Journal of Glaucoma 10(Suppl 1):S39–S41
© 2001 Lippincott Williams & Wilkins, Inc.
Diurnal Measurement of Intraocular Pressure
John H. K. Liu, PhD
Department of Ophthalmology, University of California, San Diego, La Jolla, California
Elevated intraocular pressure (IOP) is a major risk
factor for the development of glaucoma and its progres-
sion. Lowering IOP is believed to be beneficial in slow-
ing down glaucomatous changes of the optic nerves and
visual field. Because IOP is a dynamic physiological
parameter, fluctuations of IOP in individuals can be im-
portant for the diagnosis and treatment of glaucoma. A
diurnal IOP curve, which usually includes measurements
taken from morning to evening, gives a better estimate of
an individual’s IOP level than a single measurement dur-
ing the office visit. Many reports have studied the im-
plication of the diurnal IOP curve generated using the
Goldmann tonometer.
It is generally accepted that the diurnal IOP fluctuation
is larger in patients with glaucoma and ocular hyperten-
sion than in healthy individuals. This was confirmed in a
recent chart review1 of multiple diurnal IOP readings
(7:45 AM to 7:00 PM) from more than 600 outpatients
with glaucoma, ocular hypertension, and normal con-
trols. For all three categories, the mean IOP was found to
be high in the morning hours with a steady decline
throughout the diurnal period. A similar high IOP read-
ing in the morning was observed in patients with normal-
tension glaucoma.2
A large diurnal IOP fluctuation also occurred at home
in patients with glaucoma who used the self-tonometer to
monitor their own IOP changes. This innovative device
allows skilled patients to perform the measurements in a
sitting position with their heads down. A recent report3
evaluated the risk associated with diurnal IOP variations
at home in patients with open-angle glaucoma. Sixty-
four patients performed the home tonometry five times a
day for 5 days. Although the mean IOP at home was
close to the office IOP, there was an average IOP fluc-
Address correspondence and reprint requests to Dr. John Liu, Uni-
versity of California, San Diego, Department of Ophthalmology, La
Jolla, CA 92093.
S39
tuation of 10 mm Hg. Data analyses showed that a large
diurnal IOP fluctuation is an independent risk factor for
the progression of glaucoma.
The diurnal IOP curve usually does not cover the noc-
turnal sleep period, roughly one third of our daily life.
The Goldmann tonometry requires the patient be in a
sitting position and would be difficult to perform when
the patient is in a recumbent position. Apart from the
technical problems, is it useful to extend the diurnal mea-
surement of IOP into the sleep period? Can a patient’s
IOP be lowered differentially through day and night by
various medications? Research data from the past few
years may have just given us reasons in searching for the
answers to the above questions.
Under strictly controlled laboratory conditions and us-
ing the pneumatonometer, changes of 24-hour IOP were
monitored in healthy young volunteers and aging
adults.4,5 Observing the habitual body positions, the noc-
turnal supine IOP during the sleep period was signifi-
cantly higher than the sitting IOP during the daytime and
evening. A significant portion of this nocturnal IOP el-
evation was due to the change of body position, from
sitting to supine. A change of body position alters the
hydrostatic relationship between the heart and the eye.
This affects the hemodynamics in the eye, including the
ocular perfusion pressure. In addition, body fluids should
distribute differently in a recumbent position, although
little is known about its implication in the eye.
When considering only the supine IOP levels, the noc-
turnal IOP was higher than the diurnal IOP in healthy
young individuals. Two independent studies have con-
firmed this observation using either the tonopen6 or the
pneumatonometer.7 It was suspected that light exposure
at night might affect the nocturnal IOP level.8 However,
an exposure to moderate illumination in young individu-
als during the sleep period did not affect the nocturnal
IOP elevation.9 Physiological mechanisms causing this
nonpostural IOP elevation at night are unclear, except
that they are unrelated to the change of blood pressure,
S40 J. H. K. LIU
which is known to fall during sleep hours. The nocturnal
fall in blood pressure, combined with higher IOP, may
compromise optic nerve circulation at night.
The 24-hour pattern of supine IOP in patients with
glaucoma appears to be different. The daytime IOP lev-
els in patients with glaucoma were shown to be higher
than the nocturnal IOP levels.6,7 It would be important to
know what mechanism causes this different IOP pattern
in patients with glaucoma. When comparing supine IOP
levels at night in patients with glaucoma and in healthy
individuals, patients with glaucoma still have higher IOP
than healthy individuals. If lowering IOP is the means to
treat glaucoma, both diurnal and nocturnal IOP should be
reduced.
