Review

Applications of the water drinking test in glaucoma

management

Remo Susanna Jr MD,*1 Colin Clement PhD FRANZCO,2,3,4 Ivan Goldberg AM

FRANZCO2,3,4 and Marcelo Hatanaka MD*1

(1) University of So Paulo School of Medicine, Brazil

(2) Discipline of Ophthalmology, University of Sydney, Sydney Australia
(3) Glaucoma Unit, Sydney Eye Hospital, Sydney, Australia
(4) Eye Associates, Sydney, Australia

*Correspondence: Remo Susanna Jr., Av. So Gualter, 99, So Paulo, SP, 05455-
000, Brazil
Email: rsusanna@terra.com.br
Marcelo Hatanaka
Email: marcelohatanaka@gmail.com

Short running title: Water drinking test and glaucoma

Received 19 September 2016; accepted 2 February 2017
Conflict of interest: None
Funding sources: None

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/ceo.12925

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ABSTRACT

Intraocular pressure (IOP) peaks and means have been considered important
factors for glaucoma onset and progression. However, peak IOP detection depends
only on appropriated IOP checks at office visits, whereas the mean IOP requires
longitudinal IOP data collection and may be affected by the interval between visits.
Also, IOP peak assessment is necessary to verify if the peak pressure of a given
patient is in target range, to evaluate glaucoma suspect risk, the efficacy of
hypotensive drugs and to detect early loss of IOP control.
The Water-drinking test (WDT) has gained significant attention in recent
years as an important tool to evaluate IOP peaks and instability.
The main objective of this review was to present new findings and to discuss
the applicability of the WDT in glaucoma management.

Keywords: Intraocular pressure, aqueous humor dynamics, glaucoma, stress

testing

INTRODUCTION

Elevated intra-ocular pressure (IOP) and mean IOP are considered the main
risk factors for the development and progression of glaucoma1-3. As a result,
reduction of IOP to an individualized target is our main treatment strategy. The
pressure at which glaucoma occurred, the target IOP and response to treatment are
most often determined by a series of single measurements over time during office
hours. However, some patients still progress with IOP apparently in the target
range. This observation has been explained on the basis that other non-IOP
dependent risk factors are contributing to the glaucoma pathogenesis in these
individuals4. An alternative explanation is that progression occurs due to high IOP
peaks not detected during routine eye examinations. Although IOP fluctuation5-7 is a
suggested risk factor for glaucoma progression, recent studies have demonstrated
that peak IOP may be a better predictor of glaucoma progression and more practical
for management guidance8-10.

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 Twenty-four hour IOP monitoring is likely to provide the purest understanding
of an individual's IOP control including mean IOP, IOP fluctuation and peak IOP11,12.
An inexpensive, non-invasive, time efficient and accurate means of measuring 24-
hour IOP is yet to become available. Current methods are time and resource-
intensive and are not always feasible in routine practice. It is because of these
limitations that the water drinking test (WDT) is so useful in glaucoma assessment
and management.
The WDT was originally conceived as a diagnostic test for glaucoma, but was
ultimately abandoned for this purpose because of low sensitivity, low specificity and
low diagnostic value13,14. Recently, this test was revived with a new focus: as a
surrogate marker for outflow facility reserve to detect IOP instability and to estimate
IOP peak pressure. Peak IOP elicited by this test may be an indicator for the
likelihood of progression15,16 and efficacy of hypotensive drugs17-21. Its potential was
highlighted in the findings of the collaborative glaucoma study22 in which 5886 eyes
without glaucoma were followed for up to 13 years. Among the risk factors identify
for new onset glaucoma, a WDT response exceeding 5mmHg was associated with a
6-fold increased risk compared with those with a WDT response less than 1mmHg.
This new concept led to a growing interest in the test. The WDT has been the
subject of multiple editorials in peer-reviewed journals since 200823-27. In an editorial
about publication and citation in ophthalmology, the authors stated that the WDT
had experienced a major and recent revival based on the fact that the 32 articles
that included this test have been cited on average 10.26 times, which is a mean
citation count above the normal and expected mean23.

HOW TO PERFORM A WDT

Eligible patients (i.e., those who are not on fluid restriction because of
systemic conditions) liquid-fast for 2-hours before the WDT. The patients baseline
IOP is then measured following which the patient drinks a given volume of water in
5 min. The volume used has not been standardized. Some authors routinely use a
fixed volume of water whereas others use a volume adjusted to body weight.

