PREVALENCE OF GLAUCOMA IN EUROPE AND PROJECTIONS TO 2050

 

Stuart et al have performed a “Two-stage, individual participant data meta-analysis” to provide updated glaucoma prevalence estimates and to quantify the current and future burden of disease in Europe.

The analysis is based on population-based European Eye Epidemiology Consortium studies with glaucoma prevalence data based on direct participant examination.

The analysis included 55415 adults ≥40 years of age (mean age, 65.6 years; 53.9% women) from 14 population-based studies (1991-2020).

The European Eye Epidemiology Consortium is a collaborative initiative of >50 European eye studies, including >180 000 participants, with the aim of promoting and facilitating epidemiologic research into common eye diseases.

The results of this analysis are as follows:

• Among the 55415 individuals included in the study, 2021 participants (3.65%) were found to have glaucoma with an age-standardized European prevalence of 2.99%.
• Older age and male sex were associated with higher prevalence.
• Despite regional and diagnostic differences in prevalence estimates, no temporal trend was identified. However, studies based on specialist opinion yielded the highest glaucoma prevalence estimate and those based on modified ISGEO criteria yielded the lowest.
• This is perhaps unsurprising given that ISGEO criteria rely on statistical cutoffs of vertical cup-to-disc ratio and cup-to-disc ratio asymmetry to define structural damage, potentially excluding cases of early disease or other characteristic features of glaucomatous optic neuropathy that may have been considered diagnostic in other studies.
• Primary open-angle glaucoma (POAG) accounted for 79.9% of all cases of glaucoma. Among other subtypes, primary angle-closure glaucoma (PACG) (9.1% of all cases) and secondary glaucoma (11.0% of all cases) were also found. 
• The prevalence for all types of glaucoma showed an increasing trend with age. However, a decline in PACG prevalence was observed after 80 years of age (PACG was most common between 60-74 years of age).
• More than half (56.4%) of cases were undiagnosed previously (new cases), with a higher proportion of undetected disease in younger participants, including >80% in those <55 years of age.
• Based on the analysis, in 2024 the burden of cases was estimated to be of 12.3 million individuals with glaucoma in Europe, including 6.9 million individuals with undiagnosed disease.
• Significant differences were found across geographic regions, with the lowest prevalence observed in Western Europe and the highest in Eastern Europe.
• Despite projections of an overall decline in total population (~11.8%) over the next 26 years, the number of glaucoma cases is projected to increase to 13.52 million (þ10.3%) by 2050. Thus, the burden of glaucoma patients is projected to grow by >1 million people by 2050 because of changing population age structure, with a preponderance of primary open-angle glaucoma.
• The annual rate of change is expected to slow, however, with a peak of 13.63 million cases reached by 2045, before a decline in total case numbers is seen.

The study concluded that:

The burden of glaucoma may be significantly underestimated if estimates are based solely on published summary statistics, rather than individual-level data, and this may have broader implications for other age-related conditions.

REFERENCE:

Stuart KV, de Vries VA, Schuster AK, Yu Y, van der Heide FCT, Delcourt C, Cougnard-Grégoire A, Schweitzer C, Brandl C, Zimmermann ME, Heid IM, Farinha C, Coimbra R, Luben RN, Hayat S, Khaw KT, Stingl JV, Pfeiffer N, Berendschot TTJM; Maastricht Study Consortium; Arnould L, Creuzot-Garcher C, Hogg R, Wright DM, Azuara-Blanco A, Vergroesen JE, Klaver CCW, Ramdas WD, Topouzis F, Giannoulis DA, Bikbov MM, Kazakbaeva GM, Jonas JB, Jansonius NM, Bourne RRA, Quigley HA, Foster PJ, Khawaja AP; European Eye Epidemiology Consortium. Prevalence of Glaucoma in Europe and Projections to 2050: Findings from the European Eye Epidemiology Consortium. Ophthalmology. 2025 Oct;132(10):1114-1124. doi: 10.1016/j.ophtha.2025.06.002. Epub 2025 Jun 9. PMID: 40499787.

MICRO INTERVENTIONAL DYNAMIC OUTFLOW CURVE (imDOC)

Micro-interventional dynamic outflow curve (miDOC) is a revolutionary technology developed by Professor Sean Ianchulev, from the New York Eye and Ear Infirmary (NYEE), USA.

While performing glaucoma procedures without miDOC, surgeons have no way of checking a patient’s exact ocular flow and pressure, a critical variable in the operating room. They can only check intraocular pressure before and after the procedure, which occasionally leaves unpredictable outcomes.

