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Once Glaucoma Starts Progressing, How Hard Is It to Stop? A New 12-Year Study Gives an Answer · Glaucoma, Vision & Longevity: Supplements & Science

• 0:00
  SPEAKER_00: Once glaucoma starts progressing, how hard is it to stop?
• 0:04
  SPEAKER_00: A new 12-year study gives an answer.
• 0:06
  SPEAKER_00: A first confirmed visual field progression event is a warning, not a guarantee that vision will keep worsening, but a large, long-running study from Bascombe Palmer Eye Institute suggests that a meaningful share of eyes do progress again, even while receiving routine care.
• 0:23
  SPEAKER_00: Published online in JAMA ophthalmology on October 22, 2026, the study found that recurrence was more likely when vision had been declining quickly before the first event and when average eye pressure remained higher afterward.
• 0:37
  SPEAKER_00: More pressure reduction was associated with less recurrence, but this was an observational study.
• 0:43
  SPEAKER_00: It cannot prove that treatment escalation caused the difference.
• 0:48
  SPEAKER_00: What the Bascombe Palmer study measured, researchers reviewed records from 7,457 eyes belonging to 5,086 people with open-angle glaucoma or suspected glaucoma.
• 1:00
  SPEAKER_00: The records spanned 1998 to 2025.
• 1:04
  SPEAKER_00: Across the full group, average follow-up was 12.4 years, with an average of 12.3 visual field tests per eye.
• 1:12
  SPEAKER_00: A visual field test measures how well a person sees in different parts of their field of vision.
• 1:17
  SPEAKER_00: The first progression analysis included all 7,457 eyes.
• 1:22
  SPEAKER_00: The recurrence analysis was narrower.
• 1:24
  SPEAKER_00: 1,951 eyes had an initial likely progression event, but only 635 had enough later visual field tests and eye pressure records for the researchers to assess recurrence.
• 1:36
  SPEAKER_00: The recurrence results therefore describe this smaller, well-monitored group, not every eye in the original registry.
• 1:43
  SPEAKER_00: How the study defined a progression event.
• 1:46
  SPEAKER_00: The researchers used guided progression analysis, a tool for comparing visual field test results over time.
• 1:52
  SPEAKER_00: It compares later tests with the average of the first two reliable tests and looks for worsening at the same test locations beyond the amount expected from normal test-to-test variation.
• 2:04
  SPEAKER_00: An eye met the study's definition of likely progression when three or more of the same locations worsened on three consecutive examinations.
• 2:13
  SPEAKER_00: The event was dated to the first of those three examinations.
• 2:17
  SPEAKER_00: This is a repeatable, computer-based signal, not a guarantee that every flag change represents irreversible glaucoma damage without any possible test or eye health influence.
• 2:28
  SPEAKER_00: To look for a second event, the researchers reset the comparison.
• 2:32
  SPEAKER_00: The first progressing visual field and the next examination became the new baseline tests.
• 2:37
  SPEAKER_00: They then reapplied the same progression rule to the remaining tests.
• 2:41
  SPEAKER_00: The recurrence analysis required at least four visual field tests after the first progressing examination.
• 2:47
  SPEAKER_00: How often did progression recur?
• 2:49
  SPEAKER_00: Across the full cohort, 1,951 of 7,457 eyes, 26.2% had an initial likely progression event.
• 2:59
  SPEAKER_00: Among the 635 eyes with enough subsequent testing and pressure data, 167-26.3% had a recurrent event during the follow-up available to the study.
• 3:11
  SPEAKER_00: The researchers also used a time-to-event method that accounts for eyes having different lengths of follow-up.
• 3:17
  SPEAKER_00: Its estimated cumulative recurrence was, for the full table, please open this article on visualfieldtest.com.
• 3:24
  SPEAKER_00: At the three-year mark, the 95% confidence interval was 11.6% to 17.1%.
• 3:30
  SPEAKER_00: At five years, it was 22.1 to 29.5%, and at 10 years it was 35.8% to 52.1%.
• 3:38
  SPEAKER_00: The number at risk fell from 635 at the start to 30 at 10 years.
• 3:42
  SPEAKER_00: It was 578 at 2 years, 382 at 4 years, 151 at 6 years, and 45 at 8 years.
• 3:50
  SPEAKER_00: The 10-year estimate is therefore much less precise than the earlier estimates.
• 3:55
  SPEAKER_00: These numbers are not contradictory.
• 3:57
  SPEAKER_00: 26.3% is the share of the 635 eyes with a recurrence recorded during their available follow-up.