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 A direct comparison between the ingestion of 1000 mL (33.8 ounces) or 500
mL (16.9 ounces) of water demonstrated that the latter failed to estimate the peak
diurnal pressure28. It has been suggested that the WDT may be performed with 800
mL (27.0 ounces) of water (R. Susanna Jr., personal communication), leading to
similar results. Further, Stamper et al. (Yuttiham K, Estermann S, Chen J, Yang
T, Lin S, Stamper RL. The relationship between progression of glaucoma and supine
and water drinking tests. World Glaucoma Congress. Boston (MA);2009. Poster 282.)
showed that the peak of the WDT elicited when using 800 mL of water was
significantly associated with the progression of open-angle glaucoma. A dose of 10
mL of water/kg of body weight has also been used29,30. This is an attempt to correct
for the effect of body mass and shift of fluid between intra-vascular, intracellular and
interstitial spaces. It is based on the presumption that a fixed volume, for example
1000mls, is likely to have a different physiological effect in a 100kg patient
compared with a 50kg patient. Although based on sound principles, this has not
been validated, although it is known to induce a significant IOP response that
correlates with diurnal IOP peak as well as the ingestion of 800 ml, but not 500 ml.
Current preference is based in part on personal experience, but also on
scientific principles. Most recent studies use 800 ml or 10 ml/kg of body weight.
Also, 2 h fasting time before the test is advised, in order to avoid any possible
influence of previous liquid ingestion over the results. It is not yet clear whether the
use of 1000ml, 800ml or 10ml/kg body weight improves the correlation or predictive
value of the WDT.
Once the water has been imbibed, the IOP is measured three to four
additional times at 15-min intervals31. The baseline IOP is the IOP value measured
immediately before water ingestion. The maximum value of the subsequent
measurements is selected as the peak IOP during the WDT. The elevation in IOP
may recover quickly or be sustained for the majority of the test.

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MECHANISM OF ACTION

The mechanism of the IOP increase after a water overload remains unclear.
Early work32 focused on outflow resistance and suggested outflow facility does
reduce but the amount of reduction is small and in isolation may not explain the
associated rise in IOP. A study published in 197233 showed intramuscular atropine
suppressed the WDT response suggesting a potential centrally mediated mechanism.
Aqueous fluorophotometry and estimation of the episcleral venous pressure
(EVP) using manometry following a 1000ml WDT has been measured in young
healthy volunteers34. Estimated EVP more than doubled within 10 minutes of the
water load and was maintained at this level for 90 minutes at which time
measurement was stopped. At the same time, increased fluorescein concentration
was detected in aqueous at 10 minutes; this returned to baseline 60 minutes after
the water load. The explanation for increased fluorescein concentration is uncertain
but it may represent negative flow or reflux of fluorescein from Schlemms canal.
These findings suggest a role for increased EVP in the WDT response and underlie
the rationale for performing the test over 60 minutes as indicated above.
More recent work has focused on the role of choroidal expansion35-37. One
study35 reported an average 20% increase in choroidal thickness during the WDT in
eyes with open angles; this finding was postulated to contribute to the IOP
response. However, such a change in choroidal thickness has not been observed
consistently and may occur more readily in eyes with angle closure36.

INTERPRETING RESULTS

Having performed a WDT with 1 hour or 45 minutes follow-up, 5 or 4 IOP

readings (a baseline and 4 or 3 follow-up) will be available for comparison. From
this, several variables can be evaluated: the peak IOP, the IOP elevation (Peak IOP -
baseline IOP), the time to peak IOP and time to recovery to baseline IOP.
Several studies have shown that peak IOP obtained with this test is strongly
correlated and in agreement with the IOP peaks that occur during the day29,38,39.
Usually but not always, eyes with higher IOP peaks after water ingestion take longer

