picture of optic disc with Drance hemorrhage

Glaucoma, a leading cause of irreversible blindness, often conjures images of elevated eye pressure and irreversible optic nerve damage. However, there exists a lesser-known, equally devastating form of the disease – normal tension glaucoma (NTG). This condition presents unique challenges in diagnosis and management, making awareness and understanding crucial for preserving vision. In this blog post, we will delve into the world of normal tension glaucoma, exploring its causes, symptoms, diagnosis, treatment options, and more.

Key Takeaways

  • Normal tension glaucoma (NTG) is a unique type of open-angle glaucoma where intraocular pressure (IOP) remains within the normal range.
  • Risk factors for NTG include age, impaired blood flow to the optic nerve, and conditions like diabetes. Vascular dysregulation, genetic predisposition and structural anomalies in the lamina cribrosa must be considered when diagnosing & treating it.
  • Diagnosis involves tonometry, visual field testing & imaging techniques. Treatment includes medication, laser therapy or surgical interventions with regular eye exams to monitor progression.

Understanding Normal Tension Glaucoma

Normal tension glaucoma (NTG), also known as normal pressure glaucoma, is a unique type of open-angle glaucoma, where intraocular pressure (IOP) remains within the normal range, typically between 10-21 mmHg. Despite the absence of elevated IOP, optic nerve damage and vision loss still occur in patients with NTG. The exact relationship between NTG and primary open-angle glaucoma (POAG) is still a matter of debate, with some experts considering NTG as a distinct disease, while others view it as a variant of POAG.

The pathophysiology of NTG remains incompletely understood, with ongoing research seeking to uncover the mechanisms behind glaucomatous optic neuropathy in the context of normal IOP. The prognosis of NTG varies, with some patients experiencing significant vision loss, while others may maintain stable visual function with appropriate treatment. Proactive management entails identifying individuals at a higher risk of visual field progression, including females, migraine sufferers, and those with optic disc hemorrhages.

Primary Open-Angle Glaucoma vs. Normal Tension Glaucoma

While both primary open-angle glaucoma and normal tension glaucoma involve progressive optic neuropathy, optic disc cupping, and visual field loss, their IOP characteristics set them apart. POAG is associated with elevated IOP, whereas NTG is characterized by normal or low IOP, typically equal to or less than 21 mm Hg. Additionally, NTG may be linked to alterations in ocular and systemic vascular function.

Visual field abnormalities in NTG patients typically manifest closer to central vision compared to those with POAG. Optic nerve changes, such as hemorrhages in the small blood vessels of the optic nerve, are more commonly observed in NTG patients. These distinctions in optic nerve damage and visual field loss can help differentiate NTG from POAG during diagnosis.

The Role of Intraocular Pressure

Intraocular pressure is a significant factor in the development of glaucoma. However, in normal tension glaucoma, other factors like vascular dysregulation and genetic predisposition also contribute to the development of the condition. It has been theorized that NTG results from an increased sensitivity to what would typically be considered a physiologically normal intraocular pressure, thus resulting in damage to the optic nerve.

Various factors independent of IOP have been suggested to contribute to NTG development, including:

  • Systemic and local vascular dysregulation
  • Hematologic abnormalities
  • Impaired cerebrospinal fluid circulation
  • Structural anomalies in the lamina cribrosa

The diagnosis and treatment of normal tension glaucoma largely hinge on the identification and comprehension of these additional factors.

Causes and Risk Factors

The development of normal tension glaucoma can be attributed to several causes, including vascular factors, genetic predisposition, and ocular blood flow abnormalities. Age and impaired blood flow to the optic nerve are prime risk factors for NTG. Other related conditions like diabetes, sleep apnea, Raynaud’s syndrome, migraines and anatomical abnormalities of the structures surrounding the optic nerve can also lead to NTG..

Comprehending the causes and risk factors of NTG aids in the disease’s early detection, diagnosis, and management. The upcoming sections will elaborate on these factors and their contribution to the development of normal tension glaucoma.

Vascular Factors

Vascular factors that have been associated with the development of normal tension glaucoma include:

  • Systemic hypertension
  • Diabetes mellitus
  • Migraine
  • Peripheral vascular disease
  • Angina

These factors can potentially reduce perfusion pressure, disrupt vascular autoregulation, and cause perfusion deficits of the optic nerve head and retina, contributing to the emergence of NTG.

Proper management of these vascular factors through appropriate interventions and treatments may help to slow the progression of normal tension glaucoma.

