Relying on single office measurements of intraocular pressure (IOP) may lead to unnecessarily aggressive therapy in patients with glaucoma. Assessing pressure fluctuations over the course of a day could provide a more accurate picture of disease risk and help reduce complications associated with overtreatment.
Arsham Sheybani, MD, highlighted these findings during his presentation, “Role of IOP Fluctuation and Ocular Pulse Amplitude in Glaucoma Progression,” at the 2025 American Academy of Ophthalmology (AAO) meeting in Orlando, Florida. “We focus so much on one pressure reading in the office,” Dr. Sheybani, an associate professor of ophthalmology and visual sciences at the Washington University School of Medicine in St. Louis, told the audience at glaucoma subspecialty day. “That is such a weak data point when you look at what’s going on globally throughout a 24-hour period.”
He cited a study from a clinic in India where patients’ average office IOP was 13 mmHg, but diurnal measurements throughout the day averaged more than 16 mmHg—a 3-point difference. Such fluctuations, he said, have implications for treatment targets. “If you’re under the assumption in your office that someone is progressing at a pressure of 13 mmHg, you’re going to be really aggressive driving them down below 10 mmHg,” explained Dr. Sheybani. However, that one-time IOP measurement may not represent the full clinical picture. Because of the natural diurnal fluctuations that can occur outside office hours, that measurement may not represent the true pressure profile, he said.
Beyond measurement variability, Dr. Sheybani emphasized that patient adherence and disease trajectory are key factors. A patient progressing at a pressure of 12 mmHg or 13 mmHg may not be maintaining that level consistently, as fluctuations or lapses in compliance can go undetected. He noted that efforts to achieve pressures below 10 mmHg must be carefully weighed against surgical risks and potential complications, particularly in patients with limited life expectancy or slowly progressing disease. He compared this to cardiology and diabetes management, where aggressively lowering endpoints such as blood pressure or A1C can increase complications. In glaucoma, targeting single-digit IOPs may similarly raise risks without providing additional benefit.
“Because when we start getting into these single digits, that’s when people have complications,” he explained.
Dr. Sheybani emphasized that reducing variability may be as important as lowering mean IOP. In some patients, average pressures remain stable postoperatively, but lower variability may reduce progression risk. “Sometimes you’ll have patients that have a pressure of 18 mmHg preoperatively, and then after phaco/MIGS they’re still around 18 mmHg, but if their variability is reduced, then that might actually lower their chance of progression,” he said.
He concluded by urging clinicians to consider fluctuations in IOP when evaluating disease progression. “If you have a patient that’s progressing at a very low pressure, you have to decide, is that actually true? Or, are they spiking higher than what you’re measuring in the office?”
By integrating this perspective, specialists may better balance effective therapy with the potential for treatment-related complications. GP