Normal tension glaucoma (NTG) is a distinct subset of glaucoma that presents unique challenges and requires specialized care. It involves the same optic nerve damage and visual field defects as other types of glaucoma, but occurs despite normal internal eye pressure, known as intraocular pressure (IOP). Here, glaucoma specialist Dr. Ruth Williams and patient advocate Hillary Golden explain more about the causes, symptoms, and treatments of NTG.*

Understanding Normal Tension Glaucoma

NTG patients often show typical optic nerve abnormalities and visual field defects, yet their IOP remains within the normal range of 12-22 mm Hg. This makes NTG distinct from other types, such as primary open-angle glaucoma and acute angle-closure glaucoma. 

Despite having normal pressures at diagnosis, NTG patients may experience pressure spikes that contribute to disease progression. This fluctuation often occurs during the early morning hours, when regular monitoring is not feasible.

One of the significant risk factors for NTG is vascular dysregulation, which includes conditions like low diastolic blood pressure and Raynaud’s syndrome. 

“Low diastolic blood pressure is a common association with normal tension glaucoma,” Williams notes. Patients with NTG are more likely to experience these vascular issues, which can exacerbate the progression of the disease. 

Williams also notes that NTG patients often require:

• More frequent monitoring, and 
• A more aggressive approach to lowering IOP to prevent further optic nerve damage.

Patient Experiences and Challenges

“While the diseases have so much diversity, and patients do too,” Williams says, “there’s one thing that is common to most glaucoma patients, and that is they’re afraid.” One of the best ways to “combat fear,” she adds, is with knowledge, emphasizing the importance of patient education. 

Golden, a patient diagnosed with severe NTG, highlights this need by sharing her eye health journey and the misconceptions she had about glaucoma when she was first diagnosed. “The two things that I thought I knew about glaucoma at that point were simply incorrect,” she recalls. 

“The first thing I thought was that you had to have high pressure to have glaucoma. My eye pressure was 13 and 14 at diagnosis. I also thought you had to be in your 70s or older to have glaucoma.” 

Despite regular check-ups with ophthalmologists, her NTG went undiagnosed for years, emphasizing the importance of thorough examinations and awareness of the disease’s subtleties.

Treatment Approaches and Strategies

The mainstay of NTG treatment is lowering IOP, even though it’s already within the normal range. Studies have shown that reducing IOP can slow or halt NTG’s progression. 

Common treatments for lowering IOP include:

• Eye drops,
• Laser therapy, and
• Surgery, such as trabeculectomy or MIGS.

“We might be more inclined to recommend surgery in normal tension patients than we might in another patient or this kind of surgery,” Williams says, noting that a tailored approach is often required.

Golden advocates for self-monitoring and proactive patient involvement. She uses a home tonometer to track her IOP fluctuations, which provides valuable data for her treatment plan. Lifestyle modifications, such as maintaining a healthy diet and regular exercise, play a crucial role in managing NTG. 

Both Williams and Golden emphasize the importance of a holistic approach to health, integrating medical treatments and lifestyle changes to manage the disease effectively.

*Glaucoma Research Foundation Videos. (2024, March 22). Normal Tension Glaucoma: What You Need to Know (Webinar) [Video File]. Retrieved from https://www.youtube.com/watch?v=X8N6WyyMNno 

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