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Editors Selection IGR 25-1

Prognostic factors: Glaucoma could be more severe and faster progressing in longer eyes

Comment by Kyung Rim Sung on:

120643 Assessing Glaucoma Severity and Progression in Individuals with Asymmetric Axial Length: An Intrapatient Comparative Study, Huh MG; Huh MG; Jeong Y; Shin YI; Shin YI et al., Ophthalmology, 2025; 132: 39-51

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In this compelling intra-patient comparative study, Huh et al. explore the association between intereye axial length asymmetry and glaucoma severity and progression.¹ By studying 95 patients with bilateral glaucoma and axial length differences exceeding 1.0 mm, the authors eliminate intersubject variability—a common confounder in glaucomatous research—and focus instead on structural and functional disparities within individuals. Their findings are both intuitive and striking: longer eyes consistently demonstrated lower thinner retinal nerve fiber layer (RNFL) and ganglion cell inner plexiform layer, worse baseline visual field indices, and faster progression rates. Importantly, these differences persisted even after correcting for ocular magnification, reinforcing that the observed anatomical discrepancies are not mere imaging artifacts, but rather reflective of true pathophysiological divergence.^1,2 Equally important is the study’s use of a long-term follow-up cohort (mean ~10 years), which lends robustness to their progression analysis. The authors further enhance interpretability by excluding patients with RNFL floor effects—often an underappreciated pitfall in structural glaucoma monitoring—thereby increasing the sensitivity of detecting true progression.^1,3 The study also identifies potential mechanistic correlates: intereye differences in intraocular pressure fluctuation and b-zone parapapillary atrophy were significantly associated with differences in progression rates, particularly in RNFL and visual field measures.^1,4 This highlights the multifactorial nature of glaucomatous damage and the added susceptibility of highly myopic eyes to lamina cribrosa deformation (LCD), as corroborated by higher rates of LCDs observed in longer eyes.⁵

These results underscore the need for clinicians to incorporate axial length differences in their interpretation of structural and functional glaucoma metrics

While the retrospective design and relatively narrow axial length asymmetry range (>1 mm, with few >2 mm cases) limit generalizability, the intrapatient model stands as a methodological strength. The study convincingly positions axial length asymmetry—not simply as a biometric footnote—but as a clinically relevant modifier of glaucomatous risk.

Taken together, these results underscore the need for clinicians to incorporate axial length differences in their interpretation of structural and functional glaucoma metrics. They also raise the possibility that asymmetric patients may benefit from closer surveillance and earlier therapeutic intervention in the longer eye.

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