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to return to baseline IOP levels than eyes with lower IOP peaks, which may reflect
the status of the drainage system of the eye.
The factors influencing time to peak IOP following the WDT are less certain.
This is because findings so far are inconsistent. For example, Mansouri et al.37
reported that highest mean peak IOP from 58 eight healthy eyes occurred at 15
minutes. Distribution of peak IOP over time in this cohort was 46% at 15 minutes,
32% at 30 minutes, in 14% at 45 minutes and 8% at 120 minutes. Similarly, Ulas et
al.40 have shown in healthy eyes that IOP elevation after WDT occurs within the first
10 minutes and recovers quickly. This is somewhat different from results with
glaucomatous eyes. Tran et al41 reported mean peak IOP was highest at 45 minutes
after water ingestion, whereas Hatanaka et al.42 found that, on average, mean peak
IOP was highest at 30 minutes, in a cohort of 88 eyes with ocular hypertension or
primary open angle glaucoma (POAG).
It has been postulated that a more rapid return to baseline IOP following the
WDT may reflect improved outflow facility26. Independent of the mechanism that
increases IOP following the WDT, an intact and active outflow facility should be
associated with rapid IOP recovery whereas impaired outflow facility is more likely to
lead to sustained IOP elevations. The WDT response is more marked in angle
closure eyes compared with open angle eyes36.

CLINICAL & RESEARCH APPLICATIONS

The WDT has applications for understanding how IOP-lowering treatments
work and why glaucoma progresses. It is an aid to understand our patients' IOP and
the way treatments control (or don't control) it.
Treatment
The WDT has been used to compare the effects of different clinical and
surgical treatment modalities in glaucoma. Medically controlled patients with
glaucoma have a greater IOP increase with the WDT than patients who have
undergone filtration surgeries despite similar baseline IOP30,31. The reason for this is
not clear but may relate to the way a functioning trabeculectomy diverts aqueous
away from conventional outflow pathways. The observation that trabeculectomy
blunts the WDT response, and therefore IOP fluctuation and peak, may explain why

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filtering surgeries decrease or halt glaucoma progression compared with medical
treatment31,43,44.
The WDT has also been used to evaluate different hypotensive medications
for glaucoma. In a comparison between latanoprost and the fixed combination of
dorzolamide and timolol, patients who received latanoprost showed significantly
smaller elevations in their IOP levels following the WDT17. These authors
demonstrated that prostaglandin analogues that act on the outflow system of the
eye are associated with better IOP stabilization during the WDT than drugs that
decrease aqueous humor production, such as -blockers and carbonic anhydrase
inhibitors. Some drugs may demonstrate similar IOP reduction in steady state
situations, but dissimilar effects on blunting IOP spikes that may occur during the
day. For this reason they may have an additional benefit on glaucoma
treatment17,18,45.
Although timolol 0.5% showed similar IOP reduction to brimonidine 2.0%,
IOP was more stable on brimonidine than with timolol. Eyes treated with timolol had
an earlier IOP spike, higher mean IOP peak (3.5 mmHg) and return to baseline took
longer in the WDT. This may be an alternative explanation for the results of
LoGTS46, in which, despite its limitations, especially regarding the highest dropout
rate in the brimonidine group, similar IOP (single measurements) were obtained in
both groups, whereas the rate of visual field progression was higher in the timolol
group. Other studies compare the efficacy of IOP reduction between drugs or the
benefit of adding drugs to a pre-existing therapeutic regimen and the mechanisms of
action of hypotensive medications19-21,47.
48
To this we can now add the findings of Waisbourd et al. which suggest a
role for the WDT in assessing response to peripheral laser iridotomy. Although no
significant change in peak WDT IOP was reported before and after treatment of
primary angle closure suspect eyes, a more rapid recovery in the WDT IOP curve
was seen post-treatment. The authors postulate that this more rapid recovery is due
to enhanced outflow facility that accompanies reduced iris - trabecular apposition.
Malerbi et al.49, within a group of 65 patients with moderate open angle
glaucoma, based on visual field criteria, and IOP15 mmHg at single office readings,

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found that 21.5% had IOP levels of >20 mmHg during the WDT, considered too
high for a target IOP of 15mmHg.
Eyes with worse visual field mean deviation (MD) values had higher IOP
peaks after water ingestion compared with their contralateral eyes that had better
visual fields despite similar mean baseline IOPs16. This suggests worse IOP control in
the eye with lower MD. This study also highlighted that despite similar baseline IOP,
eyes with similar visit-measured single IOP may have different peak IOP. This has
been confirmed by other authors and has immediate clinical relevance27,31,50. IOP
peak is an important factor for progression and usually not detected in routine
clinical examination, which may explain at least in part why patients progress with
"low IOP measurements.
Previous studies have also found a correlation between the WDT response
and progressive damage. In a prospective study of 5,886 patients with open-angle
glaucoma, Armaly et al.22 identified 5 of 26 potential risk factors that were
significantly related to the development of visual field defects: outflow facility, age,
IOP, cup-to-disc ratio, and the change in IOP after water ingestion. Compared to
single IOP measurements however, the response to WDT showed a weaker
correlation. Of relevance, the authors assessed IOP change after water ingestion,
and not IOP peaks. IOP fluctuation lacks reproducibility, and its role, as a predictor
for progression has been debatable.
Despite presenting poor collective predictive power for visual field
progression, IOP, cup-to-disc ratio and age remain important parameters in clinical
practice. Hence the importance to better evaluate the role of WDT as a tool in
glaucoma management. In a sample of normotensive glaucomatous patients
evaluated by Yoshikawa et al.51, the WDT was the main predictive test for glaucoma
progression. Even an increase of 1 mmHg in the IOP is associated with a 10%
increase in the relative risk for glaucoma conversion1 and visual field progression3,52.
To be considered clinically applicable, a test must present reproducible
results. Reproducibility has already been evaluated in different populations and
intervals between tests, both in terms of correlation, as well as concordance. While
correlation describes how strongly the measurements in each group resemble each

