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Definition of Intraocular Pressure

Updated on July 30, 2016
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Melissa Flagg is an ophthalmic technician with over 20 years of experience working with patients in the eye care field.


Joined: 5 years agoFollowers: 634Articles: 111

An Eye with Narrow Angle Closure Glaucoma

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Layers of the Cornea

The endothelium is the last layer of the cornea before the anterior chamber.
The endothelium is the last layer of the cornea before the anterior chamber. | Source

Intraocular pressure refers to the pressure inside the eye which is the result of two fluids that deliver nutrients and give the eye its shape and rigidity. These two different fluids are the aqueous and vitreous humor.

The aqueous humor (typically just called the aqueous) is found in the anterior chamber of the eye which is the space between the back of the cornea and the iris. It has the consistency of plasma and nourishes the cornea through the endothelium. It also maintains the shape of the anterior chamber and is constantly replenished and produced by the ciliary process.

The vitreous humor, or vitreous, is located in the posterior chamber of the eye behind the lens. It is a fairly thick gel-like transparent fluid that keeps the retina in place and gives the eye its shape. As we age, the vitreous starts to liquefy and collagen fibers begin to clump together forming what is most commonly known as vitreous floaters. Unlike the aqueous, the vitreous is not replenished constantly. It remains stagnant. This is why anything in the vitreous tends to stay in the vitreous such as floaters and hemorrhages.

About the Author

Melissa Flagg is an ophthalmic technician who has been examining patients on a daily basis for over 20 years.

She has had rigorous training under the supervision of an ophthalmologist and specialized in the cornea, cataracts, and retina as well as how systemic disease affects the eye. She is certified by JCAHPO as an OSC (ophthalmic scribe certified).

The Flow of Fluid in the Eye

Aqueous is a gel-like, clear fluid that drains through the trabecular meshwork, a spongy tissue that allows the fluid to flow through a system of drainage tubes known as Schlemm’s canal.

The fluid then flows out of the eye. Together with the cornea and iris, these three structures make up what is known as the angle of the eye (see diagram).

Aqueous is constantly produced by the ciliary process which is located behind the iris on either side of the lens. Because production is constant, drainage needs to be consistent.

Intraocular pressure fluctuates considerably and continually, and it is typically highest in the morning and lowest just before bedtime.

The Structures of the Angle

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Intraocular Pressure Testing - Tonometry

Tonometry is the procedure used to test the eye pressure and is an integral part of any eye exam. A tonometer is the device used to perform tonometry. The tonometry reading is taken by measuring how much pressure it takes to flatten the central portion of the cornea, and it is written in millimeters of mercury (mmhg).

A Goldman Tonometer

There are various ways to check the pressure in the eye, but the Goldman Tonometer is the most common and the most accurate.
There are various ways to check the pressure in the eye, but the Goldman Tonometer is the most common and the most accurate. | Source

Mires Seen During Tonometry

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Normal Eye Pressure Range

The normal range of pressure in the eye is anywhere from 10mmhg to 21mmhg. Some doctors will say 10mmhg to 20mmhg, but that is dependent on the individual doctor.

Anything below 10mmhg is considered to be too low, and the eye typically feels very soft. This can cause retinal detachments or lens dislocation among other things.

High pressures are typically anything over 20mmhg, but pressures over 26mmhg are dangerous. They can damage the optic nerve, causing loss of peripheral vision. This condition is known as glaucoma, and there are three main types:

  • Open Angle Glaucoma
  • Low - tension Glaucoma
  • Narrow Angle Glaucoma

Open Angle Glaucoma

By far the most common type of glaucoma, primary open angle accounts for 90 percent of all glaucoma cases, and it can have a number of different causes including:

  • Genetics
  • Ethnicity
  • Gender

Open angle glaucoma can also be the result of other diseases such as diabetic retinopathy, or the use of certain medications, such as steroids. It can even develop after a surgical procedure such as cataract surgery or LASIK. When glaucoma develops as the result of a disease or treatment it is known as secondary glaucoma.

Low – Tension Glaucoma

This type, also called normal – tension glaucoma, is difficult to diagnose. The pressure remains within the normal range, but the optic nerve still sustains damage and loss of peripheral vision still occurs.

