Current Opinion in Ophthalmology最新文献

Purpose of review: Trabecular bypass stents and ab interno canaloplasty are popular micro-invasive glaucoma surgery approaches. This review summarizes recent evidence on outcomes, safety, and comparative effectiveness of these procedures.

Recent findings: Five to 7-year studies of the iStent and Hydrus combined with cataract surgery report sustained efficacy, slower visual field progression, and cost-effectiveness versus cataract surgery alone. However, position-related inflammatory and endothelial concerns have emerged for the Hydrus. Canaloplasty via several modalities can achieve intraocular pressure (IOP) reductions of 30-40% and medication reductions up to 60%, through as long as 6  years of follow-up, with few complications. Regarding standalone delivery, prospective data supports the use of the iStent infinite in refractory glaucoma. Standalone canaloplasty evidence is strongest for the OMNI and iTrack devices, while early STREAMLINE device outcomes are promising. Comparative studies find that the Hydrus may outperform earlier-generation iStents but not the iStent infinite; canaloplasty with the STREAMLINE device demonstrates near-equivalence to iStent inject W; and gonioscopy-assisted transluminal trabeculotomy achieves lower IOP than viscodilation, albeit with more frequent hyphema.

Summary: Both trabecular bypass and canaloplasty are effective interventions for open-angle glaucoma. Stents have the largest evidence base, while canaloplasty may offer similar efficacy without implant-related concerns.

Purpose of review: The purpose of this review was to summarize the literature on preclinical and clinical studies demonstrating the impact of the intestinal microbiome in noninfectious uveitis.

Recent findings: Preclinical studies using the experimental autoimmune uveitis (EAU) model have shown commensals such as Desulfovibrio and Prevotella , as well as Ruminococcaceae , associated with uveitis, which overlap with some clinical studies in uveitis patients. Interventions that target the microbiome that can be developed for the treatment of uveitis include antibiotics, fecal metabolites or metabolite agonists that are protective in uveitis, probiotics, dietary interventions, or fecal microbial transplant.

Summary: There is significant data supporting the importance of the intestinal microbiome in noninfectious uveitis through enrichment or depletion of certain gut bacteria as well as their metabolites. Targeting the intestinal microbiome or their metabolites might be a viable option for the treatment of noninfectious uveitis.

Purpose of review: This review aims to explore the connection between diet and nutritional intake with optic nerve health for patients with glaucoma.

Recent findings: Using the AAO Grading Criteria to determine level of evidence, Level 1 and Level 2 studies reviewed here examine associations between nutritional intake and glaucoma. Increasing consumption of dietary nitrates and retinols, incorporating the Mediterranean diet, and reducing intake of ultra-processed foods to lower glaucoma risk are supported by Level 1 evidence. Level 2 evidence suggests that dietary niacin, antioxidants, fruits, and vegetables have potential to improve optic nerve health and are associated with reduced glaucoma risk. Evidence from both Level 1 and Level 2 studies suggest that combining multiple beneficial dietary components may produce more meaningful effects to reduce glaucoma risk than single dietary factors alone.

Summary: Although some studies highlight the protective role of single dietary components against glaucoma, adopting a combination of beneficial dietary habits appears to be more effective as an adjunctive treatment to enhance optic nerve health and lower glaucoma risk.

Purpose of review: This review aims to cover the current landscape of antifibrotics used in glaucoma surgery and discuss developing antifibrotic agents. This review will inform the reader of new antifibrotic agents in development, clinical trials and clinical use that may alter the standard of care in glaucoma surgery in the near future.

Recent findings: Mitomycin-C (MMC) remains the most commonly used antifibrotic in glaucoma surgery to date with expanding use beyond trabeculectomy into the world of minimally invasive bleb forming surgeries. MMC continues to cause similar side effects due to toxicity which is a main driver of innovation. Newer antifibrotic agents are under investigation at all stages of drug development from bench research to clinical use. Familiar agents such as bevacizumab, sodium hyaluronate, and matrix metalloproteinases have shown noninferior success rates to MMC when used as adjunct agents with filtration surgery. Many other antifibrotics agents are being investigated with mixed results.