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other, concordance evaluates the agreement between the evaluated parameters
(peaks and fluctuation).
IOP peaks detected by the WDT, performed 24 h apart in untreated patients
with ocular hypertension, showed excellent reproducibility (intraclass correlation
coefficient)42. The same was observed by the same research group53, in a cohort of
treated POAG patients and mean interval of 4.85 (range 3-6) months between tests.
In both studies, however, fluctuation showed only fair reproducibility. Babic et al.53
hypothesize that, while similar IOP peaks lead to a ceiling effect, fluctuation,
defined as maximum-minimum IOP, will depend on baseline IOP measurements,
which, in turn, may present small differences due to variability between tests, thus
leading to different starting baseline points and lower reproducibility parameters.
The authors also stated that in clinical practice, the importance of detecting better
repeatability of IOP peaks than fluctuation results from recent studies that found IOP
peaks as the most important IOP parameter associated with glaucoma progression8-
10
.
In both studies, reproducibility was also evaluated, based on levels of
42
agreement. Hatanaka et al. found that almost 80% of peak IOP measurements
presented differences within 3 mmHg, (95% within +5.7 mmHg), whereas Babic et
al.53 found almost 80% of IOP peak with differences within 2 mmHg (95% within -
4.24 and +3.3 mmHg) between tests.
Medina et al.54 evaluated the reproducibility of WDT performed at different
times of the day in POAG and normal individuals. The authors, based on levels of
agreement, state a poor reproducibility of IOP peaks detected by the test, since 20%
of glaucoma patients presented differences higher or equal to 3 mmHg among IOP
peaks at different tests. However, if this is the case, then 80% of their sample was,
indeed, within 3 mmHg of agreement, a proportion of reproducibility close to the
findings of Hatanaka et al.42 and Babic et al.53 Reproducibility of the WDT was also
demonstrated in patients with exfoliation syndrome and exfoliative glaucoma55.
It may be that patients peak IOP is a constant and crucial clinical parameter,
which is independent of initial IOP and underscores a patients likelihood for future
progression27.

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 Other methods to evaluate IOP profile have been described. Self-monitoring
of IOP with portable home tonometers56-58 may reveal IOP peaks not detected
during daytime tension curves58. However, validation of these devices for this
purpose is still needed. Costs and labor to perform 24-hour daily tension curves on
all patients are prohibitive. A shorter daytime tension curve and single IOP
measurements in several days are more practical, but may miss IOP peaks in 70% of
cases59,60. Continuous 24 hour IOP monitoring may also be obtained with the
Triggerfish contact lens sensor (CLS) (Sensimed AG, Lausanne, Switzerland). The
device measures the IOP indirectly, by capturing circumferential changes at the
corneoscleral area. When comparing the CLS with a diurnal tension curve performed
with a pneumatonometer, similar IOP peak timing was demonstrated by both
methods, whereas no correlation was found in terms of 24 hour IOP variation61.
The Eyemate (Implandata Ophthalmic Products GmbH; Hanover, Germany) can only
be used in patients submitted to cataract surgery. The accuracy of the IOP
measurements is still not established, as well as its clinical significance. Cost and
risks make the device not practical and difficult to be used in all patients.

