Microvasculature Dropout Serves as Early Marker of Glaucomatous Damage

Since vascular changes typically precede structural or functional decline in patients with preperimetric glaucoma, identifying eyes with microvasculature dropout at baseline could indicate which patients are at higher risk of progression and require closer monitoring, researchers argue. Photo: Michael Cymbor, OD. Click image to enlarge. A new longitudinal study published in American Journal of Ophthalmology suggests that microvasculature dropout (MvD) on OCT angiography (OCT-A) may help identify preperimetric glaucoma eyes at higher risk of progression to measurable visual field loss. In this prospective cohort analysis, eyes with baseline MvD experienced faster circumpapillary capillary density decline, were more likely to develop glaucomatous visual field defects and showed a higher rate of conversion to perimetric glaucoma than eyes without MvD. The findings suggest OCT-A vascular assessment may serve as a useful clinical tool for risk stratification in early glaucoma.The study evaluated 93 eyes from 70 participants with preperimetric glaucoma, defined as glaucomatous optic nerve damage without repeatable visual field defects at baseline. Participants were followed for a mean of 4.9 years with serial OCT, OCT-A and automated perimetry. Of the 93 eyes, 32 had baseline MvD and 61 did not. On OCT-A scans, investigators assessed both circumpapillary capillary density and circumpapillary retinal nerve fiber layer (RNFL) thickness. Visual fields were considered abnormal when repeatable defects were present on standard automated perimetry.At baseline, eyes with MvD already showed more structural compromise than eyes without MvD; specifically, the mean circumpapillary capillary density was 45.6% in the MvD group vs. 47.7% in the no-MvD group. Circumpapillary RNFL thickness was also lower in the MvD group (82.7μm vs. 90.7μm). Baseline intraocular pressure and visual field mean deviation did not differ significantly between groups.Throughout follow-up, circumpapillary capillary density declined more rapidly in the MvD group, at -0.88% per year compared with -0.23% per year in eyes without MvD. In multivariable analysis, baseline MvD remained independently associated with faster circumpapillary capillary density loss, with a coefficient of -0.63% per year. By contrast, MvD was not significantly associated with circumpapillary RNFL thinning.There were stark differences in functional outcomes between the two groups. Over a mean visual field follow-up of 6.8 years, 62.5% of eyes with baseline MvD developed perimetric glaucoma, compared with 26.2% of eyes without MvD. The researchers noted in their paper, “Consistently, preperimetric glaucoma eyes with baseline MvD had approximately a 2.5-fold higher likelihood of developing glaucomatous VF loss during follow-up than eyes without MvD,” which they argue underscores “the potential of MvD as a prognostic biomarker for disease progression in preperimetric glaucoma.”Moreover, since circumpapillary capillary density decline preceded substantial RNFL loss, this reinforces the idea that vascular changes may appear before conventional structural or functional deterioration, the authors point out in their paper.Regarding this study’s limitations, the authors caution that MvD grading can be affected by image artifacts and that longer follow-up is needed to determine how many MvD-positive eyes ultimately convert.Overall, these findings suggest that “impaired circumpapillary circulation reflected by MvD may be an early marker of glaucomatous damage and highlight the value of OCT-A-derived vascular parameters for risk stratification in early disease,” the team concluded.Click here for the journal source. Hashemi SM, Nishida T, Moghimi S, et al. Progression in preperimetric glaucoma eyes with and without microvasculature dropout. Am J Ophthalmol. May 28, 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.