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.

A total of 2782 eyes from 1812 adults with 5 or more 24-2 VFs over 5 years and at least 1 OCT scan at baseline.

Rapid progressors were defined by mean deviation (MD) slopes worse than -1 decibels (dB)/year. Demographic (age, gender, race), clinical (intraocular pressure [IOP], VF metrics, OCT measures), and socioeconomic (Social Vulnerability Index [SVI]) variables were collected. Patients were categorized based on the most intensive treatment received in the first 7 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.

Odds of treatment selection based on rapid VF progression.

Rapid progressors had significantly higher odds of receiving aggressive procedures (odds ratio [OR], 6.96, 95% confidence interval [CI], 2.61-18.55, P < 0.001), yet only 23% of rapid progressors underwent aggressive procedures in the first 7 years. In a sample of rapid progressors who were managed with medical treatment alone, we found that 85% were conservatively managed due to clinician decision-making rather than patient preference. Worse MD, smaller rim area, and higher initial IOP were associated with more aggressive intervention. Functional decline (MD slope) was not associated with treatment selection in rapid progressors. We also found that higher (worse) SVI was associated with a reduced likelihood of receiving minimally invasive procedures among rapid progressors (OR, 0.06, 95% CI, 0.00-0.78, P = 0.032).

Although rapid progression was a strong predictor of aggressive procedures, fewer than 1 in 4 patients underwent aggressive IOP-lowering interventions in the first 7 years. Rate of functional decline did not play a role in treatment selection within rapid progressors. Rapidly progressing 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 patients with rapidly progressing glaucoma.

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