CONCLUSION

There has been an increased value attributed to the occurrence of IOP peaks
as risk factors for glaucoma onset and progression9,10, and more interest has
developed to establish a target IOP peak or target IOP peak range pressure instead
of a single target IOP level. Future studies of methods to better evaluate the IOP
profile over a 24-h period are warranted. While special devices for continuous IOP
monitoring are being analyzed, their practical use on a daily basis and in high-
volume outpatient settings over a short-term period remains uncertain. The
measurements given by the Triggerfish lens device (Sensimed, Lausanne,
Switzerland) have not corresponded to the IOP measured in mmHg and also can be
influenced by biomechanics of the cornea such as corneal curvature, central cornea
thickness and hysteresis62. Some side effects such as corneal edema, hyperemia,
and discomfort have also been associated with its use. Meanwhile, the WDT is

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reproducible and shows clinically relevant results validated several times by a series
of peer-reviewed studies; it can be an important tool for IOP profile assessment in
glaucoma management.
The WDT cannot be used for the diagnosis of glaucoma; there are no positive
or negative results as in the past. The WDT may be used as a stress test to evaluate
the ability of the eye to deal with transient IOP elevations and the peak IOP elicited
by this test strongly correlates with IOP peaks that occur during the day. For this
reasons it may be an important tool to evaluate the quality of hypotensive treatment
and to detect early loss of IOP control.
One limitation of this review is the retrospective design of the majority of the
above- mentioned studies. Based on this revision, one could speculate that the
inclusion of this test as part of a routine examination, could improve IOP monitoring
and risk assessment, which, in turn, could lead to better outcomes in glaucoma
management. This concept, however, is indirect and based on all the evidences
discussed in this review. Prospective studies to further enhance this concept are
awaited.

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REFERENCES

1. Gordon MO, Beiser JA, Brandt JD, et al. The Ocular Hypertension Treatment
Study: baseline factors that predict the onset of primary open-angle
glaucoma. Archives of ophthalmology. Jun 2002;120(6):714-720; discussion
829-730.
2. The Advanced Glaucoma Intervention Study (AGIS): 7. The relationship
between control of intraocular pressure and visual field deterioration.The
AGIS Investigators. American journal of ophthalmology. Oct 2000;130(4):429-
440.
3. Leske MC, Heijl A, Hyman L, et al. Predictors of long-term progression in the
early manifest glaucoma trial. Ophthalmology. Nov 2007;114(11):1965-1972.
4. Comparison of glaucomatous progression between untreated patients with
normal-tension glaucoma and patients with therapeutically reduced
intraocular pressures. Collaborative Normal-Tension Glaucoma Study Group.
American journal of ophthalmology. Oct 1998;126(4):487-497.
5. Asrani S, Zeimer R, Wilensky J, Gieser D, Vitale S, Lindenmuth K. Large
diurnal fluctuations in intraocular pressure are an independent risk factor in
patients with glaucoma. Journal of glaucoma. Apr 2000;9(2):134-142.
6. Nouri-Mahdavi K, Hoffman D, Coleman AL, et al. Predictive factors for
glaucomatous visual field progression in the Advanced Glaucoma Intervention
Study. Ophthalmology. Sep 2004;111(9):1627-1635.
7. Caprioli J, Coleman AL. Intraocular pressure fluctuation a risk factor for visual
field progression at low intraocular pressures in the advanced glaucoma
intervention study. Ophthalmology. Jul 2008;115(7):1123-1129 e1123.
8. Konstas AG, Quaranta L, Mikropoulos DG, et al. Peak intraocular pressure and
glaucomatous progression in primary open-angle glaucoma. Journal of ocular
pharmacology and therapeutics : the official journal of the Association for
Ocular Pharmacology and Therapeutics. Feb 2012;28(1):26-32.
9. De Moraes CG, Juthani VJ, Liebmann JM, et al. Risk factors for visual field
progression in treated glaucoma. Archives of ophthalmology. May
2011;129(5):562-568.

This article is protected by copyright. All rights reserved.

