Rapidly Progressing Glaucoma: Clinical, Structural, and Socioeconomic Drivers of Treatment Escalation

To evaluate clinical and sociodemographic factors associated with selecting treatments in glaucoma patients with rapid visual field (VF) progression.

Retrospective cohort study.

2,782 eyes from 1,812 adults with 5 or more 24-2 visual fields over five years and at least one optical coherence tomography (OCT) scan.

Rapid progressors were defined by mean deviation (MD) slopes worse than -1 dB/year. Demographic (age, gender, race), clinical (intraocular pressure (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). Logistic regression was performed to identify demographic, clinical, and socioeconomic factors associated with treatment intensity.

Odds of treatment selection based on rapid VF progression.

Rapid progressors had significantly higher odds of receiving aggressive procedures (odds ratio [OR] 3.83, 95% confidence interval [CI] 2.56-5.74, p < 0.001) and any procedure (OR 3.15, 95% CI 2.28-4.35, p < 0.001), yet only 23% of rapid progressors underwent aggressive procedures in the first seven years. Among rapid progressors, worse MD and smaller rim area predicted aggressive procedures and higher IOP predicted any procedure. Higher SVI was associated with a reduced likelihood of receiving minimally invasive procedures among rapid progressors (OR 0.05, 95% CI 0.00-0.76, p = 0.031).

Although rapid progression was a strong predictor of aggressive procedures, fewer than one in four underwent aggressive IOP-lowering interventions. Baseline IOP and structural severity appeared to supersede VF progression in clinical decisions. Patients in areas of higher socioeconomic vulnerability were also less likely to receive less invasive procedures. Better integrating rates of functional decline and addressing socioeconomic barriers may help optimize care for rapidly progressing glaucoma patients.