Dr Ray O’Connor takes a look at recent clinical papers on ophthalmology, in particular the current and future burden of glaucoma in Europe, and how it may be substantially higher than previously estimated
Glaucoma is a leading cause of irreversible vision impairment and blindness globally. Open- angle glaucoma (OAG) is the most common. form, affecting 52.7 million individuals in 2020. This burden is estimated to further increase due to the aging population. Myopia, particularly high myopia, is known to be related to the development and progression of OAG. Myopia and high myopia prevalence have increased markedly in recent decades. Projections suggest they will affect 50 per cent and ten per cent of the global population by 2050, respectively.
Dr Ray O’Connor
The purpose of this systematic review and meta-analysis1 of 77 population-based publications (1991–2023) was to provide updated global and regional estimates of the prevalence and population burden of OAG, incorporating both demographic aging and the rising prevalence of myopia. United Nations population data were integrated to estimate the affected population.
Early-onset OAG (20–39 years) in 2060, attributable to high myopia, was estimated separately using projected high myopia prevalence and a pooled OAG prevalence of 4.4 per cent in this highly myopic younger population. The results were startling. Global OAG prevalence (≥40 years) is expected to rise from 2.8 per cent in 2024 to 3.5 per cent by 2060, with the affected population increasing from 80.5 million to 186.6 million.
Aging and demographic changes account for an increase to 77.3 million, leaving the additional 28.9 million cases (27.2 per cent of the total increase) attributed to the myopia epidemic. An estimated 6.1 million early-onset OAG cases due to high myopia will bring the total global OAG population to 192.7 million by 2060.
East Asia will experience the greatest relative increase, with prevalence rising by 50.5 per cent from 2.3 per cent to 3.4 per cent. The authors’ conclusion is that there is a significant, previously underestimated, increase in OAG burden globally, driven by the rising prevalence of myopia. This adds additional OAG burden, particularly to younger populations less than 40 years. Thus, myopia prevention and new targeted screening strategies are important to tackle OAG, especially in regions with a high prevalence of myopia.
Another study looking at the European Region found similar results. The study2 was a two-stage, individual participant data meta-analysis. The authors included 55,415 adults over 40 years of age (mean age, 65.6 years; 53.9 per cent women) from 14 population-based studies (1991 to 2020) with case ascertainment based on direct ophthalmic examination. Overall, 2,021 participants (3.65 per cent) received a diagnosis of glaucoma with an age-standardized European prevalence of 2.99 per cent.
Older age (odds ratio [OR], 1.32 per 5-year increase; and male sex (OR, 1.18) were associated with higher prevalence. Despite regional and diagnostic differences in prevalence estimates, no temporal trend was identified. More than half (56.4 per cent) of cases were undiagnosed previously, with a higher proportion of undetected disease in younger participants, including >80 per cent in those <55 years of age.
The authors estimated a current burden of 12.3 million individuals with glaucoma in Europe, including 6.9 million individuals with undiagnosed disease. This burden is projected to grow by over one million people by 2050 because of changing population age structure, with a preponderance of primary open-angle glaucoma. The conclusion is similar to the global study above and states that the current and future burden of glaucoma in Europe may be substantially higher than previously estimated, with a considerable proportion of disease in the general population remaining undetected.
How is all this glaucoma going to be treated? The purpose of this systematic review3 was to investigate the efficacy of monotherapies and combinations of glaucoma medications in reducing intraocular pressure (IOP) and drug interactions. The authors were particularly concerned with the relative treatment efficacy and interaction of the newly introduced E-prostanoid receptor 2 (EP2) agonists, rho-kinase inhibitors (ROCKIs), and various combination therapies.
Embase and PubMed were searched through May 20, 2025, for randomized controlled trials comparing IOP-lowering effects of topical glaucoma medications in patients with primary open-angle glaucoma or ocular hypertension. The medications evaluated included prostaglandin F2α analogs (PGFAs), nitric oxide-donating prostaglandin analogs (NO-PGA), EP2 agonists, unoprostone, α2-adrenergic agonists (AAAs), β-adrenergic blockers (BABs), carbonic anhydrase inhibitors (CAIs), ROCKIs, and their combinations. The risk of bias was assessed with Cochrane Risk of Bias Tool, and the certainty of evidence (COE) was evaluated also.
Among 166 trials (36,494 participants), PGFA-based combinations demonstrated the greatest IOP reduction (range, -7.41 to -5.81 mmHg; COE: low), with PGFAs plus CAIs ranking highest. Non-PGFA-based triple combinations and PGFA-based combinations, especially PGFA plus CAI, were the most effective. E-prostanoid receptor 2 agonists outperformed other non-PGFA treatments but ranked below PGFA and NO-PGA. Prostaglandin F2α analog plus BAB or ROCKI showed antagonism, whereas the synergy of PGFA plus CAI suggested a promising avenue for new combinations. This study will help clinicians decide on therapeutic options for this increasingly common condition.
Antioxidants are another possible therapeutic option. Although the need for effective treatments is widely recognized, the efficacy and safety of antioxidants remains uncertain. In this systematic review and meta-analysis,4 the authors aimed to evaluate the efficacy and safety of antioxidants in treating patients with primary open-angle glaucoma.
Studies from PubMed, Embase, Cochrane Library, and Web of Science published up to November 30, 2024 were reviewed. Eligible studies included adults aged 18–80 years with primary open-angle or normal-tension glaucoma, comparing antioxidant treatment with placebo or comparing a combination of topical treatment and antioxidants with topical treatment alone.
Only randomized controlled trials and crossover trials were included. Studies involving secondary glaucoma, ocular inflammation, trauma, or severe systemic disease were excluded, as were nonhuman studies. Of the 518 studies, 15 (2.9 per cent) met the final criteria. The study outcomes—intraocular pressure, visual field deterioration, ocular blood circulation, blood pressure, and adverse effects—were chosen to evaluate the efficacy and safety of antioxidant treatments in primary open-angle glaucoma.
The results showed that antioxidant supplementation reduces intraocular pressure, improves visual field mean deterioration, and enhances ocular blood circulation in patients with primary open-angle glaucoma. No significant differences were observed in blood pressure or adverse effects between the treatment and placebo groups. The authors concluded that their study highlights the potential role of antioxidants as a safe and effective therapeutic option for patients with primary open-angle glaucoma. 
References:
- Wang Z et al. Global Glaucoma Prevalence: Burden and Projection to 2060. Am J Ophthalmol 2026;283: 324–335. https://doi.org/10.1016/j.ajo.2025.12.013.
- Stuart KV et al. Prevalence of Glaucoma in Europe and Projections to 2050. Findings from the European Eye Epidemiology Consortium. Ophthalmology 2025; 132, 1114-1124. https://doi.org/10.1016/j.ophtha.2025.06.002.
- Hsia Y et al. Efficacy and Drug Interactions of Glaucoma Medications: A Systematic Review and Component Network Meta-analysis. Ophthalmology 2025 Nov;132(11):1304-1316. doi: 10.1016/j.ophtha.2025.07.009. Epub 2025 Jul 21.
- Bao J et al. Effect of antioxidants on primary open-angle glaucoma: a systematic review and meta-analysis. Front. Pharmacol. 16:1625735. doi:10.3389/fphar.2025.1625735.