10. Gardiner SK, Johnson CA, Demirel S. Factors predicting the rate of functional
progression in early and suspected glaucoma. Investigative ophthalmology &
visual science. Jun 2012;53(7):3598-3604.
11. Drance SM. Diurnal Variation of Intraocular Pressure in Treated Glaucoma.
Significance in Patients with Chronic Simple Glaucoma. Archives of
ophthalmology. Sep 1963;70:302-311.
12. Barkana Y, Anis S, Liebmann J, Tello C, Ritch R. Clinical utility of intraocular
pressure monitoring outside of normal office hours in patients with glaucoma.
Archives of ophthalmology. Jun 2006;124(6):793-797.
13. Rasmussen KE, Jorgensen HA. Diagnostic value of the water-drinking test in
early detection of simple glaucoma. Acta ophthalmologica. Apr 1976;54(2
p):160-166.
14. Roth JA. Inadequate diagnostic value of the water-drinking test. The British
journal of ophthalmology. Jan 1974;58(1):55-61.
15. Susanna R, Jr., Vessani RM, Sakata L, Zacarias LC, Hatanaka M. The relation
between intraocular pressure peak in the water drinking test and visual field
progression in glaucoma. The British journal of ophthalmology. Oct
2005;89(10):1298-1301.
16. Susanna R, Jr., Hatanaka M, Vessani RM, Pinheiro A, Morita C. Correlation of
asymmetric glaucomatous visual field damage and water-drinking test
response. Investigative ophthalmology & visual science. Feb 2006;47(2):641-
644.
17. Susanna R, Jr., Sheu WP, Latin American Glaucoma S. Comparison of
latanoprost with fixed-combination dorzolamide and timolol in adult patients
with elevated intraocular pressure: an eight-week, randomized, open-label,
parallel-group, multicenter study in Latin America. Clinical therapeutics. May
2004;26(5):755-768.
18. Vetrugno M, Sisto D, Trabucco T, Balducci F, Delle Noci N, Sborgia C. Water-
drinking test in patients with primary open-angle glaucoma while treated with
different topical medications. Journal of ocular pharmacology and therapeutics
: the official journal of the Association for Ocular Pharmacology and
Therapeutics. Jun 2005;21(3):250-257.

This article is protected by copyright. All rights reserved.

19. Facio AC, Reis AS, Vidal KS, et al. A comparison of bimatoprost 0.03% versus
the fixed-combination of latanoprost 0.005% and timolol 0.5% in adult
patients with elevated intraocular pressure: an eight-week, randomized,
open-label trial. Journal of ocular pharmacology and therapeutics : the official
journal of the Association for Ocular Pharmacology and Therapeutics. Oct
2009;25(5):447-451.
20. Hatanaka M, Grigera DE, Barbosa WL, Jordao M, Susanna R, Jr. An eight-
week, multicentric, randomized, interventional, open-label, phase 4, parallel
comparison of the efficacy and tolerability of the fixed combination of timolol
maleate 0.5%/brimonidine tartrate 0.2% versus fixed combination of timolol
maleate 0.5%/dorzolamide 2% in patients with elevated intraocular pressure.
Journal of glaucoma. Dec 2008;17(8):674-679.
21. Hatanaka M, Reis A, Sano ME, Susanna R, Jr. Additive intraocular pressure
reduction effect of fixed combination of maleate timolol 0.5%/dorzolamide
2% (Cosopt) on monotherapy with latanoprost (Xalatan) in patients with
elevated intraocular pressure: a prospective, 4-week, open-label, randomized,
controlled clinical trial. Journal of glaucoma. Jun-Jul 2010;19(5):331-335.
22. Armaly MF, Krueger DE, Maunder L, et al. Biostatistical analysis of the
collaborative glaucoma study. I. Summary report of the risk factors for
glaucomatous visual-field defects. Archives of ophthalmology. Dec
1980;98(12):2163-2171.
23. Fan JC, McGhee CN. Publication and citation in ophthalmology: glaucoma and
the water-provocation test--wring out the old and ring in the new? Clinical &
experimental ophthalmology. May 2008;36(4):304-305.
24. Danesh-Meyer HV. The water-drinking test: the elegance of simplicity. Clinical
& experimental ophthalmology. May 2008;36(4):301-303.
25. Goldberg I, Clement CI. The water drinking test. American journal of
ophthalmology. Oct 2010;150(4):447-449.
26. Clement C, Goldberg I. Water drinking test: new applications. Clinical &
experimental ophthalmology. Mar 2016;44(2):87-88.
27. Landers J. Challenging glaucoma with a water-drinking test. Clinical &
experimental ophthalmology. Apr 2015;43(3):200-201.

This article is protected by copyright. All rights reserved.

