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S. Schoenholtz, R.E. P. Frenkel, A.R. Toler; Is Low Nocturnal Diastolic Perfusion Pressure a Risk Factor for Glaucoma? . Invest. Ophthalmol. Vis. Sci. 2006;47(13):4783.
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Risk factors for glaucoma are becoming increasingly important clinically as models are developed to calculate risk. Current risk factors include age, IOP, corneal thickness, pattern standard deviation, cup to disc ratio, HRT findings, and family history. Low diastolic perfusion pressure (DPP) (diastolic BP – IOP) measured during the daytime has been associated with an increased risk of glaucoma, which reaches a six–fold excess for patients in the lowest category of perfusion pressure1. However, daytime measurement of blood pressure misses nocturnal dippers. In a study by Graham, et al., nearly all IOP–controlled patients with a nocturnal systolic dip greater than 17% and a nocturnal diastolic dip greater than 22% had progressive field loss2. In addition, patients with NTG and progressing POAG despite controlled IOP have been shown to have higher nocturnal diastolic dips and systolic dips in blood pressure compared to controls3. We investigated whether systolic and diastolic dippers have lower mean nocturnal DPP utilizing ambulatory blood pressure monitoring (ABPM), and whether decreased nocturnal DPP should be considered a glaucoma risk factor.
88 patients with glaucoma or suspicion of glaucoma underwent 24–hour ABPM. Systolic (SD) and diastolic dips (DD), DPP (Mean diastolic BP over 24hr – IOP), and nocturnal DPP (nDPP) (Mean diastolic BP from 12am to 6am – IOP) were calculated. DPP and nDPP were compared in patients with abnormal SD and DD vs. non–dippers.
Patients with abnormal SD and DD had significantly lower nDPP compared to non–dippers. (SD: 52 ± 9 non–dippers vs. 45 ± 8 dippers (p = 0.001); DD: 53 ± 9 non–dippers vs. 44 ± 8 dippers (p = 0.00002). These patients also had lower DPP, but were not clinically significant (SD: 58 ± 9 non–dippers vs. 56 ± 7 dippers; DD: 58 ± 8 non–dippers vs. 55 ± 9 dippers).
Both nocturnal systolic and diastolic dips in blood pressure are associated with decreased nocturnal diastolic perfusion pressures. Though low daytime DPP is an important risk factor for glaucoma, nocturnal measurement of DPP also appears be very important. Daytime and nocturnal DPP should be further studied and incorporated into glaucoma risk factor models. 1 Tielsch, JM., et al. Hypertension, Perfusion Pressure, and Primary Open Angle Glaucoma, Archives of Ophthalmology, 1995; 113:216–21. 2Graham, S.L. et al. Nocturnal Hypotension: Role in Glaucoma Progression, Survey of Ophthalmology, 1999; 43:S10–S16. 3Graham, S.L., et al. Ambulatory Blood Pressure Monitoring in Glaucoma, Ophthalmology, 1995; 102:61–69.
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