New study finds low diagnostic rates for patients with glaucoma referrals

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A recent retrospective cohort study has called into question the effectiveness of glaucoma referrals among adults aged 18 to 40 years, which may indicate the need for standardized referral guidelines. The study, published in JAMA Network Open, found that only 8.2% of patients who were referred and received a glaucoma evaluation were diagnosed with glaucoma. Additionally, Black and Hispanic patients were found to be at a higher risk for not receiving glaucoma evaluation after referral.¹

“This study provides a crucial step toward standardizing glaucoma-referral protocols, reducing low-yield eye-care expenditures, and ensuring reproducible and equitable care in diverse patient populations,” study authors, led by Tanner Frediani, BS, stated.

The study used glaucoma referral data from the Kaiser Permanente Southern California (KPSC) managed health care system, which is the largest integrated managed care consortium in the US. A total of 292,453 patients between the ages of 18 and 40 years were met the inclusion criteria for the study, having received first-time eye examinations with a KPSC optometrist or ophthalmologist between January 1, 2013 and December 31, 2018. Of the patients that met study criteria, 12,050 patients were identified to have referable glaucoma, with 6827 (56.7%) being evaluated with either visual field or optical coherence tomography testing within 2 years of the index date. Referable glaucoma was defined as a composite diagnosis of glaucoma suspect or any glaucoma subtype based on ICD-9 and ICD-10 codes recorded in the Kaiser EHR system. Analysis of the data collected occurred between September 2022 and August 2024.¹

Among the 6827 evaluated patients, 28.2% had a predicted risk below 2.5%, 56.4% had a predicted risk below 5.0%, and 91.1% had a predicted risk below 10.0%. The study also found that patients with diagnosed glaucoma had a greater prevalence of moderate and high myopia (40.0% vs 29.0%; P < .001), a higher mean (SD) IOP (22.3 [9.8] mm Hg vs 17.2 [4.7] mm Hg; P < .001), and a larger mean (SD) CDR (0.7 [0.2] vs 0.6 [0.2]; P < .001).¹

Study authors also showed concern that some patients with a high risk of glaucoma may not be receiving evaluations at all. “Just under half (43.3%) of the patients in our study (n = 5223 of 12 050) did not return for a glaucoma evaluation after referral, representing a glaring lost opportunity to detect glaucoma,” the authors stated. “Black and Hispanic patients were at higher risk of being lost to follow-up, even though Black race was associated with higher odds (OR, 1.90 [95% CI, 1.40-2.57]) of being diagnosed with glaucoma compared with White race.”

Additionally, the study found that the increased workload of evaluating referable glaucoma primarily falls on ophthalmologists as opposed to optometrists. During the study period, patients evaluated for glaucoma were found to have the same number of optometric visits, but a greater number of ophthalmic visits compared with the other adults in the cohort.¹

“This increased use of ophthalmologic appointments may represent a suboptimal allocation of clinician resources, given that 91.8% of all evaluated patients were not diagnosed with glaucoma. Given the significant decline in ophthalmologist density per 100 000 people from 1995 to 2017 in the US, enhancements to glaucoma-referral pathways that enable ophthalmologists to focus on higher-level patient care compared with low-yield evaluations should be considered. For example, KPSC runs a low resource teleophthalmologic monitoring program that follows individuals with suspected glaucoma with low risk after initial evaluation and detection,” study authors stated.

Reference:

1. Frediani T, Yoo K, Cho A, et al. Outcomes of glaucoma referrals in adults aged 18 to 40 years. JAMA Netw Open. 2025;8(2):e2457843. doi:10.1001/jamanetworkopen.2024.57843