In order to make the diagnosis, the patient will need to complete a visual field test to check for peripheral (side) vision loss. The ophthalmologist may also recommend an OCT or HRT of the optic nerve to determine the extent of the damage.

Narrow Angle Glaucoma

This type of glaucoma is the result of an anatomical defect of the eye. The angle is the area where the cornea and iris meet (refer to diagram above). It is also the location of the trabecular meshwork, the drainage pipes we talked about earlier.

Narrow angle glaucoma is exactly what its name says it is. The angle is very narrow which makes it difficult for aqueous to drain properly. Most of the time this isn’t really a problem and patients may go through their entire lives without even knowing they have a problem. This is because there are varying degrees of angle narrowing.

Dilated Pupil of Narrow Angle Glaucoma

Narrow angle glaucoma in the right eye. Look closely, the right pupil is slightly larger than the left which is typical of an angle closure attack.
Narrow angle glaucoma in the right eye. Look closely, the right pupil is slightly larger than the left which is typical of an angle closure attack. | Source

Sometimes, however, the patient is unfortunate enough to suffer what is called a narrow angle closure. These “attacks” are extremely painful. When the angle is closed the aqueous can’t get from the posterior chamber where it is produced to the anterior chamber where it can drain. This causes the aqueous to build up in the eye, causing the pressure to rise rapidly. The pressure can reach 70 to 85mmhg very quickly, and this can cause a number of different symptoms including:

  • Rainbows around lights
  • Nausea and/or vomiting
  • Photophobia (light sensitivity)
  • Excruciating pain (which can be a sharp pain, or a feeling of extreme pressure that many patients say feels like their eye is going to explode)
  • Extremely red sclera (the white part of the eye becomes very bloodshot)
  • Blurred or hazy vision (caused by the swelling of the cornea)
  • Pupil dilation (which is typically the cause of the narrow angle attack)

Medication Used in the Treatment of Narrow Angle Glaucoma

Isopto Carpine (most commonly called Pilocarpine) constricts the pupil. In urgent cases it is used prior to performing an LPI, and in less urgent cases it is used to to bring the pressure down.
Isopto Carpine (most commonly called Pilocarpine) constricts the pupil. In urgent cases it is used prior to performing an LPI, and in less urgent cases it is used to to bring the pressure down. | Source

Narrow angle attacks typically occur when the pupil is dilated such as in a dark movie theater. The iris actually gets trapped in the angle and blocks the aqueous from reaching the anterior chamber and the trabecular meshwork. This is one of the main reasons technicians always check the angle prior to dilating a patient.

With artificial dilation, the pupil opens wider than it normally would in say a dark room. This increases the likelihood that the iris will get stuck in the angle. It is very important for the technician to check your angles before dilating you, especially if you are hyperopic (farsighted).

Treatment for Increased Intraocular Pressure

There are only two treatments for narrow angle glaucoma:

  • Peripheral iridotomy
  • Peripheral iridectomy

Both procedures involve creating a hole in the iris to allow the aqueous to flow from the posterior chamber to the anterior chamber.

A peripheral iridotomy can be performed two ways, either with a laser (the most common way), or surgically. A laser peripheral iridotomy, or LPI, is performed with a Nd:YAG (neodymium – doped yttrium, aluminum and garnet) or argon laser and is typically an outpatient procedure. It is also the most common method for treating narrow angle glaucoma.

The peripheral iridectomy involves removing a portion of the iris to allow the aqueous to flow properly. It is a surgical procedure that is usually performed in a surgery center or hospital. Although not as common as an LPI, a peripheral iridectomy is used when an LPI fails.

A Drop Used to Treat Open Angle Glaucoma

Alphagan P is one of the main medications used to treat open angle glaucoma.
Alphagan P is one of the main medications used to treat open angle glaucoma. | Source

Open angle and low – tension glaucoma have several different treatments available including:

  • A variety of medications, both eye drops and oral pills
  • Laser surgery procedures (such as selective or argon laser trabeculoplasty)
  • Conventional surgical procedures (such as trabeculectomy)
  • Drainage implants

There are a number of different eye drops used to treat glaucoma. These include beta-blockers, carbonic anhydrase inhibitors, and prostaglandin analogs among others. There are also oral medications that can be used to treat glaucoma, which are typically diuretics the most common of which is Diamox.

