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Background Trabeculectomy, with the application of mitomycin C (MMC), has been the gold standard glaucoma-filtering surgery. The conventional method of applying MMC using soaked sponges does not ensure a controlled amount of delivery of MMC, and incidences of blebitis are reported to be associated with leftover sponges. This study aims to assess the safety and efficacy of a low dose (0.1 mg/ml) of MMC administered through subtenon injection during trabeculectomy combined with cataract extraction, addressing existing research gaps. Methods It is a prospective interventional study on patients who underwent trabeculectomy with a subtenon injection of 0.1 mg/ml of MMC combined with cataract extraction and were followed up over six months. Efficacy was determined in terms of intraocular pressure (IOP) reduction; bleb architecture was graded using the Indiana Bleb Appearance Grading System (IBAGS) and success rate, and safety was commented upon in terms of complications. Results Thirty patients were enrolled, with the majority having primary open-angle glaucoma (63.33%), while 36.67% had primary angle-closure glaucoma. Baseline IOP was 31.40(±10.38) mmHg. It significantly reduced to 14.60(±3.75) mmHg on the first postoperative day, decreasing to 9.55(±1.57) mmHg by the sixth postoperative month (p=0.001). The percentage reduction in IOP was substantial, 69.57%, by the sixth postoperative visit. Bleb morphology assessment using IBAGS revealed significant improvements in bleb height and extent and a reduction in vascularity over the six-month follow-up (p=0.001), and no eyes had bleb encapsulation. Out of the total patients, 93.33% achieved controlled IOP without anti-glaucoma medications, while 6.67% required one medication for IOP control. Complications were minimal, with transient corneal edema in six patients and manageable postoperative hypotony in one case. Conclusion A subtenon injection of MMC during trabeculectomy effectively reduces IOP and promotes favorable bleb architecture, offering an effective and safer alternative to the conventional approach.

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Objective: To characterize the effect of netarsudil 0.02% on episcleral blood flow in treatment-naive glaucoma suspect or ocular hypertension subjects. Design: Prospective, unmasked, single-arm cohort study. Participants: Ten treatment-naive patients with a diagnosis of glaucoma suspect or ocular hypertension. Methods: Erythrocyte-mediated angiography (EMA) was used to measure episcleral erythrocyte velocity, vessel diameter, and blood flow at baseline before treatment, 1 hour after drop instillation (T1), 1 to 2 weeks after daily netarsudil 0.02% drop use (T2), and 1 hour after drop instillation at the 1-to-2-week time point (T3). Intraocular pressure (IOP) and blood pressure were measured at each visit. Main Outcome Measures: Change in episcleral venous erythrocyte velocity, diameter, and blood flow between time points analyzed using generalized estimating equation models. Results: Of the 18 eligible study eyes of 10 enrolled treatment-naive subjects, baseline IOP was 16.8 ± 3.6 mmHg (mean ± standard deviation), which significantly decreased to 13.9 ± 4.2 mmHg at T1, 12.6 ± 4.1 mmHg at T2, and 11.8 ± 4.7 mmHg at T3 (P < 0.05 at each time point compared with baseline). Episcleral vessels averaged 61.3 ± 5.3 µm in diameter at baseline which increased significantly at all posttreatment time points (78.0 ± 6.6, 74.0 ± 5.2, 76.9 ± 6.9 µm, respectively; mean ± standard deviation, P < 0.05 for each time point). Episcleral venous flowrates were 0.40 ± 0.22 uL/minute (mean ± standard deviation) at baseline, which increased significantly to 0.69 ± 0.45 uL/min at T1 (P = 0.01), did not significantly differ at T2 (0.38 ± 0.30 uL/minute), and increased significantly to 0.54 ± 0.32 uL/minute at T3 (P < 0.05 compared with baseline and T2). Conclusions: Netarsudil causes episcleral venous dilation at all time points and resulting increases in episcleral venous flowrates 1 hour after drop instillation. Increased episcleral venous flow, associated with decreased episcleral venous pressure, may result in lowered IOP. Financial Disclosures: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

