Risk of Conversion to POAG Varies Among Open-Angle Glaucoma Suspects, Study Says

A nationwide analysis of more than 83,000 open-angle glaucoma suspect patients found an overall annual conversion rate to primary open-angle glaucoma of 6.1%, with risk varying substantially by patient characteristics. Younger, untreated individuals demonstrated the lowest rates of progression, while older, treated patients faced markedly higher conversion risk, supporting the use of individualized, risk-stratified monitoring strategies to ease the burden on eye doctors. Photo: Henrietta Wang, BOptom, BSc, and Jack Phu, OD, PhD. Click image to enlarge. Individuals who demonstrate risk factors such as elevated intraocular pressure (IOP) or enlarged cup-to-disc ratio (CDR) during routine eye exams are diagnosed as open-angle glaucoma (OAG) suspects and warrant long-term monitoring for conversion to primary open-angle glaucoma (POAG). Previous studies have reported relatively low annual conversion rates, ranging from 0.9% to 7.7%; however, sample sizes have been small and homogeneous. In order to better develop a pragmatic, risk-stratified framework for monitoring OAG suspects, a new study analyzed data from a nationwide health care claims system. Their results were recently published in American Journal of Ophthalmology. The retrospective cohort study included newly identified glaucoma suspects from Optum Clinformatics database spanning all 50 states. Researchers from University of Southern California assessed factors associated with diagnostic conversion to POAG. Among 83,305 glaucoma suspect patients (57.6% female; 5.4% Asian; 11.1% Black; 12.7% Hispanic; 70.8% non-Hispanic white), 20.6% converted to POAG, corresponding to an overall annual conversion rate of 6.1% (9.4% in year one, 5.3% in years two to five). Older age (hazard ratio, HR: ≥1.38), male sex (HR: 1.12), Black race (HR: 1.14), location outside the Northeast (HR: ≥1.24), record of gonioscopy (HR: 1.90) and antihypertensive treatment (HR: ≥1.31) were associated with greater hazard of conversion.  In contrast, age <40 years (HR: 0.62), Asian race (HR: 0.87), household income above $100,000 (HR: 0.89), HMO or other commercial health insurance (HR: ≤0.87), and prior cataract surgery (HR: 0.36) were associated with significantly lower hazard of conversion.Of the lowest-risk patients (<50 years; untreated), annual conversion was 2%, whereas the highest-risk patients (>70 years; treated) had a 16.7% annual conversion rate. Approximately 10.4% of patients in the full cohort received treatment during the study period, mostly topical medications. Conversion occurred at a mean age of 71.4 ±11.0 years, and a mean time from index diagnosis of glaucoma suspect to POAG of 1.6 ±1.5 years. The annual conversion rate was substantially higher among treated patients (15.2%) compared with untreated patients (5%). Ocular hypertension patients had a higher annual conversion rate (7%) than others suspicious for glaucoma (5.8%). According to the authors, these results show that the annual risk of diagnostic conversion from glaucoma suspect to patient in the general population is modest. The authors wrote that their estimates suggest that the low-risk group could potentially be monitored at intervals as long as six years while maintaining a ≤5% per-visit conversion risk. However, they caution that monitoring intervals should ultimately be determined through shared decision-making and comprehensive clinical assessment. In the study, the lowest-risk patients were evaluated every 10.3 months on average, despite AAO PPP recommendations suggesting follow-up every 12 to 24 months for low-risk individuals,” they wrote.Limitations noted in the study include the ICD-based diagnoses, which may be susceptible to miscoding and upcoding, introducing bias. Second, eye-level analyses were not performed due to the lack of laterality and granular clinical data, and conversion in one eye may have influenced management of the fellow eye, the authors wrote. Generalizability was also limited due to the inclusion of only those patients who had health insurance.Ultimately, the study authors concluded that these results may allow for a more pragmatic prioritization strategy based on age and treatment status among low-risk patients.  “Estimating per-visit conversion risk enables risk-stratified surveillance strategies that may safely reduce visit frequency for very low-risk patients while preserving timely detection in higher-risk groups, thereby improving clinical efficiency and resource allocation,” they wrote in AJO.Click here for the journal source. Yoo K, Wu L, James A, et al. Risk-stratified monitoring of open angle glaucoma suspects based on diagnostic conversion risk. AJO. June 3, 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.