Ocular hypertension
At a glance
Elevated IOP without demonstrated glaucomatous damage. Estimate lifetime risk before deciding on treatment.
CAVE
- Exclude angle closure, steroid response and secondary pressure elevation.
- A normal OCT alone does not exclude glaucoma.
Clinical presentation
- Usually an incidental finding.
- Confirm the measurement on a separate occasion when clinically appropriate.
Diagnosis & investigations
- Confirm IOP with Goldmann applanation on separate occasions when safe. Record gonioscopy, pachymetry, stereoscopic disc assessment, OCT and reliable standard automated perimetry. Document steroids, pseudoexfoliation, pigment dispersion and family history.
- The OHTS/EGPS calculator uses age, IOP, central corneal thickness, vertical cup-to-disc ratio and pattern standard deviation. It estimates 5-year conversion within its validated population, not lifetime disability, and is not a substitute for assessing secondary causes.
Differential diagnosis
- Early glaucoma, measurement artefact, thick cornea and secondary glaucoma.
Treatment
- Observe when estimated lifetime risk is low and follow-up is reliable. Favour pressure lowering with a higher risk profile, concerning disc findings, higher repeated IOP or substantial life expectancy; discuss the treatment burden.
- Do not convert pachymetry into a purported “true IOP” by a correction table. Thick cornea does not automatically make a high reading harmless. Document the target and the reason for observation or treatment.
Follow-up
- At reassessment repeat IOP and evaluate the nerve and fields according to baseline reliability and suspected change. New reproducible structural or field damage changes the diagnosis and management to glaucoma. The table distinguishes observation from NICE intervals for treated OHT.
| Finding | Action | Timing / detail |
|---|---|---|
| No damage, low lifetime risk | Observation with a recorded baseline and an agreed reassessment plan | Earlier review if IOP rises, tests are unreliable or the nerve changes |
| NICE pathway: IOP ≥24 mmHg and lifetime risk of visual impairment | Offer 360° SLT when suitable; prostaglandin analogue if SLT is declined, unsuitable or insufficient | 24 mmHg is a UK treatment-pathway threshold, not a universal definition of glaucoma |
| Treated OHT: IOP uncontrolled | Review management and reassess | NICE: 1–4 months; sooner for marked elevation or symptoms |
| Treated OHT: IOP controlled | Uncertain conversion: reassess sooner; no conversion: longer interval | NICE: 6–12 months if uncertain, 18–24 months if no conversion; these intervals are not a rule for untreated patients |
Risk factors & context
- Interpret pressure together with corneal thickness, age, family history and the optic nerve.
- Risk is not determined by a single pressure reading.
Complications
- Conversion to glaucoma.
- Unnecessary treatment also carries adverse effects, cost and a long-term adherence burden.
When to refer
- New disc or field changes warrant reassessment as glaucoma; marked pressure elevation requires prompt evaluation.
References 3
- NICE · Glaucoma: diagnosis and management ↗NG81 · updated 26 January 2022 · 1.2 Diagnosis; 1.4 Treatment; 1.5 Reassessment
- European Glaucoma Society · Terminology and Guidelines for Glaucoma ↗6th edition · 2025 · Clinical examination; classification; treatment principles
- OHTS / EGPS · Risk calculator and limitations ↗Online model · accessed 20 September 2026 · Required measurements; validated ranges; cautions
UK guidance: referral pathways and funding criteria may differ elsewhere.