AAO’s Updated PPP for POAG Emphasizes Individualized Monitoring

Winners in the new AAO guidance include corneal hysteresis, sustained-release therapy, SLT and minimally invasive surgeries, all of which are given greater prominence in glaucoma management. Notable refinements also affect the use of OCT and perimetry. Click image to enlarge. Last week, the American Academy of Ophthalmology (AAO) released four new Preferred Practice Pattern (PPP) updates—one for adult eye exam protocols and three pertaining to glaucoma. Among those revised is the PPP for primary open-angle glaucoma, which, compared to 2021 guidelines, places greater emphasis on equitable care, adjunct risk metrics like corneal hysteresis, macular and ganglion cell layer imaging and more intensive monitoring to detect fast progression. The AAO also strengthens its position on SLT being a first-line treatment and incorporates newer evidence on sustained drug-delivery and minimally invasive procedures. “With an additional 160 references cited compared to 2021, there was a tremendous amount of additional research assessed, distilled and added to the guidelines,” says Andrew Rixon, OD, of the Memphis VA Medical Center. He adds, “These updates were all warranted and add to our growing understanding of glaucoma, extending beyond just the disease but to the patient having the disease.”Below, we’ll summarize the key changes in the 2026 PPP for POAG. Details on the updates were elicited by using ChatGPT to compare the 2021 and 2026 documents, which were then edited for clarity and clinical significance, and enhanced with feedback from Dr. Rixon. Look to our news feed for similar reports on the other two glaucoma PPPs later this week.Framing and Risk StratificationThe AAO now recognizes race and ethnicity as social—not biologic—constructs, while maintaining its stance that “these characteristics remain an important risk factor for POAG.” A growing body of evidence links racial and ethnic disparities—as well as social determinants of health such as income, housing and education—to differences in outcomes and monitoring frequency. Therefore, the updated guidelines suggest that all future interventions take all these factors into account.“We have to consider the entire person, what circumstances they may come from and how that can impact care,” says Dr. Rixon. “The movement away from racialization in health care is a long-overdue change and an important update, as it shows a broader philosophical change in not only glaucoma, but medicine overall.”Various changes have also been made to POAG risk stratification. In 2021, the AAO outlined the following risk factors for the development of POAG: older age, African race or Latino/Hispanic ethnicity, elevated intraocular pressure (IOP), family history of glaucoma, low ocular perfusion pressure, type 2 diabetes, myopia and thin central cornea. The 2026 revision evolved this list to include lower systolic and diastolic blood pressure, disc hemorrhage, larger cup-to-disc ratio, higher pattern standard deviation on threshold visual field testing and lower corneal hysteresis.Receiving the most emphasis in the 2026 document is corneal hysteresis, which now has its own dedicated section. There, the AAO summarizes evidence linking low hysteresis to faster visual field loss, supporting its adjunctive use in risk and monitoring strategies. Considering this new research, the revised PPP elevates corneal hysteresis from a secondary consideration to a key risk factor and recommends it as an adjunct in progression assessment. Low intracranial pressure is also more prominently discussed among contributing factors compared to 2021. Dr. Rixon comments that the increased emphasis on both metrics in the new PPP “signals the acceptance of the complexity of the biomechanics involved in glaucoma.”Diagnosis, Testing and MonitoringStructural imaging receives stronger and more consistent emphasis in the revised PPP; the AAO now consistently recommends that clinicians perform circumpapillary RNFL and macular ganglion cell layer analysis at baseline and follow-up in POAG patients. The document also reinforces caution around “red disease” and overreliance on normative databases.Other follow-up recommendations for POAG patients have also shifted, now incorporating clustered field testing to identify fast progressors who require closer observation. For quick reference, the AAO created two charts illustrating consensus-based guidelines for POAG monitoring. The first one, revised from the 2021 PPP, outlines general follow-up intervals for POAG patients. A second newly added table provides detailed recommendations for the frequency of visual field and optic nerve evaluation.“Oftentimes, due to insurance, testing on glaucoma patients amounts to a one-size-fits-all checklist,” explains Dr. Rixon. “This consensus chart breaks down the stage of disease, highlights the stability of the disease and subsequently provides more customized recommendations on structural and functional test frequency,” which he hopes may “help practitioners better conceptualize the uniqueness of the individual’s disease and attack it accordingly.”Home IOP monitoring remains endorsed in the updated guidelines, with expanded discussion of home rebound tonometry and contact lens sensors for 24-hour IOP patterning. The AAO also details the implications of virtual reality perimetry. It notes that while this VF testing method has shown good agreement to standard automated perimetry in controlled settings, “[f]urther research is needed to determine the capacity of virtual reality visual field testing to detect glaucoma and monitor disease progression in real-world conditions.” Population ScreeningThe updated guidance reiterates that using IOP alone to screen for glaucoma is inadequate and stresses that combined structural (OCT) and functional (VF) testing is superior to either modality alone. While the AAO mentions the potential value of telemedicine and artificial intelligence for more efficient glaucoma screening, it extends caution regarding the potential