This has affected the precision of glaucoma surgery. Some surveys have reported more than 50 percent of the patients undergoing trabeculectomy and drainage device implants unable to achieve complete postoperative success and medication independence. In some cases, it is not until the follow-up appointment that ophthalmologists discover the procedure may not have worked and/or has possible complications.

miDOC allows eye surgeons to measure and respond to critical fluid dynamics inside the eye in real time – an advance that may significantly improve precision and outcomes in glaucoma and other ophthalmic procedures.

During surgery, miDOC enables continuous measurement of key parameters including:

1. Pressure
2. Flow
3. Outflow facility
4. Ocular rigidity/Compliance

These measurements provide new insight into how surgical interventions affect the eye in real time.

By providing real-time biometric feedback, miDOC has the potential to elevate glaucoma surgery to a new era of digital-guided precision.

NYEE is the only eye center in the US to use this technology and conduct the first-in-human clinical study. Surgeons started using it in patients in July 2025 and have completed the first 20 cases. According to investigators, all procedures were successfully completed with intra-operative biometric guidance.

Investigators at NYEE plan to further refine the technology and pursue regulatory pathways for broader clinical use. 

Slow-Coagulation Continuous-Wave Cyclophotocoagulation

 

Slow coagulation continuous wave trans-scleral cyclophotocoagulation (CW-TSCPC) is an emerging relatively noninvasive intervention that can be used in different patient populations. The procedure uses the traditional G-probe and continuous wave (CW) laser, with a modified balance of power and duration for enhanced safety compared to the conventional protocol.

Slow coagulation CW-TSCPC delivers photocoagulative laser energy to the ciliary body using a fixed lower power of energy over a longer duration, thereby theoretically decreasing the risk of collateral damage surrounding the ciliary body and severe inflammation from necrotic high energy disruption of the ciliary body.

The greater pressure-lowering effect observed with Slow coagulation CW-TSCPC may be attributed to more substantial structural changes in the ciliary body, whereas the micropulse (MP) technique does not appear to produce significant histologic changes.

The standardized technique involves the following parameters: 1250 mW, 4 s/spot, 20 spots, delivering a total energy of 100 J.

The recently described variation—the Double-Arc Slow-Coagulation protocol—employs a dual-row application strategy, divided in upper (ciliary body shadow) and lower (1.5 mm behind) arcs. Initial results with this technique have demonstrated favorable IOP control and a low rate of complications in the management of refractory glaucomas.

The most frequent complications reported in a study comparing Slow coagulation CW-TSCPC with MP-LT are clinically significant visual acuity loss (20.0% in the Slow coagulation CW-TSCPC group and 26.7% in the MP-LT group), transient anterior segment inflammation (30.0% vs. 23.3%), and transient corneal edema (13.3% vs. 20.0%). 

Pupillary abnormalities, cystoid macular edema, iris synechiae, and iris neovascularization occur with varying frequencies. Hypotony has been reported in 6% patients following Slow coagulation CW-TSCPC.

Pupillary abnormalities are often linked to a more anterior application of the laser, closer to the iris root.

A two-center, randomized, clinical trial in a population of patients with refractory glaucoma, Slow coagulation CW-TSCPC demonstrated superior IOP control, with fewer IOP-lowering medications and a lower rate of surgical failure compared to MP-LT over an 18-month follow-up. Fewer reapplications and additional surgeries were required in the Slow coagulation CW-TSCPC group.

Another study of pseudophakic glaucoma reported lowering of IOP from 27.5±9.8 mm Hg preoperatively to 16.1±6.3 mm Hg postoperatively with a mean percentage reduction of IOP of 42.1% and 75.7% of eyes having ≥20% decrease in their baseline IOP.

Another study in virgin eyes reported that 52.2% of the treated eyes had ≥20% reduction of IOP from baseline. Interestingly, the IOP reduction was noted to more in patients with higher baseline IOP (>21 mm Hg). Slow coagulation TSCPC treatment resulted in a significant decrease of glaucoma medications from 3.8±1.0 to 2.8±1.4 at baseline and last visit, respectively. 

These findings highlight Slow coagulation CW-TSCPC as a reliable technique for managing different types of patients with glaucoma. 

RHEUMATOID DISEASES AND GLAUCOMA RISK

Glaucoma is characterized by retinal ganglion cell (RGC) neurodegeneration. Elevated intraocular pressure (IOP) is a major risk factor for the development of glaucomatous optic neuropathy and RGC loss. However, pressure-independent mechanisms also play a role in RGC damage. 

