Section 4 – Risk factors

1. Risk factors for glaucoma progression should be ascertained in all patients with glaucoma or suspected of being at increased risk of glaucoma.
2. Clinical risk factor assessment in glaucoma serves two roles. It provides (a) prognostic information; and (b) a basis for disease management.
   Comment: While proof of causality is desirable, the pragmatic nature of clinical medicine allows the use of risk factors of varying evidence quality and even clinical signs to be used in clinical management.
3. The use of risk factors in clinical management should take into account: (a) the strength of the risk factor for disease progression; and (b) the practicality and potential harm of reducing that risk factor.
4. Ocular hypertension is itself a strong risk factor for glaucoma, with rates of progression depending on the presence or absence of other risk factors.
   Comment: Accounting for these risk factors is critical to clinical decision making in the management of OHT patients.
   Comment: Risk factor assessment in OHT helps determine an individual’s need for IOP lowering medication and also informs on the frequency of follow up.
5. Risk calculators provide a means for quantifying risk of glaucoma progression in appropriate individuals with similar baseline characteristics to those present in the study.
   Comment: The utility of these risk calculators in clinical practice still needs to be determined.
6. Higher mean IOP is a strong risk factor for glaucoma progression.
   Comment: More studies are needed to evaluate the role of other IOP parameters as risk factors for glaucoma progression.
7. A thinner central cornea is a risk factor for progression in patients with higher baseline IOP.
8. The presence of pseudo-exfoliation syndrome is an independent risk factor for progression.
9. The presence of a disc haemorrhage, older age, and lower ocular perfusion pressure are risk factors for progression. Comment: The relationship between low blood pressure and risk of progression is complex.
10. While estimates of risk of progression for individual patients based on completed large clinical trials are available, the use of such estimates varies considerably in clinical practice.
11. There is greater information available regarding the importance of risk factors for progression from early to moderate disease than from moderate to severe disease.
    Comment: Few adequately powered studies have prospectively assessed the risk factors for blindness from glaucomatous disease.
12. The relative importance of risk factors for progression may vary depending upon the stage of glaucomatous disease.
    Comment: Some risk factors that do not appear to be important predictors of progression from early to moderate glaucoma may be relatively more important in predicting progression from moderate to severe disease and vice versa.
13. Studies that longitudinally assess risk factors for functional vision loss and blindness from glaucomatous disease are needed.

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