Longitudinal Structural and Functional Trajectories Following Netarsudil Intensification or Surgical Escalation in Primary Open-Angle Glaucoma

Purpose To characterize short-term structural and functional progression trajectories in medically uncontrolled primary open-angle glaucoma (POAG) managed with adjunctive netarsudil intensification or immediate surgical escalation.Methods This retrospective cohort study included 110 eyes with POAG receiving maximally tolerated medical therapy. Thirty-seven eyes underwent netarsudil intensification and 73 eyes underwent trabeculectomy or tube shunt surgery. Stabilized inverse probability weighting was applied to balance baseline covariates. The primary outcome was the 12-month slope of visual field mean deviation (MD). Secondary outcomes included retinal nerve fiber layer (RNFL) thinning rate and intraocular pressure (IOP) reduction.Results The estimated MD progression rate was −0.61 ± 0.58 dB/year in the netarsudil group and −0.42 ± 0.55 dB/year in the surgical group (between-group difference −0.17 dB/year; 95% CI, −0.38 to 0.04; p = .112). RNFL thinning rates were −1.8 ± 2.1 µm/year and −1.1 ± 1.9 µm/year, respectively (between-group difference −0.7 µm/year; 95% CI, −1.6 to 0.2; p = .138). Surgical management achieved greater IOP reduction (−12.3 ± 3.8 mmHg vs − 5.4 ± 2.3 mmHg; p < .001). During follow-up, 27% of eyes in the netarsudil group required subsequent surgical escalation.Conclusions Although surgery achieved greater IOP reduction, short-term structural and functional trajectories remained similar after treatment escalation over 12 months.