A Unified, Progression-Integrated, Structural Model for Classification of Open-Angle Glaucoma and Individuals at Risk

To propose a comprehensive, evidence-based classification system for open-angle glaucoma that integrates risk profiling, modern optic nerve functional and structural diagnostic testing and analytics, and disease progression rate.

We synthesized data from landmark randomized clinical trials and utility analysis studies. Critical gaps in current systems were identified, specifically regarding the "preperimetric" window and macular vulnerability. A new staging framework was developed to align disease definitions with biological severity, rates of progression, and therapeutic urgency.

The proposed system stratifies the glaucoma continuum into the following 7 stages. Stages 0, 1, and 2 are assigned using a formalized risk-factor framework in eyes without glaucomatous optic neuropathy (GON). Stage 0 (healthy) denotes individuals with no identifiable risk factors for glaucoma. Stage 1 (at risk) corresponds to a single minor risk factor with otherwise low calculated risk (eg, Ocular Hypertension Treatment Study 5-year risk <5% rather than arbitrary intraocular pressure cutoffs), whereas stage 2 (glaucoma suspect) requires at least 1 major risk factor or at least 2 minor risk factors. Stage 3 (mild glaucoma) reflects the presence of GON detected by optical coherence tomography before visual field loss occurs. Stage 4 (moderate glaucoma) denotes the presence of peripheral visual field damage limited to 1 visual hemifield. Stage 5 (severe glaucoma) uses central 5° involvement and/or widespread disease to reflect the impact on quality of life. Stage 6 (end-stage glaucoma) reflects significant glaucoma-related visual disability. A novel "(+) disease" modifier, analogous to retinopathy of prematurity staging systems, is introduced to denote clinically significant active progression, signaling the need for more intensive surveillance or treatment.

We propose a comprehensive staging framework for open-angle glaucoma that integrates structural imaging, functional testing, and progression risk into a unified classification system. By incorporating optical coherence tomography-defined GON and a modifier for active progression, this framework is intended to align disease classification with contemporary diagnostics and longitudinal risk assessments.