57. Erichev V.P., Asratyan G.K. Micro stenting as a first surgery for primary glaucoma. RMJ Clinical Ophthalmology 2014; 14(2):76-78.
58. Avetisov S.E, Erichev V.P., Asratyan G.K. Microshunting in glaucoma surgery in artiphakic eyes. Natsional’nyi zhurnal glaukoma 2013; 3-1:44-47.
59. Erichev V.P., Asratyan G.K. Efficacy and safety of microshunting in primary glaucoma surgery. Glaukoma. Zhurnal NII GB RAMN 2012; 4: 50-53.
60. Yerichev V.P., Asratyan G.K. Mini-shunting in glaucoma surgery. Glaucoma 2012; 2:66-71.
61. Hashimoto Y., Michihata N., Matsui H., Fushimi K., Yasunaga H., Aihara M. Reoperation rates after Ex-PRESS versus trabeculectomy for primary open-angle or normal-tension glaucoma: a national database study in Japan. Eye (Lond) 2020; 34(6):1069-1076. https://doi.org/10.1038/s41433-019-0641-6.
62. Hallaj S, Wong JC, Hock LE, Kolomeyer NN, Shukla AG, Pro MJ, Moster MR, Myers JS, Razeghinejad R, Lee D. Long-Term Surgical Outcomes of Glaucoma Drainage Implants in Eyes with Preoperative Intraocular Pressure Less than 19 mmHg. J Ophthalmol 2024; 2024:6624021. https://doi.org/10.1155/2024/6624021.
63. Schargus M., Theilig T., Rehak M., Busch C., Bormann C., Unterlauft J.D. Outcome of a single XEN microstent implant for glaucoma patients with different types of glaucoma. BMC Ophthalmol 2020; 20(1):490. https://doi.org/10.1186/s12886-020-01764-8.
64. Chang E.K., Gupta S., Chachanidze M., Hall N., Chang T.C., Sola-Del Valle D. Safety and efficacy of microinvasive glaucoma surgery with cataract extraction in patients with normal-tension glaucoma. Sci Rep 2021; 11(1):8910. https://doi.org/10.1038/s41598-021-88358-6.
65. Oo H.H., Hong A.S.Y., Lim S.Y., Ang B.C.H. Angle-based minimally invasive glaucoma surgery in normal tension glaucoma: A systematic review and meta-analysis. Clin Exp Ophthalmol 2024; 52(7):740-760. https://doi.org/10.1111/ceo.14408.
66. Kuerten D., Walter P., Baumgarten S., Fuest M., Plange N. 12-month outcomes of ab interno excisional goniotomy combined with cataract surgery in primary open-angle glaucoma and normal tension glaucoma. Int Ophthalmol 2023; 43(8):2605-2612. https://doi.org/10.1007/s10792-023-02659-5.
67. Clement C., Howes F., Ioannidis A.S., Shiu M., Manning D., Lusthaus J., et al. Two-Year Multicenter Outcomes of iStent inject Trabecular Micro-Bypass Stents Combined with Phacoemulsification in Various Types of Glaucoma and Ocular Hypertension. Clin Ophthalmol 2020; 14:3507-3517. https://doi.org/10.2147/OPTH.S271646.
68. Benekos K., Katsanos A., Haidich A.B., Dastiridou A., Nikolaidou A., Konstas A.G. The Effect of Phacoemulsification on the Intraocular Pressure of Patients with Open-angle Glaucoma: A Systematic Review and Meta-Analysis. J Glaucoma 2024; 33(8):576-586. https://doi.org/10.1097/IJG.0000000000002386.
69. Gillmann K, Hornbeak DM. Rates of visual field change and functional progression in glaucoma following trabecular microbypass implantation of iStent technologies: a meta-analysis. BMJ Open Ophthalmol 2024; 9(1):e001575. https://doi.org/10.1136/bmjophth-2023-001575
Review
For citations:
Vitkov A.A., Glazko N.G., Bakunina N.A., Seleznev A.V., Brezhnev A.Yu., Kuroyedov A.V. Features of medical and surgical treatment of normal-tension glaucoma. National Journal glaucoma. 2026;25(1):66-75. (In Russ.) https://doi.org/10.53432/2078-4104-2026-25-1-66-75
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