A Unified, Progression-Integrated, Structural Model (PRISM) for Classification of Open Angle Glaucoma and Individuals at Risk.

Purpose

To propose a comprehensive, evidence-based classification system for open-angle glaucoma (OAG) that integrates risk profiling, modern optic nerve functional and structural diagnostic testing and analytics, and disease velocity.

Methods

We synthesized data from landmark randomized clinical trials and utility analysis studies. Critical gaps in current systems were identified, specifically regarding the 'pre-perimetric' window and macular vulnerability. A new staging framework was developed to align disease definitions with biological severity, rates of progression, and therapeutic urgency.

Results

The proposed system stratifies the glaucoma continuum into seven stages. Stages 0, 1, and 2 are assigned using a formalized risk-factor framework in eyes without glaucomatous optic neuropathy (GON). Stage 0 (healthy) denotes individuals with no identifiable risk factors for glaucoma. Stage 1 (At Risk) corresponds to a single minor risk factor with otherwise low calculated risk (e.g., OHTS 5-year risk less than 5% rather than arbitrary IOP cutoffs), whereas Stage 2 (Glaucoma Suspect) requires at least one major risk factor or at least two minor risk factors. Stage 3 (Mild Glaucoma) reflects the presence of GON detected by optical coherence tomography (OCT) prior to visual field loss. Stage 4 (Moderate Glaucoma) denotes the presence of peripheral visual field damage limited to one visual hemifield. Stage 5 (Severe Glaucoma) utilizes central 5-degree involvement and/or widespread disease to reflect Quality of Life impact. Stage 6 (End-stage Glaucoma) reflects significant glaucoma-related visual disability. A novel "(+) Disease" modifier, analogous to retinopathy of prematurity staging systems, is introduced to denote clinically-significant active progression, signaling the need for more intensive surveillance or treatment.

Conclusion

We propose a comprehensive staging framework for open-angle glaucoma that integrates structural imaging, functional testing, and progression risk into a unified classification system. By incorporating OCT-defined glaucomatous optic neuropathy and a modifier for active progression, this framework is intended to align disease classification with contemporary diagnostics and longitudinal risk assessment.