Both antibodies and CD4 T–cells as well as microbiota take part in the pathogenesis of both glaucoma and rheumatoid arthritis (RA).

Heat shock proteins (HSPs) which originate in bacteria cross-react with RGC epitopes and were detected in a rat model of retinal injury. Enhanced expression of HSPs in the retina was associated with glaucoma-like neuropathology and previous studies have also suggested a pathogenic role for HSPs in RA. 

Since autoimmunity and inflammation, the main characteristics of rheumatic diseases, are related to glaucoma, it was suggested that glaucoma should be included in the spectrum of autoimmune disorders.

A few studies related to the association of rheumatoid diseases and glaucoma are presented here:

1. A Mendelian randomization (MR) analysis was performed by Meng et al, to investigate the causal effects of six common rheumatic diseases on glaucoma. MR is an established approach for making causal inferences in epidemiology.

Six rheumatic diseases were included: ankylosing spondylitis (AS), rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), Sicca syndrome/Sjögren’s sydrome (SS), dermatomyositis (DM), and gout.

Using two-sample MR, the authors found that AS is associated with a higher risk of both POAG and PACG.

Considering the high incidence of AS in the general population (0.1%–0.5%), it is necessary to further explore the relationship between AS and glaucoma in future studies.

Two-sample MR suggests that AS is related to a higher risk of both POAG [odds ratio (OR): 1.28, 95% confidence interval (CI) 1.13–1.44; p = 1.1 × 10−4] and PACG (OR: 1.55, 95% CI: 1.09–2.09, p = 1.4 × 10−2). 

Multivariable MR shows a similar trend of the effect of AS on POAG (OR: 1.52, 95% CI: 1.22–1.90, p = 1.9 × 10−4) and PACG (OR: 2.05, 95% CI: 1.06–3.95, p = 3.2 × 10−2). 

However, no significant association was observed between the other five rheumatic diseases and glaucoma.

Therefore, AS is related to an increased risk of POAG and PACG, and the importance of glaucoma screening in these patients cannot be stressed enough.

Meng Y, Tan Z, Su Y, Li L, Chen C. Causal association between common rheumatic diseases and glaucoma: a Mendelian randomization study. Front Immunol. 2023 Sep 19;14:1227138. doi: 10.3389/fimmu.2023.1227138. PMID: 37799717; PMCID: PMC10550209.

2. However, Kim et al, conducted a cohort study of 10245 older Korean adults risk-set matched using propensity score, and reported patients with RA were more likely than matched controls to subsequently develop POAG, with hazard ratios ranging from 1.44 to 2.12.

These findings suggest that RA is associated with subsequent development of glaucoma. The role of an immune-mediated common pathophysiological pathway warrants further investigation.

Kim SH, Jeong SH, Kim H, Park E, Jang S. Development of Open-Angle Glaucoma in Adults With Seropositive Rheumatoid Arthritis in Korea. JAMA Netw Open. 2022;5(3):e223345. doi:10.1001/jamanetworkopen.2022.3345.

3. Teng used a two-sample Mendelian MR analysis to investigate the causal associations between RA, cataract and glaucoma in European and East Asian populations. Results revealed that RA had an increased risk of cataract (OR = 1.041, 95% CI = 1.019–1.064; P = 2.08×10−4) and glaucoma (OR = 1.029, 95% CI = 1.003–1.057; P = 2.94×10−2).

The authors concluded that oxidative stress and local inflammation are responsible for these causal associations.

Teng M, Wang J, Su X, Tian Y, Wang J, Zhang Y (2024) Causal associations between rheumatoid arthritis, cataract and glaucoma in European and East Asian populations: A bidirectional two-sample mendelian randomization study. PLoS ONE 19(3): e0299192. doi:10.1371/journal.pone.0299192.

Glaucoma and rheumatoid diseases appear to have some common pathogenetic pathways, such as inflammation and immunity. Theoretically, there is a significant association between the two conditions. However, studies have not conclusively shown the level of commonality between the two. Further research is required to reach a verdict on their association.

NANOPHTHALMOS

Nanophthalmos is a heritable condition characterized by a small, but structurally normal eye, with resultant high hyperopia (+8D to +25D). Defining features of nanophthalmos include a short axial length (less than 20-21 mm), with a proportional decrease in anterior segment dimensions, i.e., corneal diameter and anterior chamber depth. Despite a reduction in global ocular volume, the eye contains a normal sized lens.