One needs to consider the natural body position in
studying the pattern of IOP during sleep, which should
complement the diurnal IOP curve from the morning to
evening. In real life, a nocturnal IOP elevation most
likely happens, and the IOP fluctuation within the 24-
hour cycle can be even larger because of various physical
activities and their related body positions. Technically,
tonometers that are capable of measuring IOP in various
body positions have an advantage over the Goldmann
tonometer. When performing measurements in various
body positions, different measuring angles should yield
the same IOP level, which has not been verified for all
the tonometers.
The efficacy of an IOP-lowering drug may vary by
time. Time effect of a specific drug would depend upon
the pharmacokinetic properties of the drug and its for-
mulation. There are other factors that can affect the ef-
ficacy of an IOP-lowering drug over the course of the
day and night. A steady state IOP is determined by three
variables: the rate of aqueous humor formation, outflow
facility, and episcleral venous pressure. It is known that
formation of aqueous humor flow varies according to the
circadian cycle.10 Since the aqueous humor flow rate is
only half during the sleep period, a nocturnal IOP eleva-
tion obviously cannot be driven by the aqueous humor
formation. An increase of outflow resistance must be
involved. Studies have found that timolol, a beta-blocker,
is unable to suppress aqueous humor flow during sleep.10
This suggests that timolol may have a limited IOP-
lowering effect at night. One recent study11 evaluated the
circadian IOP pattern, using the noncontact tonometer, in
patients with glaucoma under topical timolol treatment.
Nocturnal IOP was found to be significantly higher than
IOP during the day. In other reports,6,12 timolol was less
effective than latanoprost and dorzolamide in lowering
IOP, in both sitting and supine positions, at certain time
points during the sleep period.
J Glaucoma, Vol. 10, No. 5, (Suppl. 1), 2001
The IOP-lowering effect of latanoprost has been
shown throughout the day and night.13 The mechanism
of latanoprost in lowering IOP is believed to be on the
uveoscleral outflow, which may not vary along the cir-
cadian cycle. There has been no study to investigate the
circadian pattern of outflow facility, which would be
affected by the conventional outflow through the trabec-
ular meshwork and the uveoscleral outflow. Interest-
ingly, a recent study14 showed that episcleral venous
pressure in healthy individuals is higher at night than
during the day and the alteration is related to the change
of body position. An elevation of episcleral venous pres-
sure at night, therefore, may contribute to the nocturnal
IOP elevation. Whether the elevated episcleral venous
pressure can be a new target site for lowering IOP is
unclear.
The pharmacological data call our attention to the im-
portance of evaluating the effectiveness of antiglaucoma
medications in lowering IOP throughout the day and
night. It can be a serious concern that a commonly used
IOP-lowering drug is ineffective during the sleep period.
Another challenging question concerns the 24-hour IOP
level in patients with glaucoma with surgical treatments.
Because there is no issue of pharmacokinetics or phar-
macodynamics associated with glaucoma surgeries, is
the surgical treatment better than the medical treatment
in maintaining a lower IOP throughout the day and
night? A 24-hour IOP monitoring in patients with glau-
coma using the noninvasive laser trabeculoplasty may
provide some critical information.
The diagnosis and treatment of glaucoma should rely
primarily on the information of optic neuropathy and
related visual filed loss. Diurnal measurement of IOP
would add valuable information, especially when a
single office IOP reading seems to be irrelevant to an
individual glaucoma case. Ideally, a continuous minute-
by-minute monitoring of IOP in glaucoma patients
should help to answer many questions discussed above.
An implantable pressure transmitter is available for
monitoring IOP in laboratory animals. However, no such
device is forthcoming for considerations of human clini-
cal trials. Until a perfect human device is ready, the
diagnosis and treatment of glaucoma may include infre-
quent, if not sporadic, measurements of IOP. Information
gathered from the past few years has convinced some of
us that a few measurements of IOP in a glaucoma patient
during the daytime period are insufficient. However,
how much of an expansion of the diurnal measurement
of IOP is needed to assist the best diagnosis and treat-
ment of glaucoma requires continuous research by clini-
cians and scientists.
 DIURNAL MEASUREMENT OF INTRAOCULAR PRESSURE
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J Glaucoma, Vol. 10, No. 5, (Suppl. 1), 2001