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AIMS: To estimate the changes in intraocular pressure (IOP) during the first 24 h after transscleral cyclophotocoagulation (TCP). METHODS: A prospective single-centre study, where patients with glaucoma destined for treatment with TCP were asked for participation. The IOP was measured prior to TCP and at 1, 2, 4, 6 and 24 h post-TCP. An IOP spike was defined as an elevation of IOP of ≥5 mmHg compared with baseline. The visual acuity (VA) was examined at baseline and after 24 h. RESULTS: The mean IOP prior to TCP in 58 eyes of 58 patients was 26.2 (±8.9 SD) mmHg. Twenty-three eyes (40%) experienced an IOP spike at some examination timepoint during the first 24 h. The mean value of the IOP spike was 12.1 (±6.9) mmHg. Fifty-six per cent of the eyes with pseudoexfoliation glaucoma (PEXG) experienced an IOP spike, and 16% had an IOP spike ≥20 mmHg. The IOP was significantly reduced at the 24 h examination by 8.1 (±7.8) mmHg (n = 58). The VA 24 h after TCP was unchanged compared with baseline. CONCLUSION: Clinically significant IOP spikes were common in the first 24 h post-TCP. Almost one in five eyes had an increase of 10 mmHg and in almost one in 10 eyes, the IOP increase was 20 mmHg or higher. Eyes with PEXG had a higher occurrence of IOP spikes and displayed a greater magnitude of IOP elevation. Prophylactic post-operative IOP-lowering medication should be considered to prevent further glaucoma damage.

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The term glaucoma encompasses various neurodegenerative eye disorders, among which the most common is primary open-angle glaucoma (POAG). Recently, the essential role of human retinal astrocytes (HRA) in glaucoma progression has been placed in the spotlight. It has been found that placing the endoplasmic reticulum (ER) under stress and activating PERK leads to apoptosis of HRA cells, which inhibits their neuroprotective effect in the course of glaucoma. Therefore, the aim of the present study was to evaluate the effectiveness of the small-molecule PERK inhibitor LDN-0060609 in countering ER stress conditions induced in HRA cells in vitro. The activity of LDN-0060609 was studied in terms of protein and mRNA expression, cytotoxicity, genotoxicity, caspase-3 level and cell cycle progression. LDN-0060609 at 25 µM proved to be a potent inhibitor of the major PERK substrate, p-eIF2α (49% inhibition). The compound markedly decreased the expression of pro-apoptotic ER stress-related genes (ATF4, DDIT3, BAX and Bcl-2). Treatment with LDN-0060609 significantly increased cell viability, decreased genotoxicity and caspase-3 levels, and restored cell cycle distribution in HRA cells with activated ER stress conditions. These findings indicate that the small-molecule PERK inhibitor LDN-0060609 can potentially be developed into a novel anti-glaucoma agent.

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This review examines the evolution, current status, and future potential of minimally invasive glaucoma surgeries (MIGS), a significant advancement in the treatment of glaucoma, a leading cause of irreversible blindness. MIGS offer a less invasive alternative to traditional glaucoma surgeries, primarily aimed at reducing intraocular pressure, minimizing tissue trauma, and providing a safer profile. With the emergence of devices such as the Trabectome, iStent, and others, MIGS have expanded the surgical toolkit, allowing personalized, patient-centered care. Despite their advantages, MIGS face challenges such as efficacy in severe cases, long-term data, and accessibility. Ongoing research and technological innovations continue to refine their capabilities and applications, promising to further transform glaucoma management and patient outcomes. This paper provides an in-depth analysis of MIGS, reflecting on their impact and contemplating future directions in this dynamically evolving field.