• 4:04
  SPEAKER_00: The 43.5% figure is the estimated cumulative chance by 10 years, accounting for differences in follow-up time.
• 4:11
  SPEAKER_00: It does not mean that 43.5% of all 7,457 eyes recurred.
• 4:17
  SPEAKER_00: The paper also notes that recurrence was recorded more often in the 635 eye analysis than in the broader group of eyes with initial progression, 26.3% versus 15.2%, in part because eyes without enough later tests could not register a recurrence.
• 4:34
  SPEAKER_00: Which eyes were more likely to progress again?
• 4:36
  SPEAKER_00: The strongest signal was how quickly the visual field had already been worsening.
• 4:41
  SPEAKER_00: In the study's adjusted analysis, each 1 decibel per year faster loss in mean deviation, a summary measure of visual field damage, was associated with a 73% higher hazard of recurrence.
• 4:54
  SPEAKER_00: Hazard describes the relative rate of a new event over time.
• 4:58
  SPEAKER_00: It is not the same as an individual's absolute probability of recurrence.
• 5:02
  SPEAKER_00: Other adjusted associations included higher average eye pressure after the first event, each additional 1 mm of mercury, was associated with a 9% higher recurrence hazard.
• 5:14
  SPEAKER_00: Greater pressure reduction, each additional 10% of reduction from the pre-event average, was associated with an 11% lower hazard.
• 5:23
  SPEAKER_00: The pressure level and percentage reduction were analyzed in separate models because they were related.
• 5:29
  SPEAKER_00: They should not be added together as if they were independent effects.
• 5:33
  SPEAKER_00: Older age, each additional five years, was associated with roughly an 8 to 11% higher hazard, depending on the model.
• 5:41
  SPEAKER_00: Visual field damage at the first event, eyes with a less negative mean deviation score, generally less advanced loss, had a higher measured recurrence hazard.
• 5:51
  SPEAKER_00: The authors cautioned that progression can be harder to detect in advanced disease because damaged test locations have less remaining range to worsen.
• 6:00
  SPEAKER_00: The study's combined prediction model had moderate, not high, ability to distinguish which eyes would recur.
• 6:07
  SPEAKER_00: It is a useful risk signal, not a validated calculator for an individual patient.
• 6:13
  SPEAKER_00: Fast progressors stood out.
• 6:15
  SPEAKER_00: Among 96 eyes losing more than 1 decibel per year before the first event, 42.7% had recurrent progression, compared with 23.4% of slower progressing eyes.
• 6:27
  SPEAKER_00: The difference was about 19 percentage points.
• 6:30
  SPEAKER_00: This does not mean that every fast progressing eye will worsen again or that every slower progressing eye is safe.
• 6:37
  SPEAKER_00: It does mean that the earlier rate of change contains important information.
• 6:41
  SPEAKER_00: A first progression event in an eye that was already losing field quickly deserves particular attention.
• 6:48
  SPEAKER_00: What happened to fast progressing eyes after the first event?
• 6:51
  SPEAKER_00: The study compared the change in mean deviation slope for fast progressing eyes that did and did not have a recorded recurrence.
• 6:59
  SPEAKER_00: Fast progressors without a recorded recurrence slowed from about minus 1.71 to minor.39 decibels per year after the first event.
• 7:08
  SPEAKER_00: Fast progressors with recurrence slowed less, from about 1.70 to minus 1.31 decibels per year.
• 7:16
  SPEAKER_00: The group's pre-event slopes were nearly identical.
• 7:19
  SPEAKER_00: Afterward, the non-recurrence group had a lower average pressure, 14.0 versus 16.2 mm of mercury, and a pressure reduction greater than 20% was more common among them, 36.4% versus 12.2%.
• 7:34
  SPEAKER_00: These are striking observations, but they do not establish why the group's courses diverged.
• 7:40
  SPEAKER_00: Does this show that stronger pressure lowering changed the disease course?
• 7:44
  SPEAKER_00: It is consistent with that possibility, but it is not proof.
• 7:49
  SPEAKER_00: Pressure lowering is already supported by randomized trials as a way to reduce glaucoma progression.
• 7:55
  SPEAKER_00: In the Baskom-Palmer study, recurrence was also associated with higher post-event pressure, and eyes with a larger pressure reduction tended to fare better, but the study did not randomly assign people to different pressure targets or treatment plans.
• 8:11
  SPEAKER_00: Several other explanations could contribute.
• 8:13
  SPEAKER_00: Regression to the mean, an eye selected because it had a particularly steep prior decline or a triggering progression event may show a less extreme slope later, even without an effective treatment change.
