Glaucoma can progress even with treatment. The most common reasons include suboptimal IOP control, non-adherence to drops, normal-tension progression, and unrecognised structural risk factors. Finding the cause and adjusting treatment early can prevent further vision loss, says Dr Shibal Bhartiya.
Glaucoma progresses in some patients despite regular treatment. This does not mean the treatment has failed, it means the treatment plan needs review.
Understanding why glaucoma advances is the first step toward stopping it. Several factors can drive progression even when eye pressure appears controlled.
Dr Shibal Bhartiya is a fellowship-trained glaucoma specialist and Mayo Clinic Research Collaborator with over 25 years of experience. Her approach focuses on identifying risk before damage is irreversible, simplifying treatment decisions, and protecting vision long-term. Emphasis on early detection, risk assessment, and continuity of care. She is rated 5 stars across 1,500+ patient reviews on Google.
What Does Progression Mean in Glaucoma?
Progression means measurable worsening of the optic nerve or visual field over time. Specialists confirm it using two or more reliable visual field tests and OCT imaging showing thinning of the retinal nerve fibre layer.
A single abnormal test does not confirm progression. Consistent change across multiple visits does.
Why Glaucoma Progresses Despite Drops
1. Eye Pressure Is Still Too High
The target intraocular pressure (IOP) is individual. A pressure that seems normal may still be too high for a given optic nerve. Studies show that lower IOP targets reduce progression rates in moderate and advanced glaucoma significantly.
If visual fields are worsening, the current pressure target may need revision downward.
2. Drops Are Not Working as Expected
Peak pressure often occurs in the early morning, outside clinic hours. A single office reading may miss harmful pressure spikes. Diurnal IOP curves — tested over several hours — can reveal fluctuations that drive unseen damage.
3. Non-Adherence to Eye Drop Therapy
Studies using electronic monitoring show that patients use drops correctly only 50 to 70 percent of the time. Missing doses, incorrect technique, or preservative intolerance all reduce drug efficacy. Non-adherence is the most correctable cause of progression.
4. Normal-Tension Glaucoma Behaving Differently
Some patients have optic nerve damage at pressures within the normal range. This is normal-tension glaucoma (NTG). It may involve poor vascular supply to the nerve, sleep apnoea, low blood pressure at night, or other systemic factors that drops alone cannot address.
5. Structural Risk Factors Not Yet Addressed
Thin corneas cause IOP readings to appear falsely low. A myopic or tilted optic disc is harder to interpret on imaging. Disc haemorrhages are a strong marker of ongoing progression and must be documented carefully.
6. Systemic Factors Affecting the Optic Nerve
Low systolic blood pressure, anaemia, sleep apnoea, and vascular disorders can reduce blood flow to the optic nerve. Treating these conditions alongside glaucoma can slow visual field loss in susceptible patients.
| Reason for Progression | What It Means | Next Step |
| IOP target not low enough | Nerve still under excess pressure | Lower target IOP or add therapy |
| Pressure spikes between visits | Diurnal fluctuation causing damage | Diurnal IOP curve or 24-hour monitoring |
| Drop non-adherence | Inconsistent pressure lowering | Technique review, preserve-free drops, fixed combos |
| Normal-tension glaucoma | Vascular or non-pressure mechanism | Systemic workup, cardiology review |
| Thin cornea or high myopia | IOP underestimated by tonometry | Corneal-corrected IOP, adjusted targets |
| Disc haemorrhage | Active ischaemia at optic nerve | Close follow-up, often signals rapid progression |
| Systemic comorbidity | Poor vascular supply to nerve | Treat sleep apnoea, anaemia, hypotension |
When to Consider Laser or Surgery
If maximum tolerated medical therapy does not achieve the revised IOP target, laser trabeculoplasty (SLT) or surgery becomes necessary. Selective laser trabeculoplasty is effective in open-angle glaucoma and can reduce the drop burden significantly.
Minimally invasive glaucoma surgery (MIGS) procedures such as iStent and iStent inject offer an option for mild to moderate glaucoma with lower surgical risk. Trabeculectomy remains the benchmark for advanced disease requiring very low pressures.