Genetic Predisposition

Genetic predisposition plays a role in the risk of developing normal tension glaucoma through the presence of certain gene mutations or variants. Research has identified multiple genes, such as CDKN2B-AS and genes on chromosome 8, that may be associated with normal tension glaucoma.

However, the exact mechanisms by which these genetic factors contribute to the development of the condition remain under investigation. A family history of glaucoma is also associated with an elevated risk of normal tension glaucoma.

Ocular Blood Flow

Ocular blood flow abnormalities, which may be associated with low blood pressure, are believed to be linked to the development of normal tension glaucoma (NTG), although the precise mechanisms are yet to be determined. Abnormalities in ocular blood flow may result from systemic vascular dysregulation, leading to perfusion deficits in the optic nerve head and retina.

Grasping the link between ocular blood flow and NTG aids in the formulation of targeted treatment strategies to manage the disease.

Identifying Symptoms and Signs

Normal tension glaucoma is often asymptomatic until advanced stages, making early detection and diagnosis challenging. However, optic nerve changes and visual field abnormalities may be present in NTG patients, providing valuable clues to the presence of the condition.

Comprehending the symptoms and signs associated with NTG is key to prompt diagnosis and intervention. The subsequent sections will provide detailed insights into the asymptomatic nature of NTG, optic nerve changes, and visual field abnormalities.

Asymptomatic Nature

The asymptomatic nature of normal tension glaucoma poses a significant challenge in its early detection and diagnosis. Patients may not experience any signs until the condition has advanced substantially, potentially leading to irreversible vision loss.

The reasons behind the asymptomatic nature of NTG remain unclear, but it could be linked to the gradual optic neuropathy and visual field loss associated with the disease. Regular eye exams and screenings are essential to facilitate early detection and diagnosis of NTG.

Optic Nerve Changes

Normal tension glaucoma is associated with glaucomatous optic nerve changes, including damage to the optic nerve head and progressive thinning of the retinal nerve fiber layer. These changes can result in corresponding visual field deficits.

Optic nerve head rim thinning and hemorrhages are among the optic nerve changes that may be observed in NTG patients. Detecting and monitoring these changes is essential for the diagnosis and management of normal tension glaucoma.

Visual Field Abnormalities

Visual field abnormalities, such as nasal step scotomas and arcuate scotomas, can be present in normal tension glaucoma patients. These visual field defects are typically more pronounced and located closer to the central visual field in NTG than in other forms of glaucoma.

Visual field testing is essential for identifying these abnormalities and monitoring the progression of NTG.

Diagnostic Techniques

Accurate diagnosis of normal tension glaucoma is crucial for the initiation of appropriate treatment and management strategies. A range of diagnostic techniques, including tonometry, visual field testing, and optic disc imaging, can be employed to detect and monitor NTG.

The ensuing sections will offer a more detailed exploration of the specific diagnostic techniques used for normal tension glaucoma, focusing on their methods, accuracy, and role in the diagnostic process.


Tonometry is a common diagnostic method used to measure intraocular pressure (IOP) and differentiate normal tension glaucoma from other types of glaucoma. Measuring IOP is essential for diagnosing and monitoring glaucoma, as it is a significant risk factor for the condition. The test involves using a calibrated instrument to measure the fluid pressure inside the eyes, with eye drops used to numb the eye before the procedure.

Although tonometry is a valuable tool in detecting normal tension glaucoma, it should be used in conjunction with other diagnostic methods for a comprehensive evaluation.

Visual Field Testing

Visual field testing, which includes assessing peripheral vision, is a key diagnostic tool for normal tension glaucoma, as it helps detect glaucomatous field loss by examining discrepancies between the superior and inferior hemi-fields. Automated static perimetry is one such test, used to assess the patient’s ability to detect light stimuli at various locations within the visual field. The results are then evaluated to identify any areas of reduced sensitivity or visual field defects, which may be indicative of glaucoma.

Consistent visual field testing is indispensable for the detection and tracking of normal tension glaucoma’s progression.

Optic Disc Imaging

Optic disc imaging is essential in diagnosing normal tension glaucoma, as it allows for the evaluation of optic disc cupping and other structural alterations in the optic nerve. These modifications can suggest the existence of glaucoma even when there is no elevated intraocular pressure.

