New PPP for POAG Suspects Refines Risk Factors and Foregrounds SLT

The 2026 PPP for POAG suspects states that the decision to treat depends on IOP and other risk factors. Treatment should also be initiated upon evidence of conversion to POAG, including characteristic optic nerve changes, abnormalities on circumpapillary RNFL or macular ganglion cell layer imaging or visual field defects. SLT is recommended over drops as the first-line option. Click image to enlarge. The American Academy of Ophthalmology (AAO) recently updated three Preferred Practice Patterns related to glaucoma care—one for primary open-angle glaucoma (POAG), another for POAG suspects and a third for primary angle-closure disease. Earlier this week, we published a news story highlighting the key changes to 2026 POAG guidelines, and today, we’ll tackle how protocols have shifted in the update for POAG suspects. Details 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 a similar report on the primary angle-closure disease PPP tomorrow.Diagnosis, Imaging and Risk FactorsLike the new PPP for POAG, the revised guidelines for POAG suspects place increased emphasis on the use of combined structural and functional testing. Contrary to 2021, the 2026 PPP explicitly states that clinicians should include circumpapillary RNFL and macular ganglion cell layer thinning as acceptable structural evidence in a POAG suspect. The AAO also advises doctors to consider macular ganglion cell analysis in high myopia, where RNFL can be diffusely thin.“Placing emphasis on the role of imaging the macula in these cases was an important addition and one that, in some cases, successfully overcomes the difficulties increased axial length will create in assessing circumpapillary RNFL,” says Andrew Rixon, OD, of the Memphis VA Medical Center.The document relays stronger caution that “red disease” on OCT does not always represent glaucoma, and normative databases can often create false-positive results, such as in patients with high myopia. To avoid misinterpretation of scans, it recommends that clinicians carefully evaluate the full report, ensuring good scan quality and considering myopia-related artifacts. The new PPP for POAG suspects reiterates the expanded list of risk factors outlined in the POAG PPP, which now include elevated intraocular pressure (IOP), older age, family history of glaucoma, Black race or Latino/Hispanic ethnicity, diabetes mellitus, lower systolic and diastolic blood pressure, lower ocular perfusion pressure, myopia, thinner central cornea, lower corneal hysteresis, disc hemorrhage, larger cup-to-disc ratio and higher pattern standard deviation on threshold visual field testing. Of these, corneal hysteresis is discussed most prominently in the new PPP, as a recent study correlated lower values to faster visual field index decline. Regarding perimetry methods, standard automated perimetry is retained as the standard for routine management.Treatment and ManagementTwenty-year data from the Ocular Hypertension Treatment Study (OHTS) was released in 2021, revealing a 45.6% cumulative incidence of POAG in patients with elevated IOP, with 25.2% experiencing visual field loss. Dr. Rixon points out the stark reality that “patients’ risk of mortality is comparable to their risk of developing glaucoma,” reinforcing the need for long‑term monitoring of POAG suspects.The OHTS study also concluded that lowering IOP reduces the odds of converting from ocular hypertension to POAG, suggesting that treating patients with elevated pressure—and especially those with additional risk factors—should be considered to lower the risk of POAG conversion. Dr. Rixon notes, “Individual risk stratification and custom intervals of monitoring remain a requirement when we manage these patients.”Selective laser trabeculoplasty (SLT) is now considered the first‑line treatment for ocular hypertension, supported by six-year extension data of the LiGHT trial; at three years, that study reported a higher proportion of patients who received SLT vs. drops achieved the target IOP or below. As far as the goal of treatment in POAG suspects who have agreed to the intervention, the AAO maintains its 2021 recommendation, being that “a reasonable initial target is a 20% reduction in IOP based on the OHTS.” The cadence of follow-up remains individualized; patients should be seen at least every 12 to 24 months, with more frequent intervals warranted for POAG suspects with multiple risk factors. New in the 2026 PPP is the recommendation that patients with lower corneal hysteresis receive closer follow-up, as should those with thin central corneal thickness, elevated IOP, disc hemorrhage, large cup-to-disc ratio, high pattern standard deviation, pseudoexfoliation or pigment dispersion, syndrome or family history. “The priority placed on individualized care based on the extent of risk is important,” comments Dr. Rixon, who adds, “The classification of glaucoma suspect may seem more innocuous than the classification of glaucoma, but that doesn’t mean you won’t see certain patients at similar intervals.”Recommendations to Improve AdherenceAdherence to medications and follow-up remains a leading issue among glaucoma patients and suspects, but the new PPP offers several solutions to help reduce these barriers. It encourages clinicians to educate patients on their condition, how to instill their drops and the importance of continued monitoring. One new practical suggestion it offers is using a “teach-back” technique, which may involve “asking patients to explain what they understand about being a glaucoma suspect.” The AAO explains, “Patients with higher levels of literacy may ask questions that lead to a more complex discussion, but patients who do not understand the information provided to them initially may miss the opportunity to engage in their disease management.” The 2026 PPP also points out that legislation in many states permits early drop refills, which could improve adherence for certain patients if their clinician lets them know this option exists.Reflecting on these suggestions, Dr. Rixon notes, “The incorporation of strategies to combat lack of adherence to medications and follow-up is foundational. A patient-centric approach is a best practice and should maximize outcomes when used.”TakeawaysThe newly revised PPP for POAG suspects aligns closely with 2021 recommendations but places greater emphasis on individualized management and custom monitoring intervals based on established risk factors, which now include lower corneal hysteresis. Moreover, it highlights the importance of considering macular ganglion cell analysis—and being cautious of “red disease”—in myopes. Click here for the journal source. Gedde SJ, Kolomeyer NN, Challa P, et al. Primary open-angle glaucoma suspect 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.