28. Kerr NM, Danesh-Meyer HV. Understanding the mechanism of the water
drinking test: the role of fluid challenge volume in patients with medically
controlled primary open angle glaucoma. Clinical & experimental
ophthalmology. Jan 2010;38(1):4-9.
29. Kumar RS, de Guzman MH, Ong PY, Goldberg I. Does peak intraocular
pressure measured by water drinking test reflect peak circadian levels? A pilot
study. Clinical & experimental ophthalmology. May 2008;36(4):312-315.
30. Danesh-Meyer HV, Papchenko T, Tan YW, Gamble GD. Medically controlled
glaucoma patients show greater increase in intraocular pressure than
surgically controlled patients with the water drinking test. Ophthalmology. Sep
2008;115(9):1566-1570.
31. Medeiros FA, Pinheiro A, Moura FC, Leal BC, Susanna R, Jr. Intraocular
pressure fluctuations in medical versus surgically treated glaucomatous
patients. Journal of ocular pharmacology and therapeutics : the official journal
of the Association for Ocular Pharmacology and Therapeutics. Dec
2002;18(6):489-498.
32. Kronfeld PC. Water drinking and outflow facility. Investigative ophthalmology.
Jan 1975;14(1):49-52.
33. Spaeth GL, Vacharat N. Provocative tests and chronic simple glaucoma. I.
Effect of atropine on the water-drinking test: intimations of central regulatory
control. II. Fluorescein angiography provocative test: a new approach to
separation of the normal from the pathological. The British journal of
ophthalmology. Mar 1972;56(3):205-216.
34. Diestelhorst M, Krieglstein GK. The effect of the water-drinking test on
aqueous humor dynamics in healthy volunteers. Graefe's archive for clinical
and experimental ophthalmology = Albrecht von Graefes Archiv fur klinische
und experimentelle Ophthalmologie. Mar 1994;232(3):145-147.
35. De Moraes CG, Reis AS, Cavalcante AF, Sano ME, Susanna R, Jr. Choroidal
expansion during the water drinking test. Graefe's archive for clinical and
experimental ophthalmology = Albrecht von Graefes Archiv fur klinische und
experimentelle Ophthalmologie. Mar 2009;247(3):385-389.

This article is protected by copyright. All rights reserved.

36. Arora KS, Jefferys JL, Maul EA, Quigley HA. Choroidal thickness change after
water drinking is greater in angle closure than in open angle eyes.
Investigative ophthalmology & visual science. Sep 2012;53(10):6393-6402.
37. Mansouri K, Medeiros FA, Marchase N, Tatham AJ, Auerbach D, Weinreb RN.
Assessment of choroidal thickness and volume during the water drinking test
by swept-source optical coherence tomography. Ophthalmology. Dec
2013;120(12):2508-2516.
38. Vasconcelos-Moraes CG, Susanna R, Jr. Correlation between the water
drinking test and modified diurnal tension curve in untreated glaucomatous
eyes. Clinics. Aug 2008;63(4):433-436.
39. De Moraes CG, Furlanetto RL, Reis AS, Vegini F, Cavalcanti NF, Susanna R, Jr.
Agreement between stress intraocular pressure and long-term intraocular
pressure measurements in primary open angle glaucoma. Clinical &
experimental ophthalmology. Apr 2009;37(3):270-274.
40. Ulas F, Balbaba M, Celebi S. Effects of a water-loading test on intraocular
pressure and corneal hysteresis in young healthy subjects. Journal of
glaucoma. Feb 2014;23(2):101-104.
41. Tran T, Niyadurupola N, O'Connor J, Ang GS, Crowston J, Nguyen D. Rise of
intraocular pressure in a caffeine test versus the water drinking test in
patients with glaucoma. Clinical & experimental ophthalmology. Jul
2014;42(5):427-432.
42. Hatanaka M, Alencar LM, De Moraes CG, Susanna R, Jr. Reproducibility of
intraocular pressure peak and fluctuation of the water-drinking test. Clinical &
experimental ophthalmology. May-Jun 2013;41(4):355-359.
43. Guedes RA, Guedes VM, Chaoubah A. [Use of water drinking test after non-
penetrating deep sclerectomy]. Journal francais d'ophtalmologie. Dec
2005;28(10):1076-1080.
44. Chen CH, Lu DW, Chang CJ, Chiang CH, Chou PI. The application of water
drinking test on the evaluation of trabeculectomy patency. Journal of ocular
pharmacology and therapeutics : the official journal of the Association for
Ocular Pharmacology and Therapeutics. Feb 2000;16(1):37-42.

This article is protected by copyright. All rights reserved.