Optic disc imaging provides objective evidence of optic nerve damage, helping to validate the diagnosis and guide treatment choices. Techniques such as stereo disc photography and optical coherence tomography (OCT) are used to obtain detailed images of the optic disc, assisting in the early detection and monitoring of normal tension glaucoma.

Treatment Options for Normal Tension Glaucoma

Treatment options for normal tension glaucoma include medication, laser therapy, and surgical interventions, with the primary goal of reducing intraocular pressure. It is important to note that as normal tension glaucoma patients have normal IOP levels, the focus of the treatment is on further lowering the IOP to reduce the risk of optic nerve damage and vision loss.

The upcoming sections will delve into the different treatment options for normal tension glaucoma, examining their mechanisms, efficacy, and possible side effects.


Medications, such as prostaglandin analogs and calcium channel blockers, can help lower intraocular pressure and stabilize vascular tone in normal tension glaucoma patients. Prostaglandin analogs are often used as a first-line therapy for NTG, while calcium channel blockers aid in stabilizing vascular tone by decreasing vascular resistance, potentially improving blood flow to the optic nerve and impeding the progression of glaucomatous optic neuropathy.

It is important to follow the prescribed medication regimen and consult with a healthcare professional for tailored dosage recommendations.

Laser Therapy

Laser therapy, including laser trabeculoplasty, can be employed to treat normal tension glaucoma by enhancing aqueous humor outflow. Laser trabeculoplasty is a procedure that involves using a laser to target and treat the trabecular meshwork, which is responsible for draining fluid from the eye. The laser energy is used to help improve the drainage of fluid, thus reducing intraocular pressure and managing the progression of glaucoma.

Laser trabeculoplasty has been demonstrated to be an effective treatment option for normal tension glaucoma, with potential risks including temporary inflammation, redness, and discomfort in the treated eye.

Surgical Interventions

Surgical interventions, such as minimally invasive glaucoma surgery (MIGS) and trabeculectomy, can be used to treat normal tension glaucoma when other treatments are insufficient.

MIGS is a surgical procedure that involves the use of microscopic-sized equipment or implants, precision lasers, and tiny incisions in the eye to lower eye pressure. Trabeculectomy, on the other hand, involves the creation of a new drainage path for the aqueous humor to exit the eye and lower intraocular pressure.

Both of these surgical interventions aim to reduce or prevent optic nerve damage caused by elevated eye pressure.

Monitoring and Managing Normal Tension Glaucoma

Monitoring and managing normal tension glaucoma involves regular eye exams, lifestyle modifications, and patient education and support. Early detection, diagnosis, and intervention are crucial for preserving vision and preventing the progression of the disease.

The subsequent sections will elaborate on the significance of regular eye exams, lifestyle modifications, and patient education and support in the management of normal tension glaucoma.

Regular Eye Exams

Regular eye exams, including IOP measurements and optic nerve assessments, are crucial for monitoring normal tension glaucoma progression and adjusting treatment as needed. Eye exams can measure intraocular pressure, which is essential in evaluating the risk of glaucoma, and evaluate the optic nerve and identify any signs of damage or changes that may suggest normal tension glaucoma.

Monitoring the condition through regular eye exams enables prompt intervention and management to avoid vision loss.

Lifestyle Modifications

Lifestyle modifications, such as maintaining a healthy diet and exercising regularly, can help manage normal tension glaucoma, low tension glaucoma, and improve overall eye health.

A balanced diet, comprising of fruits and vegetables, can reduce the risk of developing normal tension glaucoma. Regular exercise has been found to lower intraocular pressure in normal tension glaucoma patients. However, it is important to consult with a healthcare provider or ophthalmologist for specific exercise recommendations tailored to individual conditions.

Patient Education and Support

Patient education and support are essential for understanding normal tension glaucoma, adhering to treatment plans, and coping with the psychological burden of the disease. The psychological impact of having a chronic, vision-threatening condition should not be disregarded, and incorporating psychological support into the care plan for normal tension glaucoma patients can be achieved through:

  • Patient education
  • Counseling and therapy
  • Support groups
  • Collaborative care

Differential Diagnosis and Other Considerations

Differential diagnosis of normal tension glaucoma includes optic neuritis, ocular hypertension, and other glaucoma subtypes. It is important to consider and rule out these conditions during the diagnostic process for normal tension glaucoma, as they may present with similar symptoms and signs but require different treatment strategies.

The upcoming sections will discuss the various conditions that must be accounted for and eliminated during the diagnostic process for normal tension glaucoma.