• 8:26
  SPEAKER_00: This is especially relevant when comparing a very fast pre-event period with the period afterward.
• 8:32
  SPEAKER_00: Treatment selection bias.
• 8:34
  SPEAKER_00: Clinicians may intensify treatment for eyes thought to be at greatest risk.
• 8:38
  SPEAKER_00: In observational data, treatment and disease severity are intertwined, and the direction of the resulting bias is not predictable.
• 8:47
  SPEAKER_00: Unknown treatment and adherence.
• 8:49
  SPEAKER_00: The investigators did not have records of medication changes, laser treatment, surgery, or how consistently treatment was used.
• 8:56
  SPEAKER_00: A lower recorded pressure could reflect any mix of treatment changes, improved adherence, or ordinary variation.
• 9:04
  SPEAKER_00: Selection and follow-up.
• 9:06
  SPEAKER_00: Only 635 of the 1,951 eyes with initial progression had the post-event tests and pressure data needed for this analysis.
• 9:14
  SPEAKER_00: Eyes that remain in care and receive more tests also have more opportunity for another event to be detected.
• 9:21
  SPEAKER_00: Long-term estimates depend on assumptions about eyes that leave follow-up.
• 9:26
  SPEAKER_00: So the study supports a clinically plausible message.
• 9:29
  SPEAKER_00: Pressure reduction may help after progression is detected, but it does not show that a particular escalation caused the slowing scene in one subgroup.
• 9:38
  SPEAKER_00: What does the pressure after the event tell us?
• 9:41
  SPEAKER_00: The proportion of eyes with a recorded recurrence rose across the study's categories of average post-event pressure.
• 9:48
  SPEAKER_00: For the full table, please open this article on VisualFieldTest.com.
• 9:53
  SPEAKER_00: These are crude recurrence proportions by pressure category, not proof of a safe cutoff or a guarantee that a particular pressure prevents damage.
• 10:02
  SPEAKER_00: The analysis found a graded association, but some eyes still progressed even when their recorded average was 12 mm of mercury or lower.
• 10:11
  SPEAKER_00: A low clinic average does not necessarily capture pressure peaks, pressure throughout the day and night, or whether treatment was consistently used.
• 10:20
  SPEAKER_00: Nor does this study establish that all ongoing damage at a low measured pressure is truly independent of pressure.
• 10:28
  SPEAKER_00: Other factors may matter too.
• 10:30
  SPEAKER_00: Blood pressure patterns and blood flow to the optic nerve have been studied.
• 10:34
  SPEAKER_00: For example, one prospective study in people with normal tension glaucoma found an association between prolonged nighttime blood pressure dips and later visual field loss.
• 10:46
  SPEAKER_00: But those factors were not measured in the Bascom Palmer recurrence study, and such findings do not prove that changing blood pressure prevents glaucoma progression.
• 10:56
  SPEAKER_00: Patients should not change blood pressure medicines on their own.
• 10:59
  SPEAKER_00: Concerns belong in a discussion with their eye doctor and prescribing clinician.
• 11:06
  SPEAKER_00: Pressure-independent injury and neuroprotection remain important research questions.
• 11:11
  SPEAKER_00: The European Glaucoma Society's current guidance says there is not enough evidence to recommend neuroprotective agents as glaucoma treatment.
• 11:20
  SPEAKER_00: Pressure lowering remains the established treatment approach, even though it may not stop progression in every eye.
• 11:28
  SPEAKER_00: What do the major glaucoma trials add?
• 11:30
  SPEAKER_00: The Bascombe Palmer study asks a specific question: what happens after an eye has already shown likely progression?
• 11:37
  SPEAKER_00: The major trials help assess the broader claim that lowering eye pressure can slow glaucoma, but most studied initial treatment rather than recurrence after a first event.
• 11:47
  SPEAKER_00: Early manifest glaucoma trial.
• 11:49
  SPEAKER_00: In people with early glaucoma, treatment lowered average pressure by about 25%.
• 11:54
  SPEAKER_00: Over a median of six years, progression occurred in 45% of treated participants and 62% of controls.
• 12:03
  SPEAKER_00: This is randomized evidence that treatment can delay progression, but it was not a trial of a particular pressure reduction after a first progression event.
• 12:11
  SPEAKER_00: Early manifest glaucoma trial, United Kingdom glaucoma treatment study.
• 12:16
  SPEAKER_00: In a randomized placebo-controlled study of open-angle glaucoma, average pressure reduction at 24 months was 3.8 mm of mercury with latanoprost and 0.9 with placebo.
• 12:28
  SPEAKER_00: The hazard of visual field deterioration was lower in the latanoprost group.