Dr Shibal Bhartiya’s published research includes peer-reviewed work on 24-hour IOP monitoring and diurnal pressure fluctuation: one of the most under-recognised drivers of progression in treated glaucoma. She has co-authored guidelines on surgical decision-making when medical therapy fails to halt optic nerve damage. As Clinical Director of Ophthalmology at Marengo Asia Hospitals, Gurugram, she manages complex progression cases with a structured protocol: reassess the IOP target, confirm adherence, evaluate vascular and systemic risk, and escalate to laser or surgery when the nerve continues to lose ground.
How Often Should You Be Reviewed?
Patients with progressing glaucoma need more frequent review — often every three to four months. Visual fields should be repeated at least four times a year if progression is suspected. OCT of the optic nerve head and RNFL should accompany each visit.
Waiting six or twelve months between visits when progression is active is not safe practice.
The Role of a Second Opinion
Glaucoma management decisions are complex. If your visual fields continue to worsen, a second opinion from a fellowship-trained glaucoma specialist adds value. Fresh eyes on your imaging, IOP pattern, and structural data can identify a missed cause.
Bringing your previous visual fields, OCT scans, and medication list to the consultation helps the specialist assess the rate of change accurately.
Known for her structured approach to glaucoma risk assessment and progression analysis, Dr Shibal Bhartiya provides trusted second opinions for patients seeking clarity before major treatment decisions. Both, in person, and online.
Frequently Asked Questions
Can glaucoma progress even with normal eye pressure?
Yes. Normal-tension glaucoma progresses at IOP readings within the statistical normal range. The optic nerve in these patients is more sensitive to pressure or more dependent on blood supply. Treatment often involves additional systemic assessment alongside IOP lowering.
How do I know if my glaucoma is progressing?
Your specialist tracks visual field tests and OCT scans over time. Progression is confirmed when two or more reliable tests show consistent worsening. You may not notice early progression — which is why regular monitoring matters.
What pressure should I aim for if my glaucoma is progressing?
The target varies by disease severity and rate of progression. Advanced or rapidly progressing glaucoma typically requires a target below 12 mmHg. Your specialist calculates this based on your structural damage and life expectancy.
Are there lifestyle changes that help slow progression?
Regular aerobic exercise, avoiding head-down positions such as headstands, good sleep hygiene, and managing vascular risk factors all support optic nerve health. Omega-3 supplementation and antioxidant nutrition are areas of ongoing research.
Is surgery the only option if drops stop working?
Not always. Selective laser trabeculoplasty is a non-incisional option that works well in many patients. If laser is not sufficient, MIGS procedures offer a middle path between drops and conventional surgery.
Consult a Glaucoma Specialist
If your glaucoma is progressing despite treatment, you need a specialist review, not just a medication change. The cause must be identified before the right intervention can be chosen.
About the Author
This article was written by Dr Shibal Bhartiya, fellowship-trained glaucoma specialist and Mayo Clinic Research Collaborator, Clinical Director at Marengo Asia Hospitals, Gurugram, known for ethical, patient-centred glaucoma care and independent glaucoma second opinions. She is also the Program Director for Community Outreach & Wellness; and for the Marengo Asia International Institute of Neuro and Spine. This article was updated in May 2026.
She has published peer-reviewed research on glaucoma management, examining how treatment decisions should balance medical evidence, patient preferences, and long-term vision outcomes.
As Editor-in-Chief of Clinical and Experimental Vision and Eye Research and Executive Editor of the Journal of Current Glaucoma Practice (Pubmed Indexed, official journal of the International Society of Glaucoma Surgery), Dr Shibal Bhartiya brings editorial and research depth to every clinical decision. Her 200+ publications, including 90+ PubMed-indexed publications and 28 edited textbooks span glaucoma biology, surgical outcomes, health equity, and emerging diagnostics.
Access her work on Pubmed, Google Scholar, ResearchGate and ORCID.
Dr Shibal Bhartiya
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