Optic Neuritis

Optic neuritis, an inflammation of the optic nerve, can present with similar symptoms and signs as normal tension glaucoma. However, optic neuritis is typically associated with pain and reduced visual acuity and may be linked to multiple sclerosis or other autoimmune diseases.

Diagnosis of optic neuritis involves a thorough examination and diagnostic tests such as magnetic resonance imaging (MRI). Treatment for optic neuritis may include intravenous steroid therapy, plasma exchange therapy, and antibiotics in combination with steroids.

Ocular Hypertension

Ocular hypertension, characterized by elevated IOP without optic nerve damage, should be ruled out when diagnosing normal tension glaucoma. Unlike normal tension glaucoma, ocular hypertension does not result in optic nerve damage or visual field loss, but it is a known risk factor for glaucoma.

Diagnosing ocular hypertension typically involves eye pressure examination, gonioscopy, and evaluation of symptoms and visual changes.

Other Glaucoma Subtypes

Other glaucoma subtypes, such as angle-closure glaucoma and secondary glaucoma, should also be considered and ruled out during the diagnostic process for normal tension glaucoma.

Angle-closure glaucoma is a condition in which the drainage canals in the eye become obstructed, resulting in an increase in intraocular pressure. Secondary glaucoma refers to glaucoma that results from another underlying condition or cause.

Proper diagnosis and identification of the specific subtype of glaucoma are vital for determining the most appropriate treatment options.


In conclusion, normal tension glaucoma is a unique and often misunderstood form of glaucoma that occurs without elevated intraocular pressure. Despite its seemingly benign nature, NTG can result in significant vision loss if left undiagnosed and untreated. Understanding the causes, symptoms, diagnostic techniques, and treatment options for normal tension glaucoma is crucial in preserving vision and improving the quality of life for those affected by the disease. Early detection, timely intervention, and ongoing monitoring are key in managing this potentially sight-threatening condition.

Frequently Asked Questions

What can cause normal tension glaucoma?

Normal tension glaucoma can be caused by a variety of factors, such as an optic nerve that is more sensitive and fragile to normal amounts of pressure, family history, Asian descent, abnormalities in blood flow and structural weakness of the optic nerve tissue, fatty deposits in the arteries, and conditions that impair circulation.

What percentage of people with normal tension glaucoma go blind?

Approximately 10% of people with normal tension glaucoma will go blind in 1 eye, and only about 2% in both eyes over a 20-year period.

Is normal tension glaucoma worse than open angle glaucoma?

There is no difference in severity between normal tension glaucoma (NTG) and open angle glaucoma (POAG), as the only difference is the intraocular pressure (IOP).

What is the average age of normal tension glaucoma?

The average age of patients with Normal Tension Glaucoma is generally in the 60s, though it is unusual for those under 50. There is also a greater prevalence among Asian ancestry populations.

Can you have glaucoma with normal pressure?

Glaucoma is a group of eye conditions that damage the optic nerve, even with normal eye pressure. Normal tension glaucoma is one type of primary open angle glaucoma, where there is no elevation of intraocular pressure, and can lead to vision loss if not monitored and treated properly.


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  2. “Normal-Tension Glaucoma: A Comprehensive Review of Pathophysiology and Optimal Management.” Eye and Brain Journal. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5483226/
  3. “Normal Tension Glaucoma: An Overview.” Glaucoma Research Foundation. https://www.glaucoma.org/glaucoma/normal-tension-glaucoma-an-overview.php
  4. “Normal Tension Glaucoma: A Review.” Clinical Ophthalmology Journal. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6049031/
  5. “Normal Tension Glaucoma: A Practical Approach.” Journal of Ophthalmic and Vision Research. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3612932/
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  7. “Normal Tension Glaucoma: Diagnosis and Management.” American Family Physician. https://www.aafp.org/afp/2016/1015/p764.html
  8. “Normal Tension Glaucoma: A Review of Current Understanding and Treatment Options.” Journal of Clinical Medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7464732/


Photo graph of Dr. Conlon operating with loops on.

Dr. M. Ronan Conlon started his career in the field of ophthalmology at the same time as the development of refractive eye surgery in Canada. In 1996, he brought laser technology to Canada from Germany, which allowed him to perform laser eye surgery before it was available in the United States. With the establishment of the Conlon Eye Institute, Dr. Conlon has performed more than 40,000 refractive procedures and has advanced his expertise in LASIK and refractive cataract surgery.

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