• 12:32
  SPEAKER_00: Again, this supports pressure lowering, not a precise post-progression target.
• 12:38
  SPEAKER_00: United Kingdom Glaucoma Treatment Study, Advanced Glaucoma Intervention Study.
• 12:43
  SPEAKER_00: In people with advanced glaucoma after surgery, eyes with pressure below 18 mm of mercury at all visits had little average visual field worsening, while less consistent pressure control was associated with more worsening.
• 12:58
  SPEAKER_00: Pressure levels were not randomly assigned, so this supports an association, not a universal below 18 is safe rule.
• 13:06
  SPEAKER_00: Advanced glaucoma intervention study.
• 13:08
  SPEAKER_00: Collaborative initial glaucoma treatment study.
• 13:11
  SPEAKER_00: This trial compared initial medicine with surgery and used eye-specific pressure targets.
• 13:17
  SPEAKER_00: Even with aggressive treatment, substantial worsening of mean deviation was observed in more than one-fifth of participants by eight years.
• 13:25
  SPEAKER_00: Treatment effects varied with factors including the amount of damage at the start.
• 13:30
  SPEAKER_00: Collaborative initial glaucoma treatment study.
• 13:33
  SPEAKER_00: Collaborative normal tension glaucoma study.
• 13:36
  SPEAKER_00: This trial is especially relevant because participants were selected for documented progression, high-risk defects, or other warning signs.
• 13:45
  SPEAKER_00: A 30% pressure reduction goal was studied.
• 13:48
  SPEAKER_00: The results favored lowering pressure, but interpretation of visual field outcomes was complicated by cataracts, which were more common after some surgical treatments.
• 13:58
  SPEAKER_00: Collaborative Normal Tension Glaucoma Study.
• 14:02
  SPEAKER_00: Together, these studies support lower pressure as a way to reduce risk while showing that it does not guarantee stability and that treatment targets cannot be reduced to one number for everyone.
• 14:14
  SPEAKER_00: Should the target be based on the person's own rate of progression?
• 14:18
  SPEAKER_00: Yes.
• 14:19
  SPEAKER_00: Once a reliable personal rate is available, it should carry substantial weight.
• 14:24
  SPEAKER_00: A percentage reduction or pressure formula can be a useful starting point.
• 14:28
  SPEAKER_00: It cannot tell whether that pressure is adequate for a particular optic nerve.
• 14:33
  SPEAKER_00: The American Academy of Ophthalmology says target pressure should be individualized and adjusted as the disease course becomes clear.
• 14:41
  SPEAKER_00: The European Glaucoma Society likewise emphasizes that there is no single target appropriate for every patient and includes progression rate among the factors to consider.
• 14:51
  SPEAKER_00: American Academy of Ophthalmology Guidance.
• 14:54
  SPEAKER_00: European Glaucoma Society Guidelines.
• 14:56
  SPEAKER_00: The practical distinction is important.
• 14:58
  SPEAKER_00: A target is a working estimate, not a promise that damage will stop.
• 15:03
  SPEAKER_00: If repeated, reliable testing shows continued loss at that target.
• 15:08
  SPEAKER_00: The estimate may need to be reconsidered.
• 15:10
  SPEAKER_00: The rate of loss, current damage, pressure history, life expectancy, the other eye, and the risks and burdens of further treatment all matter.
• 15:18
  SPEAKER_00: A simple model of different prior rates.
• 15:21
  SPEAKER_00: The study reported a 1.73-fold higher recurrence hazard for each 1 decibel per year faster prior loss.
• 15:29
  SPEAKER_00: The table below applies that model mathematically, comparing the three example rates while holding other measured factors constant.
• 15:37
  SPEAKER_00: For the full table, please open this article on VisualFieldTest.com.
• 15:41
  SPEAKER_00: Under this model, the eye losing 0.7 decibels per year has about a 1.3 times hazard compared with the eye losing 0.2.
• 15:49
  SPEAKER_00: The eye losing 1.5 has about twice the hazard.
• 15:53
  SPEAKER_00: These are relative model estimates, not absolute probabilities, validated personal forecasts, or proof that a specific treatment will offset the risk.
• 16:02
  SPEAKER_00: The study's overall prediction model had only moderate discrimination.
• 16:07
  SPEAKER_00: How much additional pressure reduction might be considered?
• 16:10
  SPEAKER_00: There is no randomized trial establishing one universal extra pressure reduction after a confirmed event.
• 16:17
  SPEAKER_00: In the Bascom Palmer study, mean pressure was 16.4 mm of mercury before the first event and 14.5 afterward.