45. Brubaker RF. Targeting outflow facility in glaucoma management. Survey of
ophthalmology. Apr 2003;48 Suppl 1:S17-20.
46. Krupin T, Liebmann JM, Greenfield DS, Ritch R, Gardiner S, Low-Pressure
Glaucoma Study G. A randomized trial of brimonidine versus timolol in
preserving visual function: results from the Low-Pressure Glaucoma
Treatment Study. American journal of ophthalmology. Apr 2011;151(4):671-
681.
47. Christiansen GA, Nau CB, McLaren JW, Johnson DH. Mechanism of ocular
hypotensive action of bimatoprost (Lumigan) in patients with ocular
hypertension or glaucoma. Ophthalmology. Sep 2004;111(9):1658-1662.
48. Waisbourd M, Savant SV, Sun Y, Martinez P, Myers JS. Water-drinking test in
primary angle-closure suspect before and after laser peripheral iridotomy.
Clinical & experimental ophthalmology. Mar 2016;44(2):89-94.
49. Malerbi FK, Hatanaka M, Vessani RM, Susanna R, Jr. Intraocular pressure
variability in patients who reached target intraocular pressure. The British
journal of ophthalmology. May 2005;89(5):540-542.
50. Mocan MC, Kasim B, Muz E, et al. Intraocular Pressure Characteristics of
Exfoliative Glaucoma and Exfoliation Syndrome as Determined With the Water
Drinking Test. Journal of glaucoma. Mar 2016;25(3):301-305.
51. Yoshikawa K, Inoue T, Inoue Y. Normal tension glaucoma: the value of
predictive tests. Acta ophthalmologica. Aug 1993;71(4):463-470.
52. Medeiros FA, Alencar LM, Sample PA, Zangwill LM, Susanna R, Jr., Weinreb
RN. The relationship between intraocular pressure reduction and rates of
progressive visual field loss in eyes with optic disc hemorrhage.
Ophthalmology. Nov 2010;117(11):2061-2066.
53. Babic M, De Moraes CG, Hatanaka M, Ju G, Susanna R, Jr. Reproducibility of
the water drinking test in treated glaucomatous patients. Clinical &
experimental ophthalmology. Apr 2015;43(3):228-233.
54. Medina FM, Rodrigues FK, Filho Pde T, Matsuo T, Vasconcellos JP, Costa VP.
Reproducibility of water drinking test performed at different times of the day.
Arquivos brasileiros de oftalmologia. May-Jun 2009;72(3):283-290.

This article is protected by copyright. All rights reserved.

55. Ozyol E, Ozyol P, Karalezli A. Reproducibility of the water-drinking test in
patients with exfoliation syndrome and exfoliative glaucoma. Acta
Ophthalmol. Dec 2016;94(8):e795-e798.
56. Mudie LI, LaBarre S, Varadaraj V, et al. The Icare HOME (TA022) Study:
Performance of an Intraocular Pressure Measuring Device for Self-Tonometry
by Glaucoma Patients. Ophthalmology. Aug 2016;123(8):1675-1684.
57. Noguchi A, Nakakura S, Fujio Y, et al. A Pilot Evaluation Assessing the Ease of
Use and Accuracy of the New Self/Home-Tonometer IcareHOME in Healthy
Young Subjects. Journal of glaucoma. Oct 2016;25(10):835-841.
58. Sood V, Ramanathan US. Self-Monitoring of Intraocular Pressure Outside of
Normal Office Hours Using Rebound Tonometry: Initial Clinical Experience in
Patients With Normal Tension Glaucoma. Journal of glaucoma. Oct
2016;25(10):807-811.
59. Zeimer R. Circadian variations in intraocular pressure. In: Ritch R, Shields MB,
Krupin T, editors. The Glaucomas. St Louis: CV Mosby Co; 1996.
60. Liu JH, Zhang X, Kripke DF, Weinreb RN. Twenty-four-hour intraocular
pressure pattern associated with early glaucomatous changes. Investigative
ophthalmology & visual science. Apr 2003;44(4):1586-1590.
61. Liu JH, Mansouri K, Weinreb RN. Estimation of 24-Hour Intraocular Pressure
Peak Timing and Variation Using a Contact Lens Sensor. PloS one.
2015;10(6):e0129529.
62. Mottet B, Aptel F, Romanet JP, Hubanova R, Pepin JL, Chiquet C. 24-hour
intraocular pressure rhythm in young healthy subjects evaluated with
continuous monitoring using a contact lens sensor. JAMA ophthalmology. Dec
2013;131(12):1507-1516.

This article is protected by copyright. All rights reserved.