24-hour BP Monitoring Could Help Glaucoma Risk Stratification

Which patients with glaucoma may benefit from 24-hour BP monitoring? Recent findings suggest a targeted approach for BP monitoring in eyes with progressive changes in RNFL or standard automated perimetry despite low levels of IOP. Photo: HeartTec Solutions. Click image to enlarge. Glaucomatous eyes that progress rapidly are at high risk for visual disability, so identifying systemic vascular risk factors may improve early risk stratification and future therapeutic strategies. Many researchers have speculated that certain glaucoma patients—for example, those with or at high risk for visual field progression—may be identified with 24-hour blood pressure (BP) monitoring with systemic hypotension while using systemic arterial hypertension medication. In a recent study published in American Journal of Ophthalmology, researchers from Bascom Palmer Eye Institute in Miami determined that lower minimum 24-hour systemic BP measured by ambulatory monitoring was independently associated with faster rates of retinal nerve fiber layer (RNFL) thinning in primary open-angle glaucoma (POAG). Office-based BP monitoring was not predictive of RNFL loss.The Vascular Imaging in Glaucoma Study at the Bascom Palmer included 79 eyes from 42 participants with glaucoma (mean age: 68.5) who underwent 24-hour ambulatory BP monitoring at baseline. Follow-up evaluations were conducted at four-month intervals and included ophthalmic examination, BP measurement and peripapillary RNFL thickness measurement with spectral-domain OCT. Eyes underwent an average of 13 OCT exams over 43 months of follow-up. The association between BP and RNFL loss over time was assessed using linear mixed-effects models adjusted for age, sex, race, baseline RNFL thickness, central corneal thickness and intraocular pressure (IOP).The mean rate of RNFL loss was -0.34µm/year (median: -0.32). After adjusting for confounding factors, every 10mm Hg lower in 24-hour minimum mean arterial pressure (MAP), systolic BP and diastolic BP was associated with -0.542µm/year, -0.360µm/year and -0.458µm/year  faster RNFL loss, respectively. Eyes in the lowest category of average 24-hour MAP (81-90mm Hg) and minimum 24-hour diastolic BP (35-47mm Hg) experienced significantly faster progression compared to those at the highest level, with differences of -0.68µm/year and -0.63µm/year, respectively.“This prospective study shows that lower minimum 24-hour BP values, specifically MAP, systolic BP and diastolic BP, are independently associated with faster rates of RNFL loss in glaucomatous eyes,” the researchers wrote in their paper. “These associations are consistent with, but do not prove, a causal vascular mechanism.”They concluded that 24-hour BP monitoring, more so than isolated measures done in-office, may help identify glaucoma patients at greater risk of progression and that their study supports the integration of ambulatory BP monitoring into glaucoma risk stratification strategies. “Isolated BP measurements may underestimate the frequency and severity of episodic or sustained hypotensive episodes” that can be detected using 24-hour BP monitoring. The team also noted that further research should explore whether mitigating systemic hypotension can help preserve optic nerve structure and function in eyes at high risk for glaucoma progression.Click here for the journal source. Zhou DB, Jammal AA, Donkor R, Greenfield DS. Association between 24-hour blood pressure and rates of retinal nerve fiber layer progression in glaucoma: the Vascular Imaging in Glaucoma Study. Am J Ophthalmol. June 21, 2026. [Epub ahead of print].      This article was developed by the editorial staff in conjunction with experts in the field. In the process, AI may have been among the editorial tools used to meet the goals of human editors, who approved all content.