Risk-Stratified Interventional Management and Surgical Decision-Making in Primary Glaucoma

Primary glaucoma is a leading global cause of irreversible visual impairment, necessitating management strategies to preserve visual function over a lifetime. This narrative review synthesizes contemporary evidence on risk stratification, target intraocular pressure (IOP), and interventional decision-making for primary open-angle glaucoma (POAG) and the primary angle-closure disease (PACD) spectrum. A risk-stratified approach integrates baseline risk factors, gonioscopic anatomy, structural optical coherence tomography (OCT), standard automated perimetry, rate of progression, life expectancy, ocular surface status, medication adherence, patient preference, and resource setting. Early laser or surgical intervention can reduce medication burden and improve IOP control in selected patients. However, conservative medical management and observation remain appropriate when progression risk is low or procedural risk is disproportionate. Landmark trials support first-line selective laser trabeculoplasty in suitable POAG. Additionally, evidence supports primary trabeculectomy as an option for advanced disease and early lens extraction for selected older patients with primary angle closure or primary angle-closure glaucoma. Artificial intelligence, polygenic risk scores, and sustained-release platforms serve as promising adjuncts. Nevertheless, these technologies require external validation, equitable implementation, and clearly defined clinical action thresholds before routine adoption. Overall, glaucoma care should transition from a uniform sequence prioritizing topical medications toward an individualized, evidence-based escalation strategy. This approach optimally balances visual prognosis, procedural risk, and patient-centered outcomes.