Incidence and Risk Factors of Recurrent Visual Field Progression in Glaucoma

A confirmed visual field progression event in glaucoma typically prompts intensification of intraocular pressure (IOP)-lowering therapy, yet the factors associated with recurrent progression after that first event remain poorly characterized.

To evaluate the incidence of recurrent visual field progression after an initial Guided Progression Analysis (GPA) likely-progression event and the factors associated with a recurrent event.

This cohort study was conducted among patients receiving routine ophthalmic care between 1998 and 2025 at a single tertiary academic center (Bascom Palmer Ophthalmic Registry). Data were analyzed from February 2026 to August 2026.

The primary outcomes were the cumulative probability of recurrent visual field progression and hazard ratios (HRs) for factors associated with recurrence.

A total of 7457 eyes of 5086 patients with open-angle glaucoma or suspected glaucoma were included, with a mean (SD) follow-up of 12.4 (4.6) years. Mean (SD) patient age was 60.5 (13.1) years, and 4468 eyes (59.9%) were from female patients. By self-reported race and ethnicity, 203 eyes (2.7%) were from Asian patients, 1718 (23.0%) from Black patients, 1677 (22.5%) from Hispanic patients, and 5536 (74.2%) from White patients. A total of 1951 eyes (26.2%) developed initial GPA likely progression; 635 eyes had adequate follow-up after first progression and IOP data. Among those, 167 (26.3%) recurred. Kaplan-Meier cumulative recurrence was 13.8% at 3 years (95% CI, 11.6%-17.1%) and 43.5% at 10 years (95% CI, 35.8%-52.1%). In multivariable Cox analysis, faster mean deviation (MD) loss before first progression (HR, 1.73 per 1 decibel [dB]/y; 95% CI, 1.39-2.15), higher mean IOP after the first event (HR, 1.09 per 1 mm Hg; 95% CI, 1.05-1.13), less negative MD at first progression (HR, 1.08 per 1 dB; 95% CI, 1.04-1.12), and older age (HR, 1.11 per 5 years; 95% CI, 1.03-1.19) were independently associated with recurrence. Each 10% greater IOP reduction was associated with lower hazard (HR, 0.89; 95% CI, 0.83-0.94). Among eyes with pre-event MD slopes faster than -1.0 dB/y, recurrence occurred in 42.7% of eyes vs 23.4% in slower-progressing eyes (difference, 19.3%; 95% CI, 8.8%-29.9%).

Findings from this cohort study suggest that recurrent visual field progression after a first GPA progression event is common; eyes at highest risk had faster pre-event visual field loss, less advanced damage at first progression, higher postevent IOP, and older age. These results may help target intensified monitoring and IOP lowering toward higher-risk eyes.