Large diurnal fluctuations in intraocular pressure are an independent risk factor in patients with glaucoma

Purpose: To study the risk associated with diurnal intraocular pressure (IOP) variations in patients with open-angle glaucoma. Patients and Methods: Sixty-four patients (105 eyes) from the practices of two glaucoma specialists successfully performed home tonometry with a self-tonometer five times a day for 5 days. All patients had open-angle glaucoma and documented IOP below 25 mm Hg over a mean follow-up period of 5 years. Baseline status and time to progression of visual field loss were identified from the clinical charts. The level and variability of diurnal lOP obtained using home tonometry were characterized. Risk of progression was analyzed using a nonparametric time-to-event model, incorporating methods for correlated outcomes. Results: Although mean home IOP and baseline office IOP were similar (16.4 ± 3.6 mm Hg and 17.6 ± 3.2 mm Hg, respectively), the average IOP range over the 5 days of home tonometry was 10.0 ± 2.9 mm Hg. Baseline office IOP had no predictive value (relative hazard, 0.98). The diurnal IOP range and the IOP range over multiple days were significant risk factors for progression, even after adjusting for office IOP, age, race, gender, and visual field damage at baseline (relative hazards [95% confidence intervals], 5.69 [1.86, 17.35] and 5.76 [2.21, 14.98]). Eighty-eight percent of patients in the upper twenty-fifth percentile of IOP and 57% of patients in the lower twenty-fifth percentile progressed within 8 years. Conclusions: In patients with glaucoma with office IOP in the normal range, large fluctuations in diurnal IOP are a significant risk factor, independent of parameters obtained in the office. Fluctuations in IOP may be important in managing patients with glaucoma. Development of methods to control fluctuations in IOP may be warranted.