Despite clear evidence linking rapid glaucoma progression with vision loss, how clinicians respond to fast deterioration in real-world practice remains poorly understood. A new retrospective study led by researchers from Vanderbilt University and the Johns Hopkins Wilmer Eye Institute sheds light on the complex interplay between clinical severity, socioeconomic status, and treatment escalation in glaucoma management.
Using data from 2,782 eyes of 1,812 patients followed over at least five years, the researchers examined which patients received medical, minimally invasive, or aggressive surgical interventions – and why. Rapid progressors were defined as eyes with a mean deviation (MD) loss worse than –1 dB per year on standard automated perimetry.
While rapid progressors were, as expected, more likely to undergo surgical intervention, the proportion receiving aggressive procedures was surprisingly low. Only 23% of rapidly progressing eyes underwent filtering surgery or external ciliodestruction, and only 42% undertook any non-medical procedures within seven years of diagnosis.
Those with faster visual field loss had greater odds of aggressive treatment (odds ratio [OR] 3.83, p < 0.001) and of receiving any procedure (OR 3.15, p < 0.001). Yet baseline characteristics – such as worse MD, thinner RNFL, and higher intraocular pressure (IOP) – proved to be stronger drivers of surgical decision-making than the rate of decline itself. In other words, structural and IOP parameters often outweighed functional progression when determining whether to escalate treatment.
The study also incorporated the Social Vulnerability Index (SVI) to assess how community-level socioeconomic factors influence care. Notably, patients living in high-SVI (more deprived) areas were five times less likely to receive minimally invasive glaucoma surgery (MIGS), despite similar disease severity. This finding suggests that socioeconomic vulnerability may restrict access to newer, lower-risk interventions – even in patients with objectively rapid disease progression.
The results of the study underscore a key paradox: rapidly progressing glaucoma does not consistently trigger timely treatment escalation. Clinicians may rely heavily on static measures – IOP and OCT-based structure – rather than dynamic measures such as VF slope, which could delay aggressive intervention in those most at risk of blindness.
Fewer than one in four rapidly progressing eyes receive aggressive surgical treatment within seven years, despite clear risk of irreversible vision loss. The message for ophthalmologists is clear: functional progression data should play a more prominent role in guiding glaucoma escalation, and addressing socioeconomic barriers is also essential to ensuring equitable access to sight-preserving therapy.
Using data from 2,782 eyes of 1,812 patients followed over at least five years, the researchers examined which patients received medical, minimally invasive, or aggressive surgical interventions – and why. Rapid progressors were defined as eyes with a mean deviation (MD) loss worse than –1 dB per year on standard automated perimetry.
While rapid progressors were, as expected, more likely to undergo surgical intervention, the proportion receiving aggressive procedures was surprisingly low. Only 23% of rapidly progressing eyes underwent filtering surgery or external ciliodestruction, and only 42% undertook any non-medical procedures within seven years of diagnosis.
Those with faster visual field loss had greater odds of aggressive treatment (odds ratio [OR] 3.83, p < 0.001) and of receiving any procedure (OR 3.15, p < 0.001). Yet baseline characteristics – such as worse MD, thinner RNFL, and higher intraocular pressure (IOP) – proved to be stronger drivers of surgical decision-making than the rate of decline itself. In other words, structural and IOP parameters often outweighed functional progression when determining whether to escalate treatment.
The study also incorporated the Social Vulnerability Index (SVI) to assess how community-level socioeconomic factors influence care. Notably, patients living in high-SVI (more deprived) areas were five times less likely to receive minimally invasive glaucoma surgery (MIGS), despite similar disease severity. This finding suggests that socioeconomic vulnerability may restrict access to newer, lower-risk interventions – even in patients with objectively rapid disease progression.
The results of the study underscore a key paradox: rapidly progressing glaucoma does not consistently trigger timely treatment escalation. Clinicians may rely heavily on static measures – IOP and OCT-based structure – rather than dynamic measures such as VF slope, which could delay aggressive intervention in those most at risk of blindness.
Fewer than one in four rapidly progressing eyes receive aggressive surgical treatment within seven years, despite clear risk of irreversible vision loss. The message for ophthalmologists is clear: functional progression data should play a more prominent role in guiding glaucoma escalation, and addressing socioeconomic barriers is also essential to ensuring equitable access to sight-preserving therapy.
