In a patient with primary open‑angle glaucoma who has confirmed visual‑field progression despite current treatment, what is the next step in management?

Management of POAG with Confirmed Visual Field Progression

When a patient with primary open-angle glaucoma demonstrates confirmed visual field progression despite current treatment, you must lower the target IOP and intensify therapy immediately—this is a clear indication that the current pressure is inadequate to prevent ongoing optic nerve damage. 1

Immediate Management Steps

Confirm True Progression

• Ensure the visual field progression is confirmed on repeat testing before making treatment changes, as single abnormal tests can be unreliable 1, 2
• Verify patient adherence to current medications, as poor adherence is a common cause of apparent treatment failure 1

Reassess and Lower Target IOP

• Downward adjustment of target pressure is mandatory when progressive optic disc, RNFL, or visual field changes occur 1
• The new target should typically be 20-30% lower than the current mean IOP, though more aggressive reduction may be needed depending on severity 2
• For advanced glaucoma with progression, target IOP should be reduced to below 15 mmHg, as studies show eyes with mean IOP <17 mmHg remain stable while those >21 mmHg uniformly progress 3, 4

Treatment Intensification Algorithm

Step 1: Optimize Medical Therapy

• Add another topical medication from a different class if not already on maximal medical therapy 1
• If already on multiple medications, consider switching to more efficacious agents (prostaglandin analogues are most effective) 1, 5
• Ensure proper instillation technique and timing of medications 1

Step 2: Consider Laser Trabeculoplasty

• Laser trabeculoplasty should be considered when medications alone are insufficient, or when adherence, cost, convenience, or side effects are limiting factors 1
• This can provide additional 25-38% IOP reduction 1

Step 3: Surgical Intervention

• Trabeculectomy or other filtering surgery should be considered when medical and laser therapy fail to achieve target IOP 1
• Trabeculectomy provides the greatest IOP reduction (46-60% reduction) and has been shown to slow visual field deterioration more effectively than medical therapy alone in progressive disease 1

Follow-Up Timing

• Schedule follow-up in 2-8 weeks after treatment adjustment to assess response and side effects from the new regimen 1
• More frequent monitoring (every 2-4 months) is warranted for patients with documented progression until stability is confirmed 1

Critical Pitfalls to Avoid

• Do not continue the same treatment regimen when progression is documented—this guarantees continued vision loss 1
• Do not assume achieving the original target IOP is sufficient; progression despite reaching target means the target was set too high 1
• Do not delay surgical referral in patients with advanced disease and rapid progression, as medical therapy may be inadequate 1, 4
• Recognize that eyes with mean IOP between 17-21 mmHg still have approximately 50% risk of progression, so aggressive lowering is often necessary 3