Nanophthalmos is usually a sporadic disorder. Six major genes have been implicated in isolated nanophthalmos, including MFRP, PRSS56, BEST1, TMEM98, CRB1, and MYRF . For two of these genes (TMEM98, MYRF), the trait is inherited in an autosomal dominant manner, while the remaining genes cause recessive disease (MFRP, PRSS56, BEST1, CRB1). Additionally, several genes have been associated with nanophthalmos as part of a multisystem syndrome, including MYRF and FAM111A. 

Nanophthalmos may present as an isolated disorder or be part of a syndrome. These syndromes include: “nanophthalmos, retinitis pigmentosa, foveoschisis and optic drusen syndrome”, “oculo-dento-digital syndrome (ODD syndrome)”, “autosomal dominant vitreoretinochoroidopathy with nanophthalmos (ADVIRC)”and “Kenny-Caffey syndrome”.

Defining the genetic etiology is important for patient counseling and management since the different genetic causes are associated with varying ocular and systemic features. Glaucoma and other ocular complications secondary to nanophthalmos may be difficult to manage and genetic diagnosis can be helpful for early recognition.  

Nanophthalmos is frequently associated with ocular complications, presenting as high hyperopia with amblyopia and partially accommodative esotropia in early childhood. Given the anterior segment structure, patients are predisposed to angle closure and the resulting angle closure glaucoma, and often need cataract surgery early in life. Many cases of nanophthalmos complicate with uveal effusion with or without exudative retinal detachment. This is attributed to blockage of outflow from the vortex venous system secondary to a thickened sclera.

On distant direct ophthalmoscopic examination or indirect ophthalmoscopy without using a lens, a peculiar glow can be seen and the retinal vessels may be visible. Prominent iris convexity and impending angle closure with peripheral anterior synechiae (that may eventually form) may be observed beyond the fourth decade.

Diagnosis and monitoring for glaucoma in nanophthalmos are rather difficult due to a small disc, where even a small cup may be a sign of glaucoma. Additionally, visual field testing can be inaccurate because many patients have high plus lenses and reduced BCVA. In these cases SD OCT may detect subtle wedge-shaped loss of nerve fiber layer. HRT may assist in monitoring the deterioration of disc parameters. Stereo fundus photos can offer reliable documentation of disc morphology. These patients are also predisposed to malignant glaucoma.

Histology shows all three scleral layers have abnormal collagen fibrils that are frayed and split. The frayed fibrils contribute to scleral inelasticity which causes sequestration of extracellular fluid and consequently choroidal congestion, choroidal detachment, and/or exudative retinal detachment.

Vision loss may also result from other associated retinal findings, including foveal hypoplasia, optic disc drusen, retinoschisis and foveoschisis, retinitis pigmentosa, chorioretinal folds, or central retinal vein occlusions, or complications from ocular surgery. 

An important condition in the differential diagnosis of nanophthalmos is posterior microphthalmos. In posterior microphthalmos, anterior segment parameters are normal or slightly smaller though the axial length is small and the refraction is hyperopic. The posterior segment commonly shows reduction of capillary free zone, crowded optic disc, elevated papillomacular fold, chorioretinal folds, fine retinal folds, uveal effusion syndrome, pigmentary retinopathy and sclerochoroidal thickening on ultrasound.

Correction of the hyperopia with glasses that resemble aphakic spectacles usually results in moderate to good visual acuities. Contact lenses are a better cosmetic alternative. Strabismus surgery can be attempted, but the eyes are usually situated deep in the orbit and difficult to operate. The expansion of the orbital socket can be guided by the axial length of the eye. If the axial length is < 16 mm, the orbital growth is likely to be reduced resulting in facial asymmetries. 

Glaucoma is poorly responsive to medications. It can be managed by peripheral iridotomy or peripheral iridoplasty. However, the management of angle closure in nanophthalmos patients is primarily by lens extraction, but complications can occur in up to 40–60% of cases. Intraoperative and post-operative risks include increased rates of corneal endothelial damage, capsular rupture and vitreous loss, intraoperative aqueous misdirection, uveal effusion syndrome, and cystoid macular edema. Prophylactic scleral windows may reduce the rate of complication, owing to a thickened sclera and choroid that may predispose these conditions. 

While genetic therapies for nanophthalmos have not yet reached the clinical realm, there is some promise for gene replacement strategies for MFRP based on animal models.