Glaucoma Treatment Tied to IOP Levels, Research Challenges 22 mm Hg Cutoff
Glaucoma treatment decisions may be influenced by a decades-old clinical benchmark—an intraocular pressure (IOP) of 22 mm Hg—even though current research demonstrates a continuous relationship between IOP and glaucoma risk, meaning that elevated pressure at any level increases risk, not just above that specific threshold. A study published March 10, 2026, in JAMA Ophthalmology highlights this potential disconnect between established practice and evolving scientific understanding.
The research, led by Ashley Polski, MD, of the department of ophthalmology at Moran Eye Center, University of Utah, analyzed data from over 184,000 eyes across seven academic centers within the Sight Outcomes Research Collaborative database. Researchers examined patterns in IOP-lowering treatment initiation—defined as a latest prescription, laser treatment, or surgery—at varying IOP levels. The findings suggest a noticeable uptick in treatment commencement when IOP surpassed 22 mm Hg, indicating that this number continues to serve as a significant clinical trigger point.
The Historical Context of the 22 mm Hg Threshold
The 22 mm Hg benchmark has roots in historical observations linking elevated IOP to glaucoma development. For many years, it served as a convenient and readily applied guideline for clinicians. Yet, as our understanding of glaucoma’s complex pathophysiology has deepened, it’s become clear that the relationship between IOP and disease progression isn’t a simple “above/below” scenario. Instead, risk increases incrementally with rising IOP, even at levels traditionally considered within the normal range. Selective laser trabeculoplasty (SLT), for example, is a treatment option often considered when IOP is elevated, but the study suggests that clinicians may be delaying intervention for patients with pressures below 22 mm Hg, even if those pressures represent an increased risk compared to lower levels.
What the New Data Reveals
The study’s analysis of over 1.8 million clinic visits revealed a gradual increase in the likelihood of treatment as IOP rose from 17 mm Hg to 21 mm Hg. However, the researchers observed a more substantial jump in treatment initiation specifically at 22 mm Hg. This inflection point suggests that clinicians may be consciously or unconsciously adhering to this historical cutoff, potentially leading to delayed treatment for individuals whose IOP, while below 22 mm Hg, still poses a significant glaucoma risk.
“Numerous studies have highlighted a continuous association between IOP and glaucoma risk,” the authors wrote. “There is no clinical basis to support a true IOP cutoff of 22 mm Hg in glaucoma decision-making.”
Implications for Patient Care and Future Research
The findings have important implications for how glaucoma is managed in clinical practice. The study underscores the need for clinicians to move beyond rigid adherence to the 22 mm Hg threshold and instead adopt a more individualized approach to risk assessment. This involves considering a range of factors beyond IOP, including optic nerve appearance, visual field testing, family history, and other relevant clinical data.
The researchers suggest that clinical decision support systems could play a role in reducing reliance on heuristics—mental shortcuts—and promoting more informed treatment decisions. These systems could integrate patient data and provide clinicians with personalized risk assessments and treatment recommendations. Emerging research into the potential protective effects of GLP-1 medications on glaucoma risk further emphasizes the need for a holistic approach to patient care.
Understanding the Study’s Limitations
It’s important to acknowledge the limitations of this study. The analysis relied on retrospective data from electronic health records, which may be subject to biases and inaccuracies. The study did not directly assess patient outcomes, so it’s unclear whether delayed treatment based on the 22 mm Hg threshold had a negative impact on vision. Further research is needed to determine the optimal IOP targets for individual patients and to evaluate the effectiveness of different treatment strategies.
Broader Context: Glaucoma Prevalence and Risk Factors
Glaucoma is a leading cause of irreversible blindness worldwide, affecting an estimated 79.6 million people globally in 2020, according to a comprehensive review published in The Lancet. While elevated IOP is a major risk factor, it’s not the only one. Other factors, such as age, family history, ethnicity, and certain medical conditions, can also increase the risk of developing glaucoma. African Americans, for example, have a higher risk of developing glaucoma and experiencing more rapid disease progression compared to Caucasians.
What’s Next for Glaucoma Management?
The evolving understanding of glaucoma and its risk factors is driving ongoing research and innovation in the field. Current areas of focus include:
- New diagnostic technologies: Researchers are developing more sensitive and accurate methods for detecting early signs of glaucoma, such as optical coherence tomography (OCT) and visual field testing.
- Novel therapeutic approaches: Beyond IOP-lowering medications and surgery, researchers are exploring new therapies that target different pathways involved in glaucoma pathogenesis, including neuroprotection and neuroregeneration.
- Personalized medicine: The goal is to tailor treatment strategies to the individual patient’s risk profile and disease characteristics.
The findings from this study serve as a reminder that clinical practice should be informed by the latest scientific evidence. By moving beyond outdated benchmarks and embracing a more nuanced approach to risk assessment, clinicians can optimize glaucoma management and help preserve vision for their patients. Patients concerned about their glaucoma risk should discuss their individual circumstances with a qualified ophthalmologist.