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Excerpt:

IntroductionYes – glaucoma can indeed strike one eye while sparing the other, or at least cause one eye to be much worse than its fellow. In fact, it is surprisingly common for glaucoma to present asymmetrically: a large fraction of newly diagnosed patients have one eye with higher pressure, more optic nerve damage, or worse visual field loss than the other. Indeed, even classic forms of glaucoma that are generally bilateral often begin or are detected in one eye first. Clinicians report that roughly one- to two-thirds of patients show significant inter-eye differences in at least one measure at diagnosis. For example, one study found that interocular pressure differences of 3 mmHg or more were highly predictive of glaucoma [64] and other research shows that meaningful visual field or nerve-fiber loss asymmetry can occur in on the order of tens of percent of patients. This asymmetry is clinically important – it both preserves useful vision (since the “good” eye compensates) and masks the disease (because the patient doesn’t notice a problem until very late). In this article we will explore unilateral and asymmetric glaucoma in depth. We begin with why one eye can be affected more than the other, then discuss how the healthy eye hides the loss in the bad eye. We review all known causes of truly one-sided glaucoma (from eye trauma to inflammatory disease to eye structure differences). We explain why one optic nerve might be more vulnerable than the other even under similar eye pressure, and why we sometimes see glaucoma only in one eye in angle-closure disease. We cover how doctors use the two eyes as a pair of internal controls to diagnose and track glaucoma, and what else must be ruled out when damage is very uneven. Finally, we talk about what life is like for a patient with glaucoma in “only one eye,” including the coping, driving, and treatment issues unique to this situation. In each section we will point out relevant studies or clinical observations to back up the discussion () () (). With any luck, you’ll come away with a clear understanding that asymmetric glaucoma is not mild – it’s sneaky, and requires special vigilance in both diagnosis and treatment.How and Why Glaucoma Can Affect One Eye More Than the OtherUnder ideal conditions, glaucoma tends to be a bilateral disease (affecting both eyes) because many risk factors – like blood pressure, genetics, and age – are systemic. However, eyes are not identical twins, and even in the same person there can be meaningful differences between the two eyes. These differences can occur at every level: eye pressure, drainage anatomy, history of injury or disease, and even the susceptibility of the optic nerve. Below we list the main factors that can lead to one eye developing glaucoma (or worse glaucoma) when the other eye is relatively healthy.Inter-eye pressure asymmetry. In most people, the pressures in the right and left eye are similar, but often one eye runs a bit higher. Even a seemingly small difference can matter. Studies show a clear dose–response effect: as the gap in pressure grows, the risk of glaucoma soars. For example, one multicenter study found that when the IOP (intraocular pressure) difference between eyes was 3 mmHg, the chance of having glaucoma rose to about 6%; if one eye was >6 mmHg higher, that risk jumped to ~57% ()

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