Study: Fewer Than One in Four Rapid Progressors Undergo Aggressive Glaucoma Procedures

The study highlights a potential gap in aggressive intervention for glaucoma patients with rapid functional decline, with clinicians often relying more on baseline disease severity markers than functional progression for treatment escalation. Rapidly progressing patients in areas of higher socioeconomic vulnerability were also less likely to receive less invasive procedures. Photo: Brian D. Fisher, OD. Click image to enlarge. In a recent study, researchers from Wilmer Eye Institute of Johns Hopkins University investigated factors influencing treatment decisions for glaucoma patients experiencing rapid visual field (VF) progression. They found that despite rapid progression being a strong predictor of aggressive or minimally invasive procedures, less than a quarter of patients received aggressive interventions within seven years. Individuals in areas of higher socioeconomic vulnerability were also less likely to receive less invasive procedures. The findings were reported in Ophthalmology.The study included a total of 2,782 eyes from 1,812 adults with five or more 24-2 visual fields over five years and at least one OCT scan at baseline.Rapid progressors were defined by mean deviation (MD) slopes worse than -1 dB/year. Demographic (age, gender, race), clinical (IOP, VF metrics, OCT measures) and socioeconomic (social vulnerability index or SVI) variables were collected. Patients were categorized based on the most intensive treatment received in the first seven years: medical management, minimally invasive procedures (e.g., minimally invasive glaucoma surgery or laser) or aggressive procedures (e.g., filtering surgery or external ciliodestruction). Multinomial regression was performed to identify demographic, clinical and socioeconomic factors associated with treatment intensity.Rapid progressors had significantly higher odds of receiving aggressive procedures, yet only 23%—fewer than one in four—underwent aggressive procedures in the first seven years. The data showed that 85% were conservatively managed due to clinician decision-making rather than patient preference.Higher baseline IOP, worse MD and smaller optic disc rim area or thinner retinal nerve fiber layer (RNFL) at presentation significantly increased the likelihood of aggressive or minimally invasive procedures. However, they also found no significant difference in MD slope between treatment groups for rapid progressors. “In other words, a faster rate of MD worsening was not associated with more aggressive treatment within the rapid progressor cohorts,” the authors wrote in their paper. “This relatively low percentage and similar MD slopes between treatment categories for rapid progressors is clinically significant and may not be intuitive, as rapid progression typically raises clinical concerns warranting aggressive interventions to preserve visual function.”This data suggests that rapid progression, as defined retrospectively from at least five VF tests, may not always align with initial clinical impressions or decisions which may be based on baseline disease severity or IOP. “In our chart review of 100 random rapid progressors managed conservatively, we found that 36% of the time VF progression was not documented in the chart,” the authors explained in their paper. “Since clinicians may not have easily recognizable longitudinal VF progression data when initially deciding on treatment escalation, our results underscore the potential value of incorporating standardized and timely measures of VF loss rate earlier in clinical decision-making processes to better identify and manage patients who may rapidly progress or incorporating models which can forecast rapid progression risk from early data points,” they concluded. This highlights a potential gap in aggressive intervention among patients demonstrating rapid functional decline, as most rapidly progressing patients did not receive definitive aggressive procedures, the authors pointed out.There were also socioeconomic barriers to care. For instance, a higher social vulnerability index was associated with a reduced likelihood of rapid progressors receiving minimally invasive procedures.The authors concluded that better integrating rates of functional decline and addressing socioeconomic barriers may help optimize care for rapidly progressing glaucoma patients.Click here for the journal source. Hin Lee L, Xie Y, Pan A, et al. Rapidly progressing glaucoma: clinical, structural and socioeconomic drivers of treatment escalation. Ophthalmology. October 3, 2025. [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.