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Editors Selection IGR 21-1

Progression / Prognostic Factors: What drives VF progression in angle-closure disease over a decade?

Comment by Benjamin Xu on:

127569 Risk Factors for Visual Field Progression in Primary Angle Closure Disease Over 10 Years: The CUPAL Study, Shen R; Chan PP; Ling A et al., Investigative Ophthalmology and Visual Science, 2025; 66: 59

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This article presents a robust, prospective evaluation of long-term risk factors for visual field (VF) progression in primary angle-closure disease (PACD) using data from the Chinese University of Hong Kong (CUHK) PACG Longitudinal (CUPAL) study.1 The authors addressed a critical gap in glaucoma epidemiology by extending follow-up to at least 10 years, thereby moving beyond the short-term analyses that have dominated prior PACD natural history research.2–4 The study cohort comprised 129 PACD eyes, encompassing primary angle-closure suspect (PACS), primary angle-closure (PAC), and primary angle-closure glaucoma (PACG) subgroups. Standardized Humphrey VF 24-2 testing was conducted biannually, and longitudinal progression was adjudicated using guided progression analysis. Two primary predictors were derived from the first year of follow-up — intraocular pressure (IOP) fluctuation and initial visual field index (VFI) slope — and their associations with subsequent VF deterioration were modeled using multivariable Cox proportional hazards regression. Key findings indicate that higher initial IOP fluctuation and steeper initial VFI slope were independently associated with VF progression in PACG eyes, while in PACS/PAC eyes, only steeper initial VFI slope remained a significant predictor. This distinction underscores the heterogeneous pathophysiology across the PACD spectrum and suggests that early functional decline may forecast long-term progression even in earlier disease stages. The strengths of this study include its long duration, structured VF monitoring, and rigorous statistical approach. Limitations include its single-center design and potential confounding by treatment interventions initiated during follow-up. Nonetheless, these findings reinforce the clinical value of dynamic risk stratification in PACD management and highlight the prognostic utility of early fluctuation metrics in tailoring surveillance and therapeutic strategies.

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