limitations of AI, including “difficulty understanding discriminatory factors and generalizability to different patient groups.” Medical Therapy and AdherenceDrug delivery advances feature prominently in the 2026 PPP. The AAO reports on longer-term data of sustained-release implants, including bimatoprost (Durysta, Allergan) and the newer travoprost-eluting implant (iDose TR, Glaukos), which show sustained medication reduction, though the document also cautions about the risk of endothelial cell loss with repeat dosing.Adherence recommendations are also modernized in light of new systematic reviews and randomized trials that support multifaceted, tailored, face-to-face interventions as effective strategies to improve adherence and potentially cost-effectiveness.Laser ProceduresThe updated document more strongly endorses selective laser trabeculoplasty (SLT) as a first-line therapy for POAG, supported by six-year extension data of the LiGHT trial and a 2022 Cochrane review demonstrating lower disease progression and reduced need for additional glaucoma and cataract surgery compared with topical therapy. Economic analyses further reinforce SLT’s cost-effectiveness under real-world adherence conditions.The 2026 PPP also discusses a newer SLT technique—direct/selective translimbal SLT (DSLT)—though the AAO states early trials have not yet established noninferiority of the automated, non-contact modality to conventional SLT. Updated perioperative considerations confirm the benefit of short-term IOP spike prophylaxis, while evidence on steroid or NSAID use post-SLT remains mixed.The document touches on another laser-based procedure, cycloablation, which, thanks to advances in surgical technique, is now “more commonly being offered to patients earlier in the disease course.” Specifically, the 2026 guidelines highlight slow-coagulation transscleral cyclophotocoagulation and micropulse approaches, with meta-analysis data suggesting similar IOP lowering but fewer severe complications with micropulse compared with continuous-wave treatment. Incisional Surgery: MIGS and BeyondSurgical guidance is substantially expanded and refined in the 2026 PPP, providing what Dr. Rixon says is “a nice breakdown of the myriad techniques/devices available that a comanaging OD may come across.” It begins with clearer terminology distinguishing minimally invasive bleb surgery (MIBS) from non-bleb MIGS. Updated randomized and comparative data are summarized across trabecular procedures (e.g., Kahook Dual Blade, Omni Surgical System and gonioscopy-assisted transluminal trabeculotomy), with many showing meaningful IOP and medication reductions but variable incremental benefit over phaco alone. Canal-based procedures, including ab interno canaloplasty, are presented as comparable to traditional canaloplasty in small studies.Stent data are also updated, including newer trials involving trabecular and standalone devices for refractory disease, as well as continued surveillance recommendations following the 2018 recall of the suprachoroidal stent (CyPass, Alcon). For MIBS, newer meta-analyses indicate Xen gel stent (Allergan) outcomes are comparable to trabeculectomy in IOP reduction but confer higher needling rates, with ab externo approaches showing potential advantages.Filtering surgery updates incorporate five-year data from The Treatment of Advanced Glaucoma Study (TAGS), which showed that primary trabeculectomy may achieve lower IOP and less progression than primary medical therapy in advanced disease, with similar safety profiles. Additionally, long-term data from the Primary Tube Versus Trabeculectomy study concluded that both methods achieve comparable IOP control as well as failure and complication rates, though trabeculectomy led to fewer medications.Other Significant UpdatesClinical considerations for pregnant or breastfeeding patients in the 2026 PPP are similar to those in 2021, though one added recommendation is that “punctal occlusion should be emphasized when caring for patients who are pregnant or nursing and using glaucoma drop therapy.” The new document also maintains prior guidance to avoid brimonidine during breastfeeding.The 2026 PPP also includes more robust cost analyses from the last few years, which reinforce SLT as cost-effective first-line therapy. TAGS showed eye drops were more cost-effective than primary trabeculectomy in the first two years for newly diagnosed advanced glaucoma, though trabeculectomy achieved greater IOP reduction and may be more cost-effective long-term. Moreover, the document cites a study from 2021 that found conventional surgery and SLT to be more cost-effective per mmHg reduction than MIGS.Bottom LineOverall, the 2026 POAG guidance broadens glaucoma care beyond IOP reduction alone, incorporating equity, adjunct risk metrics, more intensive progression detection, stronger SLT-first evidence, expanded MIGS and sustained drug-delivery data, and updated surgical and adherence strategies—reflecting a more individualized, technology-integrated and evidence-driven approach than the 2021 recommendations. According to Dr. Rixon, these updates truly put into perspective how much the field of glaucoma is evolving.“Although most of these changes are not earth-shattering, there are some very impactful updates that practitioners can use on a daily basis—most notably, the framework for individualized testing based on correct classification,” he says. “Reviewing a comprehensive, extensively researched, and well-respected document such as this POAG PPP can only raise ODs' awareness of what the current state of primary open-angle glaucoma care is and what it should be,” Dr. Rixon concludes.Click here for the journal source. Gedde SJ, Bowden EC, Challa P, et al. Primary open-angle glaucoma preferred practice pattern. Ophthalmology. February 9, 2026. [Epub ahead of print].  This article was developed by the editorial staff in conjunction with experts in the field. In the process, AI may have been among the editorial tools used to meet the goals of human editors, who approved all content.