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BACKGROUND: Glaucoma is a widespread ophthalmological disease. Knowledge about the spread of the disease in the population is necessary with respect to further questions on comorbidities, risk factors and the provision of care. OBJECTIVE: An analysis of the use of glaucoma medications and the prevalence of glaucoma in an urban adult population was carried out. MATERIAL AND METHODS: The Hamburg City Health Study (HCHS) is a prospective, long-term, population-based cohort study that includes a random sample of 45,000 participants aged between 45 and 79 years from the general population of Hamburg, Germany. Apart from various medical parameters, data include premedication and the medical history of the participants. The use of antiglaucomatous medication among the first 10,000 study participants was analyzed and the prevalence of glaucoma was estimated according to the use of medications as well as by the self-reported history of glaucoma. Descriptive analysis and logistic regression analysis were performed to analyze the data and to calculate correlations by age and gender. RESULTS: In the study population 319 persons were on medication to lower the intraocular pressure (IOP, mean age 67.1 years, SD = 7.57 years), which is equivalent to an estimated prevalence of 3.35% (95% confidence interval, CI 3.00-3.70%). A positive correlation was observed between age and the use of IOP-lowering medication, which is statistically highly significant (p = < 0.001). The analysis by gender showed a slightly higher prevalence among women, which was not statistically significant. The estimated prevalence according to glaucoma medication and history were only partly congruent. DISCUSSION: This estimated prevalence of glaucoma is comparable to other epidemiological studies. The study results cover not only patients with manifest glaucoma but also persons who were treated for ocular hypertension. The inconsistency between the prevalence of glaucoma medication and the diagnosis of glaucoma can be explained by different treatment strategies and also by information deficits.

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This article provides an overview of real-world outcomes in glaucoma surgical procedures. While randomized clinical trials provide valuable insights, they do not fully reflect real-world clinical practice. Real-world studies enable the evaluation of outcomes in uncontrolled settings and play a crucial role in counselling and decision-making for glaucoma treatment. By examining real-world data the article aims to identify rare adverse events that may go unnoticed in controlled clinical trials. The focus is on assessing the effectiveness and safety of glaucoma surgical procedures beyond the controlled trial setting.

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Among the first structures suffering damage with an increase in intraocular pressure (IOP) and in early stage of glaucoma are the lamina cribrosa (LC) and peripapillary sclera (ppScl). Changes in these structures occur at the molecular and cellular level. Extracellular matrix (ECM) is the basis of connective tissue, provides mechanical support for the cells, facilitates intercellular interactions and transport of chemicals, including in LC and ppScl. Mechanical stress causes remodeling and disorganization of the ECM, which leads to changes in the structure of the tissue itself, an increase in its rigidity and a decrease in elasticity. Taking into account the molecular and cellular mechanisms of damage to LC and ppScl, various researchers have developed strategies and tactics for therapeutic intervention on these structures, contributing to a decrease in ECM secretion and, as a consequence, suspension of their remodeling. These approaches may in the future form the basis for the treatment of glaucomatous optic neuropathy.

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Purpose: Pilot study to evaluate adverse events and intraocular pressure (IOP)-lowering of a novel, noninvasive glaucoma procedure, femtosecond laser, image-guided, high-precision trabeculotomy (FLIGHT). Design: Prospective, nonrandomized, single-center, interventional, single-arm clinical trial. Participants: Eighteen eyes from 12 patients with open-angle glaucoma. Methods: Eighteen eyes from 12 patients underwent FLIGHT, creating a single channel measuring 500-µm wide by 200-µm high through the trabecular meshwork and into Schlemm's canal. Adverse events, IOP, and other parameters were evaluated out to 24 months. Main Outcome Measures: Outcomes were the rates and types of adverse events and the rate of postprocedure best-corrected visual acuity loss (≥ 2 lines) compared with baseline. Efficacy outcomes were reduction in mean intraocular pressure (IOP) with respect to baseline and the percentage of eyes with a ≥ 20% reduction in IOP. Results: Eighteen eyes from 12 patients were enrolled in the study; 11 patients (17 eyes) returned at 24 months. There were no serious adverse events related to the laser treatment. Well-defined channels were clearly visible at 24 months by gonioscopy and anterior segment OCT, with no evidence of closure. At 24 months, the mean IOP was reduced by 34.6% from 22.3 ± 5.5 to 14.5 ± 2.6 mmHg (P < 5e-5), with an average of 2.0 ± 1.2 hypotensive medications compared with 2.2 ± 1.1 at baseline (P = 0.22). Fourteen out of the 17 study eyes (82.3%) achieved a ≥ 20% reduction in IOP at 24 months when compared with baseline. Conclusion: The FLIGHT system demonstrated a favorable safety profile in this initial pilot study, with no device-related serious adverse events. The channels appeared patent at 24 months, indicating medium-term durability. Financial Disclosures: Proprietary or commercial disclosure may be found after the references.

