Fast Progressors in Glaucoma Mostly Defined by VF

OCT can overcome some limitations of VF (e.g., subjectivity, learning effects, test–retest variability and time consumption) in determining fast glaucoma progression and may detect changes in eyes without measurable functional loss. Click image to enlarge. Fast glaucoma progression is generally defined using numerical cut-offs applied to the rate of progression. However, no consensus guidelines exist for standardized thresholds, and multiple methods are used to estimate progression rates. A recent systematic review published in Ophthalmology Glaucoma reviewed the definitions of fast glaucoma progression reported in the literature to clarify how fast progression is currently defined and to identify the most commonly adopted criteria and analytic approaches.The researchers found that definitions of fast progression vary widely across the literature. Much of this variability reflects differences in numerical thresholds and analytic methods, and to a lesser extent the parameters and imaging devices used. Most studies (78.7%) based their definitions only on visual field (VF). Discouragingly, 5.7% of studies combined structural and functional definitions. The remaining 15.6% of studies defined fast progression exclusively on structural criteria.“Defining fast progression solely on structural change may lead to unnecessarily aggressive management in patients without functional decline, or conversely to underestimation of risk when functional deterioration predominates,” the study authors wrote in their paper. “Structural assessment should therefore be interpreted alongside functional change rather than replacing it.”Of 31,856 records identified, 122 met the eligibility criteria, yielding 88 definitions of fast progression, including 66 unique criteria and 16 analytic methods. The most frequent definition was MD rate <-1.0dB/year calculated using ordinary least squares regression (13 studies, 10.7%). Among structural definitions, the most common was global peripapillary retinal nerve fiber layer (pRNFL) thickness decay ≥90th percentile of the study sample using ordinary least squares regression. When analyzed separately, MD rate <-1.0dB/year was the most commonly used measure (25 studies, 20.5%), and ordinary least squares regression the most frequent analytic method (79 studies, 64.8%).Visual field (VF) testing was used in 103 studies (84.4%), OCT in 25 (20.5%) and confocal scanning laser tomography and OCT-A in one study each (0.8%). Seven studies (5.7%) combined VF with a structural device (six with OCT, one with confocal scanning laser tomography) and one study combined OCT and OCT-A. Among VF-based studies, 2 (1.9%) used central testing (10-2), while among OCT-based studies, four (16.0%) focused on macular parameters. MD was the most frequently adopted index (81 studies, 66.3%), followed by pRNFL thickness (21 studies, 17.2%). Among OCT parameters, pRNFL thickness remained the most widely used (84.0%), while macular parameters were rarely employed (16.0%).The researchers proposed that MD was used most frequently, likely due to its straightforward interpretation, automated calculation and integration into standard perimetry software.“These features make it suitable for large-scale studies and for settings with limited expertise or resources,” they noted. “However, as a global index, MD averages sensitivity across the visual field and may mask localized defects, potentially delaying detection of localized fast progressors.”The review concluded that studies on clinical cohorts are needed to clarify how these definitions affect the proportion of patients classified as fast progressors and to better understand the practical impact of this heterogeneity.Click here for the journal source. Servillo A, Patelli C, Ghirardi A, et al. Definitions of fast progression in glaucoma literature. Ophthalmol Glaucoma. May 25, 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.