• 16:25
  SPEAKER_00: The average percentage reduction, calculated eye by eye, was 8.7%.
• 16:30
  SPEAKER_00: Each additional 10% of reduction was associated with an 11% lower recurrence hazard.
• 16:36
  SPEAKER_00: That is evidence of an association, not a guaranteed treatment effect.
• 16:41
  SPEAKER_00: As a population level illustration only, the study's model would associate a 10% point greater total reduction with a hazard ratio of 0.89.
• 16:51
  SPEAKER_00: Extending the same model mathematically to 20% points gives about 0.79.
• 16:57
  SPEAKER_00: Those calculations assume the observed relationship continues in a straight line.
• 17:02
  SPEAKER_00: The study did not randomize those reductions, so they should not be read as causal promises.
• 17:07
  SPEAKER_00: Earlier European guidance described a further 20% reduction as one possible response when progression threatened quality of life despite a target being reached.
• 17:16
  SPEAKER_00: The current guidance emphasizes individualized targets rather than a universal increment.
• 17:22
  SPEAKER_00: At the study's average post-event pressure of 14.5, a further 10% to 20% would equal roughly 1.5 to 2.9 mm of mercury arithmetically.
• 17:34
  SPEAKER_00: That is not a recommended target for any individual.
• 17:37
  SPEAKER_00: The appropriate amount, if any, depends on the eye's measured course, pressure history, existing damage, treatment tolerance, and clinical judgment.
• 17:46
  SPEAKER_00: If your glaucoma has already progressed once, what matters most next?
• 17:51
  SPEAKER_00: For predicting another detected progression event in this study, the factors can be ranked practically, with an important caveat.
• 17:59
  SPEAKER_00: The model was not designed to prove that the items can be ranked precisely against one another because their units differ.
• 18:06
  SPEAKER_00: Previous progression speed.
• 18:08
  SPEAKER_00: This was the clearest warning signal.
• 18:10
  SPEAKER_00: Each 1 decibel per year faster prior loss was associated with a 73% higher recurrence hazard.
• 18:17
  SPEAKER_00: Fast progressors had recurrence recorded more often than slower progressors.
• 18:22
  SPEAKER_00: Current average eye pressure.
• 18:24
  SPEAKER_00: Each additional 1 mm of mercury after the first event was associated with a 9% higher hazard.
• 18:31
  SPEAKER_00: Percentage pressure reduction.
• 18:33
  SPEAKER_00: Each additional 10% of reduction was associated with an 11% lower hazard.
• 18:39
  SPEAKER_00: This was assessed in a separate model from current pressure, so it is not an independent extra benefit to add on top.
• 18:46
  SPEAKER_00: Age.
• 18:47
  SPEAKER_00: Older age was independently associated with recurrence, although the increase per five years was modest.
• 18:52
  SPEAKER_00: Damage severity at the first event.
• 18:55
  SPEAKER_00: In this study, less advanced damage was associated with more recorded recurrence, likely in part because further change is harder to detect in very damaged test locations.
• 19:06
  SPEAKER_00: That does not mean advanced glaucoma is less serious.
• 19:09
  SPEAKER_00: Advanced damage can make any additional loss more consequential.
• 19:13
  SPEAKER_00: The most useful predictor in this study was the eye's previous rate of visual field loss.
• 19:18
  SPEAKER_00: Current pressure and the amount of pressure reduction also mattered.
• 19:23
  SPEAKER_00: The central lesson is not that every eye should be driven to the same pressure, or that progression can always be stopped.
• 19:30
  SPEAKER_00: It is that after a reliable progression event, the eye's own history should help determine how closely it is watched and whether its treatment target still makes sense.
• 19:41
  SPEAKER_00: Sources Moloch and Colleagues, JAMA Ophthalmology, October 22, 2026, Rialini, Invited Commentary in JAMA Ophthalmology Early Manifest Glaucoma Trial, United Kingdom Glaucoma Treatment Study, Advanced Glaucoma Intervention Study, Collaborative Initial Glaucoma Treatment Study, Collaborative Normal Tension Glaucoma Study, American Academy of Ophthalmology, Primary Open Angle Glaucoma, Preferred Practice Pattern, European Glaucoma Society, 6th Edition Guidelines.
• 20:11
  SPEAKER_00: All links to sources are available in the text version of this article.
• 20:15
  SPEAKER_00: You can find the full article at Visual Fieldtest.com.
• 20:19
  SPEAKER_00: Thanks for listening.
• 20:20
  SPEAKER_00: To check your visual field, click the link at the bottom of this article or visit Visualfieldtest.com.