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Aim: To investigate the efficacy and safety of micropulse laser trabeculoplasty (MLT) using a 577 nm yellow wavelength laser randomly assigned to either 1500 or 1000 mW in patients with primary open-angle glaucoma (POAG). Methods: A prospective, double-blinded study of POAG patients was performed in a single center. MLT treatment included a 577 nm micropulse laser (IRIDEX IQ 577TM, IRIDEX, Mountain View, CA, USA) to 360° of the trabecular meshwork at randomly assigned varying powers: 1500 mW in one eye (MLT 1500 group) and 1000 mW in the other (MLT 1000 group). Best-corrected visual acuity (BCVA), intraocular pressure (IOP), corneal central thickness (CCT), and endothelial cell count (ECC) were evaluated at baseline (T0), post-operative 1 h (T1), 24 h (T2), 1 month (T3), 3 months (T4), and 6 months (T5) after laser treatment. Topical medications were assessed pre-treatment and at T4. Results: Among the 18 eyes included, we achieved a success rate (IOP reduced > 20%) in 77% of sampled eyes. In particular, IOP reduced at T2 and T3 with both MLT 1500 and 1000 without any significant differences (IOP reduction 22.9% vs. 17.3%, respectively, MLT1500 vs. MLT1000 at T2). The IOP returned to baseline values at T4 and T5 in both groups, with a reduction in topical medications administered from 2.5 ± 1.1 to 2.0 ± 1.2 to the 1500 mW group and from 2.4 ± 1.0 to 1.9 ± 1.0 to the 1000 mW group. At 1 h post-laser treatment, a transient IOP spike was registered among the MLT1500 group. There were no differences in CCT and ECC at any timepoint according to the laser powers. Conclusions: Over a 6-month follow-up period, 577 nm MLT at either 1500 or 1000 mW reduces IOP, enabling a stable reduction in the number of topical medications required for patients treated for POAG without any significant difference in terms of effectiveness and safety.

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AIM: To determine initial medication adherence in newly diagnosed glaucoma patients treated with anti-glaucoma drugs. METHODS: This retrospective and observational study included all patients diagnosed with glaucoma in the Primary Health Care units in Portugal during the years 2012 and 2013, which in consequence received a first prescription for anti-glaucoma drugs. Data was collected from electronic prescribing records of the primary care units and from pharmacy claims records. Initiation of glaucoma treatment and early discontinuation were measured, and the combination of (non)-initiation and early discontinuation accounted for initial medication (non)-adherence. RESULTS: A total of 3548 new glaucoma patients (40.1% male; 59.9% female) were included. The 1133 (31.9%) patients were initially classified as non-users, since there was no pharmacy claim found for their first prescription for glaucoma treatment. Additionally, 277 (11.5%) patients early discontinued their treatment, acquiring only their first prescription. Overall, the initial medication non-adherence rate was 39.7% since 1410 patients either didn't initiate treatment or discontinued it early. CONCLUSION: This study, reveals a major opportunity to improve glaucoma treatment and its control, since a large proportion of patients fail to engage with their prescribed therapy, which implies that implementation of individual or group strategies that enable patients with glaucoma to correctly perform their treatment is still needed.

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The main reasons why Amniotic Membrane (AM) is transplanted in Ophthalmology are: to provide a substrate for cellular growth and to provide tectonic support or as a biological bandage and barrier that protects the wound to facilitate an environment for wound healing. The application of AM is well-documented in corneal disorders of various aetiologies [1], however, research within the field has highlighted how it can be used in conjunctival disorders and most recently, in glaucoma and vitreoretinal procedures. This review explores the preservation modalities of AM and summarises the current literature regarding AM transplantation in Glaucoma and Vitreoretinal conditions. AM transplantation in conjunction with trabeculectomy was reported to be used in two different surgical techniques. They differ in relation to the position of the implant: below the scleral flap or over the entire exposed sclera. The results of these studies suggest that AM transplant is a safe procedure that helps in the improvement of the intraocular pressure when associated with trabeculectomies. Moreover, it enhances trabeculectomies success rates when used along with mitomycin C [2]. The use of AM is also described for managing leaking blebs. It is mentioned to be a suitable alternative to conjunctival advancement. Regarding AM transplantation in glaucoma shunt or valve surgeries, the current literature is relatively limited. However, AM has been described as a good tectonic support for shunt procedures [3]. Successful results are described in the literature for surgical treatments using AM plug for vitreoretinal procedures. In particular macular hole closure and rhegmatogenous retinal detachment. In conclusion, AM transplant is a very promising and versatile adjutant therapy. However, further studies are also required for a better understanding and refinement of surgical techniques.

