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Editors Selection IGR 9-2
Risk Factors: The potential role of blood pressure in VF progression - II
Comment by Alon Harris on:
The multifactorial nature of primary open angle glaucoma (POAG) creates unique challenges for advancing diagnostics and precision patient care. Many previous studies have found both high and low blood pressure (BP) to be strongly associated with POAG.1-4 Low ocular perfusion pressure (OPP), calculated from BP and intraocular pressure (IOP), has also been identified as a risk factor for POAG prevalence, incidence and progression in in several population-based studies.5-7 Studies have suggested the importance of maintaining blood flow and metabolic autoregulation across physiological ranges of BP and IOP. Non-physiological dips or spikes in BP and IOP in combination with faulty auto-regulation may result in imbalances that cause low retinal and optic nerve head (ONH) perfusion and ultimately retinal ganglion cell (RGC) death and visual field (VF) loss.
In this new prospective analysis, Donkor and colleagues examine the relationship between 24-hour ambulatory BP monitoring (ABPM) and the rate of change in standard automated perimetry (SAP) in 124 eyes with glaucoma (91) and suspected glaucoma (33) over 4 years. The researchers found lower mean arterial pressure (MAP) and systolic BP at baseline, as well as low systolic BP during follow-up were significantly associated with faster rates of SAP mean deviation (MD) loss.
Lower mean arterial pressure (MAP) and systolic BP at baseline, as well as low systolic BP during follow-up were significantly associated with faster rates of SAP mean deviation (MD) loss
The results are in line with the Early Manifest Glaucoma Trial6 and complement the previous work of Jammal et al. who found that when adjusted for IOP, lower MAP and diastolic arterial pressure during follow-up were significantly associated with faster rates of retinal nerve fiber layer (RNFL) loss in subjects from the Duke Glaucoma Registry.2 Strengths of the study by Donkor et al. include diurnal 24-hour ABPM and adjusting for potential confounding variables including age, IOP during follow-up, central corneal thickness, and the severity of VF loss. Limitations include absence of structural assessments including OCT assessed-RNFL, inclusion of both glaucoma and glaucoma suspects in a single cohort and no healthy controls, mixed medication use among patients and not directly assessing retinal and ONH blood flow.
The outstanding work by Donkor and associates provides exciting new prospective data linking lower systolic BP and MAP to glaucomatous VF progression. This novel contribution strengthens the paradigm that certain POAG patients may benefit from including BP in their risk assessment, especially those when a patient’s IOP is low. Interestingly, another recently highlighted article by Pham et al. (JAMA Ophthalmol. 2025;143(1):25-32. doi:10.1001/jamaophthalmol.2024.4868) (see preceding comment 121260) confirmed glaucoma and suspects over 8 years found both high and low mean BP combined with higher SD of BP and high or low IOP respectfully, were associated with faster VF progression (MD slopes). Both studies would benefit from using OCTA or other techniques to understand the impact of lower BP, MAP and OPP on retinal and ONH perfusion and metabolism. Overall, these complimentary results further reinforce the need for using advanced data science tools, including artificial intelligence and mathematical applications, to identify the combinations of BP and IOP that elevate an individual’s risk for the onset and progression of glaucoma.8
References
- Mohammadzadeh V, Su E, Mohammadi M, Law SK, Coleman AL, Caprioli J, Weiss RE, Nouri-Mahdavi K. Association of Blood Pressure With Rates of Macular Ganglion Cell Complex Thinning in Patients With Glaucoma. JAMA ophthalmology, 2023; 141(3), 251–257.
- Jammal AA, Berchuck SI, Mariottoni EB, Tanna AP, Costa VP, Medeiros FA. Blood Pressure and Glaucomatous Progression in a Large Clinical Population. Ophthalmology. 2022; 129(2), 161–170.
- Macri C, Wong CX, Tu SJ, Casson R, Singh K, Wang SY, Sun MT. Blood Pressure Measures and Incident Primary Open-Angle Glaucoma. Invest Ophthalmol Vis Sci. 2022 Dec 1;63(13):3.
- Nislawati R, Taufik Fadillah Zainal A, Ismail A, Waspodo N, Kasim F, Gunawan AMAK. Role of hypertension as a risk factor for open-angle glaucoma: a systematic review and meta-analysis. BMJ Open Ophthal-mol. 2021 Sep 28;6(1):e000798.
- Weinreb RN, Harris, A. World Glaucoma Association Consensus Series – 6. Ocular blood flow in glaucoma. Kugler Publications, Amsterdam, the Netherlands. 2009.
- Topouzis F, Wilson MR, Harris A, Founti P, Yu F, Anastasopoulos E, Pappas T, Koskosas A, Salonikiou A, Coleman AL. Association of open-angle glaucoma with perfusion pressure status in the Thessaloniki Eye Study. Am J Ophthalmol. 2013 May;155(5):843-51. doi: 10.1016/j.ajo.2012.12.007. Epub 2013 Feb 6. PMID: 23394905.
- Leske MC, Heijl A, Hyman L, Bengtsson B, Dong L, Yang Z; EMGT Group. Predictors of long-term progression in the early manifest glaucoma trial. Ophthalmology. 2007 Nov;114(11):1965-72. doi: 10.1016/j.ophtha.2007.03.016. Epub 2007 Jul 12. PMID: 17628686.
- Kellner, R., Harris, A., Ciulla, L., Rai R., Siesky, B., Topouzis, F. Verticchio Vercellin, A., Antman, G., Keller, J., Zou, D., Wikle, C., Guidoboni. G. Blood pressure and glaucoma: can physiology- enhanced artificial intelligence solve the enigma? Glaucoma Research and Clinical Advances: 2022 to 2024, pp. 1-14 Edited by J.R. Samples and W.D. Stamer (2024) Kugler Publications, Amsterdam, The Netherlands.
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