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

Abstract

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

Design: Retrospective cohort study PARTICIPANTS: 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 at baseline.

Methods: 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). Multinomial regression was performed to identify demographic, clinical, and socioeconomic factors associated with treatment intensity.

Main outcome measures: Odds of treatment selection based on rapid VF progression RESULTS: 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 seven 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).

Conclusion: Although rapid progression was a strong predictor of aggressive procedures, fewer than one in four underwent aggressive IOP-lowering interventions in the first seven 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 rapidly progressing glaucoma patients.