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PURPOSE: The aim of this study was to examine the impact of self-tonometry on clinicians' decision in glaucoma treatment. MATERIALS AND METHODS: Medical records of 133 patients who had performed self-tonometry using iCare® Home between January and December 2019 were retrospectively reviewed. Inclusion criteria were as follows: age over 18 years, all types of glaucoma, as well as ocular hypertension and glaucoma suspect, compliance with tonometer manufacturer's recommendations and monitoring over at least 2 days. The data consisted of age, gender, diagnosis, visual field index, rate of progression and type of treatment pre- and post-intraocular pressure (IOP) phasing. The following IOP measurements were used to calculate the mean and maximum IOP, and range over each day and consecutive days: Goldmann applanation tonometry (GAT) measurements from referral and training visits and iCare® Home measurements made by the trainers and the patients themselves. A total of 90 patients were included. RESULTS: Clinicians were satisfied with the actual treatment in 54.4% of the cases. There was a statistically significant difference between the clinicians' decision to maintain same treatment or to escalate therapy for all the mean and maximum IOPs measured on each single day and over a 2- or 3-day period (p < 0.002). CONCLUSION: Our results suggest that the presence of high IOP values obtained with self-tonometry supports an intensification of glaucoma treatment. Self-tonometry provides clinicians with an important complement for clinical decision-making, and under- or over-treatment may be avoided for the benefit of patients.

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This case-control study aims to compare the efficacy, safety, and postoperative burden of MicroShunt versus trabeculectomy. The first consecutive cohort of MicroShunt procedures (n = 101) was matched to recent historical trabeculectomy procedures (n = 101) at two London hospital trusts. Primary endpoints included changes in intraocular pressure (IOP) and glaucoma medications. Secondary outcome measures included changes in retinal nerve fibre layer (RNFL) thickness, rates of complications, further theatre interventions, and the number of postoperative visits. From the baseline to Month-18, the median [interquartile range] IOP decreased from 22 [17-29] mmHg (on 4 [3-4] medications) to 15 [10-17] mmHg (on 0 [0-2] medications) and from 20 [16-28] mmHg (on 4 [3-4] medications) to 11 [10-13] mmHg (on 0 [0-0] medications) in the MicroShunt and trabeculectomy groups, respectively. IOP from Month-3 was significantly higher in the MicroShunt group (p = 0.006), with an increased number of medications from Month-12 (p = 0.024). There were greater RNFL thicknesses from Month-6 in the MicroShunt group (p = 0.005). The rates of complications were similar (p = 0.060) but with fewer interventions (p = 0.031) and postoperative visits (p = 0.001) in the MicroShunt group. Therefore, MicroShunt has inferior efficacy to trabeculectomy in lowering IOP and medications but provides a better safety profile and postoperative burden and may delay RNFL loss.

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Aim: "Consensual ophthalmotonic reaction" refers to changes in intraocular pressure (IOP) in one eye, which is accompanied by a corresponding change in IOP in the contralateral eye. This study evaluates whether monocular administration of selective laser trabeculoplasty (SLT) leads to a consensual ophthalmotonic reaction and how long this effect lasts. Materials and methods: A retrospective chart review was performed on patients receiving SLT at Kresge Eye Institute in Detroit, MI, from January 2015 to August 2016. Patients were excluded if they had previous history of glaucoma incisional and/or laser procedures; required additional laser trabeculoplasty; had glaucoma medication changes during the follow-up period; experienced no decrease in IOP during the follow-up period; or had a diagnosis of angle closure on gonioscopy. Various demographic, clinical, and surgical data were collected. IOP measurements were collected at baseline and postoperatively at 1-3 months, 4-9 months, and 12-15 months. Results: At all follow-up periods, the IOP of the treated eye was decreased from baseline IOP (p ≤ 0.05, paired t-test). For the fellow eye, there was a statistically significantly decrease from baseline up to the 4-9 months follow-up period (p ≤ 0.05, paired t-test). Linear regression analysis of the percent reduction in IOP from baseline in the SLT-treated eye with the fellow eye shows a mild correlation at all-time points: R2 = 0.284 (p < 0.001) at 1-3 months; R2 = 0.348 (p < 0.001) at 4-9 months; R2 = 0.118 (p = 0.054) at 12-15 months. Conclusion: This study showed that monocular administration of SLT results in a consensual ophthalmotonic reaction. The consensual ophthalmotonic reaction appears to last for up to 4-9 months. Clinical significance: Therefore, although SLT does lead to a consensual ophthalmotonic reaction, monocular administration of SLT is not a reliable method of long-term IOP control for the contralateral non-SLT-treated eye. How to cite this article: Nassiri N, Mei F, Tokko H, et al. Consensual Ophthalmotonic Reaction Following Selective Laser Trabeculoplasty. J Curr Glaucoma Pract 2022;16(1):36-40.

