Practical Approaches To Glaucoma Suspects In Everyday Practice

Every clinician remembers their first few glaucoma suspects. The borderline IOP that doesn’t quite justify treatment. The optic disc that looks “just a little suspicious.” The OCT that raises more questions than answers. And the patient who feels perfectly fine, until they don’t.

 

Glaucoma suspects live in the grey zone of clinical practice. They test not just our diagnostic skills, but our restraint, consistency, and long-term thinking. Manage them well, and you prevent irreversible blindness. Manage them poorly or inconsistently, and you either overtreat for years or miss disease progression when it truly matters.

 

This blog takes a practical, real-world approach to evaluating and managing glaucoma suspects, the way it actually plays out in everyday clinics, not just in textbooks.

 

Who Exactly Is a Glaucoma Suspect? A Practical Definition

 

In routine practice, a glaucoma suspect is not a diagnosis. It is a risk label.

 

A patient becomes a glaucoma suspect when one or more of the following are present without definitive glaucomatous damage:

• Elevated intraocular pressure (IOP) with normal optic nerve and fields
• Suspicious optic disc appearance
• Borderline or inconsistent visual field defects
• Structural changes on OCT without functional loss
• Strong family history of glaucoma
• Thin central corneal thickness
• Secondary risk factors such as pseudoexfoliation or pigment dispersion

 

The mistake many clinicians make early on is treating glaucoma suspects as a single category. In reality, glaucoma suspects exist on a spectrum of risk, and management must be tailored accordingly.

 

The First Consultation Where Most Errors Begin

 

The first visit sets the trajectory for years of care. Rushed assessments, incomplete baselines, or overreliance on a single test often lead to unnecessary anxiety for both the doctor and the patient.

 

What Must Be Done Properly at Baseline

 

At the initial visit, the goal is not to decide on treatment. The goal is to define risk and establish a reliable baseline.

 

Key elements include:

• Multiple IOP readings, preferably at different times
• Gonioscopy — non-negotiable, yet often skipped
• Careful optic nerve head evaluation, preferably with stereoscopic assessment
• Baseline OCT of RNFL and ganglion cell complex
• Standard automated perimetry, repeated if reliability is poor
• Central corneal thickness measurement

 

One test does not make a diagnosis. Patterns over time do.

 

When High IOP Doesn’t Mean Glaucoma: Avoiding Pressure-Driven Pitfalls

 

Not every eye with high IOP develops glaucoma. And not every glaucomatous eye has high IOP.

 

Practical Points Clinicians Learn Over Time:

• A single elevated IOP reading means little
• Diurnal variation matters more than one-time spikes
• Thin corneas falsely lower measured IOP; thick corneas do the opposite
• Anxiety, squeezing, or poor technique can falsely elevate readings

Patients with ocular hypertension should never be managed by pressure numbers alone. Risk stratification matters more than thresholds.

 

Optic Disc Assessment: Still the Most Valuable Skill You Own

 

Despite advances in imaging, optic disc evaluation remains irreplaceable.

 

Technology can support judgment; it cannot replace it.

 

Red Flags That Truly Matter:

• Progressive increase in cup-to-disc ratio
• Focal neuroretinal rim thinning
• Disc hemorrhages (often underestimated)
• Violation of the ISNT rule
• Asymmetry between eyes greater than expected

OCT: Powerful Tool, Dangerous Crutch

 

OCT has transformed glaucoma care, but it has also created a generation of clinicians who trust colour codes more than clinical context.

 

How to Use OCT Correctly in Glaucoma Suspects:

• Always correlate with disc size and anatomy
• Look at raw thickness maps, not just red-green classifications
• Be cautious in high myopes and tilted discs
• Compare scans over time using the same device

 

A single “red sector” does not equal glaucoma. Progressive structural loss does.

 

Interpreting Visual Field Changes in Glaucoma Suspects

 

Visual field testing is variable, especially in early disease.

 

The most common mistake? Treating unreliable fields as disease progression.

 

Practical Interpretation Tips:

• Discard the first unreliable field
• Repeat suspicious defects before acting
• Look for consistency, not perfection
• Correlate defects with disc and OCT findings

Early glaucoma progresses slowly. Sudden dramatic field loss usually signals poor test reliability, not disease.

Risk Stratification: The Core of Decision-Making

 

Every glaucoma suspect falls into one of three practical categories:

 

1. Low-Risk Suspects

• Mild IOP elevation
• Normal discs and fields
• No strong family history

Management: Observation, yearly follow-up, education.

 

2. Moderate-Risk Suspects

• Multiple borderline findings
• Family history
• Early structural changes without field loss

 

Management: Closer monitoring, consider treatment based on age and life expectancy.

 

3. High-Risk Suspects

• Progressive structural change
• Disc hemorrhages
• Strong genetic predisposition

 

Management: Early treatment is often justified.

 

Communicating With Patients Without Creating Fear

 

How you explain “glaucoma suspect” matters.

 

Avoid language that implies disease when none exists; but never minimise risk.

 

Effective communication includes:

• Explaining risk, not diagnosis
• Emphasising monitoring as proactive care
• Setting realistic expectations
• Encouraging long-term adherence

 

An informed patient is far more likely to return for follow-up than a frightened one.

 

Common Pitfalls Even Experienced Clinicians Encounter

 

• Over-treating based on OCT alone
• Ignoring disc hemorrhages
• Underestimating family history
• Poor documentation of baseline findings
• Inconsistent testing protocols

 

Awareness of these pitfalls is what separates protocol-driven care from thoughtful clinical practice.

 

Why Managing Glaucoma Suspects Is a Skill — Not a Checklist

 

Glaucoma suspect management sits at the intersection of science, judgment, and experience.

 

It demands:

• Pattern recognition
• Longitudinal thinking
• Comfort with uncertainty
• Willingness to observe without acting prematurely

 

With evolving imaging technologies, expanding treatment options, and growing patient expectations, static knowledge is no longer enough. Managing glaucoma suspects well is not about bold interventions. It is about quiet consistency, disciplined observation, and informed restraint. And that, perhaps, is one of the most underappreciated skills in ophthalmic practice.