Laser procedures such as argon or selective laser trabeculoplasty are used to stimulate the trabecular meshwork to allow more aqueous to exit the eye. Argon laser trabeculoplasty has been used for a long time to treat glaucoma; however, selective laser trabeculoplasty was only recently approved for treatment of glaucoma. Peripheral iridotomy can also be used to treat open angle glaucoma, especially if it is the result of pigment dispersion syndrome. However, this is fairly uncommon.

Surgical procedures, such as trabeculectomy, are typically used as a last resort because they are so invasive. Trabeculectomy involves removing a portion of the trabecular meshwork and leaving a “bleb” or permanent opening in the sclera through which the aqueous exits the eye. Trabeculectomy carries with it a high risk of infection and this risk remains as long as the bleb is open.

Long – Term Care for Glaucoma Patients

Patients with glaucoma require long – term care because their intraocular pressure must be monitored frequently. Most patients are seen every six months. Patients who have glaucoma that is uncontrolled are typically seen every three months or even every month in some cases.

Patients need to be monitored frequently because of the possibility of developing a tolerance to glaucoma medications, or for further laser treatment. Patients who have had a trabeculectomy must be watched to make sure the pressure doesn’t drop too low and to ensure the bleb does not become infected.

If you or someone you know has glaucoma, it is imperative that you keep your doctors appointments and take your medications as directed.

© Copyright 2012 - 2016 by Melissa "Daughter of Maat" Flagg ALL RIGHTS RESERVED

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    • billybuc profile image

      Bill Holland 4 years ago from Olympia, WA

      Very interesting my friend. So far I don't have this to deal with.

      I hope you had a very Merry Christmas!

    • phoenix2327 profile image

      Zulma Burgos-Dudgeon 4 years ago from United Kingdom

      You recent articles has given me a new appreciation of the eye. I'm making it my New Year's resolution to get a thorough eye exam.

      Hope you had a good Christmas.

    • ChitrangadaSharan profile image

      Chitrangada Sharan 4 years ago from New Delhi, India

      A very useful article on glaucoma. Since you are a specialist in the field, I am really enlightened to go through all the information.

      Thanks for sharing this useful information with everyone.

    • Pamela99 profile image

      Pamela Oglesby 4 years ago from United States

      This is a very thorough and informative article on glaucoma and exactly how it affects the eyes. Voted up and interesting.

    • Daughter Of Maat profile image
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      Melissa Flagg 4 years ago from Rural Central Florida

      @Billybuc thank you! and yes, I did have a wonderful holiday! I trust you did as well? :D

    • Daughter Of Maat profile image
      Author

      Melissa Flagg 4 years ago from Rural Central Florida

      @phoenix The eye is so fascinating to me, it's just so intricate. Hopefully, my hubs have given you enough info to know if you're getting a thorough eye exam! I really need to get my eyes checked as well. When I was in the field, I took it for granted, I could check my vision anytime I wanted to, but now it feels odd to let someone else do it. lol

      I did have a wonderful holiday, I hope you did too!

    • Daughter Of Maat profile image
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      Melissa Flagg 4 years ago from Rural Central Florida

      @ChitrangadaSharan Thank you! Glaucoma is such an intricate condition, and can be so confusing, I wrote this in hopes of helping everyone understand in layman's terms exactly what it means. Looks like I have accomplished that, thank so much for your feedback!

    • Daughter Of Maat profile image
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      Melissa Flagg 4 years ago from Rural Central Florida

      @Pamela99 Thank you! I hope you has a wonderful holiday!

    • Lesleysherwood 4 years ago

      Wow, excellent hub. That's why I love this site, I end up reading things that I wouldn't normally think of reading and am wonderfully educated. I don't think some diabetes sufferers realize how serious Glaucoma can be. Voted Up and shared.

    • Daughter Of Maat profile image
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      Melissa Flagg 4 years ago from Rural Central Florida

      @Lesleysherwood Thank you! That's one of the main reasons I love Hubpages as well, I'm always learning new things. And you're right, most diabetics don't know that they are actually at risk for glaucoma, let alone how serious it can be.

    • Dharm 16 months ago

      By profession i m an Architect, my friend has got Wet AMD, so for him i was studying abt AMD your Hub has given me a lot of information which a layman can understand easily, and because of your such easy information i am able to talk with my ophthalmologists and also understand the problem easily.

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