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Aqueous gels formulated using hydrophilic polymers (hydrogels) and those based on stimuli-responsive polymers (in situ gelling or gel-forming systems) attract increasing interest in the treatment of several eye diseases. Their chemical structure enables them to incorporate various ophthalmic medications, achieving their optimal therapeutic doses and providing more clinically relevant time courses (weeks or months as opposed to hours and days), which will inevitably reduce dose frequency, thereby improving patient compliance and clinical outcomes. Due to its chronic course, the treatment of glaucoma may benefit from applying gel technologies as drug-delivering systems and as antifibrotic treatment during and after surgery. Therefore, our purpose is to review current applications of ophthalmic gelling systems with particular emphasis on glaucoma.

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Objective: The aim of this study was to assess the ocular morbidity due to delayed presentation in glaucoma patients because of COVID lockdown. Methodology: This was a retrospective study of 15 cases presented to us between October 2020 and February 2021. Cause of glaucoma in our study group was either primary angle closure, pseudoexfoliation, lens-induced glaucoma, or neovascular glaucoma. The cause of delayed presentation was identified and patients were treated with antiglaucoma medications, Nd-Yag laser, and surgery as per the standard treatment protocol. Results: With both medical and surgical intervention, some useful vision was restored in five cases while in rest it was not salvageable. The vision in the affected eye ranged from 6/60 in Snellen's chart to perception of light and projection of rays positive. Better results were achieved in angle, closure, and lens-induced glaucoma cases as compared to neovascular glaucoma cases. Conclusion: The time of presentation in such cases is as important as the etiopathogenesis. We are left with limited treatment options if the presentation is late. The lockdown ended but it unraveled quite a few instances of disease presentation which were totally preventable under normal circumstances. Introspection on finding out newer and proactive methods to reach people suffering from such irreversible but preventable diseases is the need of the day especially when preventable but irreversible diseases like glaucoma are considered.

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Objectives: To analyze emergency and outpatient admissions by glaucoma patients during complete lockdown due to coronavirus disease 2019 (COVID-19) to assess the effect of pandemic-related complete lockdown on glaucoma patients. Materials and Methods: This retrospective chart review included all glaucoma patients who were either examined and/or underwent emergency surgery between March 11, 2020 and May 31, 2020, a period of complete COVID-19-related lockdown in Turkey. The data were compared with data from patients seen during the same time period in 2019. Visual acuity and intraocular pressure data from patients examined after the lifting of the lockdown were also evaluated. Results: According to Turkish Ministry of Health guidelines, only emergency examinations and surgeries could be performed during the 82 days of the COVID-19 lockdown. During this period, a total of 11 eyes of 10 patients were operated and 123 patients were examined in the outpatient clinic. During the same period in 2019, 122 surgeries were performed, 39 of which were emergencies. In the first 4 weeks after the lockdown ended, 163 patients were examined at the outpatient clinic and marked visual loss was detected in 10 eyes of 9 (5.5%) patients who did not attend follow-up visits due to the pandemic. Conclusion: During the lockdown, emergency surgeries related to glaucoma decreased by 71.7% and marked visual loss was detected in 5.5% of the patients examined after the lockdown. These findings suggest that some patients were unable to present to clinics despite needing emergency care.

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