Summary: While MMC remains the gold standard antifibrotic agent for glaucoma surgery, there are numerous antifibrotic agents in development with safer side effect profiles and similar success rates that may change the surgical practice of glaucoma.

Purpose of review: To highlight emerging applications of anterior segment optical coherence tomography (AS-OCT) in the diagnosis, risk stratification, and management of angle closure glaucoma, with particular emphasis on the integration of artificial intelligence.

Recent findings: AS-OCT enables objective and reproducible quantification of anterior chamber angle parameters, overcoming the subjective and qualitative nature of traditional gonioscopy. Recent studies also suggest that AS-OCT can better predict angle closure disease and treatment outcomes than gonioscopy. Furthermore, advances in artificial intelligence-based image analysis have achieved expert-level accuracy in detecting angle closure and related anatomical features, facilitating personalized risk stratification and treatment planning. Overall, these advancements show strong potential for broad adoption to enhance clinical care and workflows.

Summary: High-resolution AS-OCT imaging combined with artificial intelligence-driven analytics is transforming the evaluation and management of angle closure disease. This noninvasive, objective approach has the potential to augment traditional methods, paving the way for more precise, personalized, and evidence-based care. Broad clinical adoption requires further rigorous prospective validation across large and diverse patient populations.

Purpose of review: Intravitreal antivascular endothelial growth factor (VEGF) injections are the cornerstone of retinal disease management but raise concern for intraocular pressure (IOP)-related complications. This review summarizes recent evidence on transient and sustained IOP elevation, structural and vascular effects, and management strategies.

Recent findings: Acute IOP spikes occur in nearly all eyes, typically resolving within an hour, but recovery is delayed in glaucoma and ocular hypertension (OHT), increasing optic nerve risk. Spike magnitude depends on patient factors (age, diabetes, vitreous volume, lens status) and technical factors (needle gauge, reflux, injection volume). Sustained IOP elevation is less predictable, with higher rates for bevacizumab and ranibizumab than aflibercept, and cumulative injection burden correlating with reduced outflow facility, retinal nerve fiber layer (RNFL) thinning, and greater need for glaucoma surgery. Acute spikes cause immediate RNFL thinning, while long-term loss is uncommon in nonglaucomatous patients. Prophylactic IOP-lowering therapy, paracentesis in high-risk eyes, and agent or delivery selection may mitigate risk.

Summary: Uniform protocols inadequately address patient-specific factors, warranting individualized management strategies. Prophylactic measures, careful agent selection, and multidisciplinary management can mitigate IOP-related complications in susceptible patients.

Purpose of review: Several high-quality prospective clinical trials have emerged in recent years that have provided evidence to support changes in management of glaucoma. This article reviews results from five recent landmark studies and discusses how they may impact clinical practice.

Recent findings: Five multicenter trials - LiGHT, ZAP, EAGLE, TAGS, and PTVT - have reshaped glaucoma management strategies. LiGHT demonstrated that selective laser therapy is a well tolerated and effective first-line therapy for open-angle glaucoma. ZAP investigated routine use of prophylactic laser peripheral iridotomy, emphasizing the importance of risk stratification in primary angle closure suspects. EAGLE established clear-lens exchange as a viable alternative to conventional treatment in select patients with angle closure anatomy. TAGS showed that primary trabeculectomy provides better intraocular pressure (IOP) control and reduced visual field progression in advanced disease. Finally, PTVT highlighted that both trabeculectomy and tube shunt surgeries remain appropriate initial surgeries, with procedure choice best guided by baseline IOP, risk tolerance, and patient goals.

Summary: Improvements in laser and surgical technology, increased understanding of the natural history of glaucoma, and evidence regarding the importance of early intervention in disease have led to fundamental changes in glaucoma practice. The five clinical trials reviewed in this article support these shifts and provide frameworks to guide clinical practice.

Glaucoma remains one of the leading causes of irreversible blindness worldwide with 80 million people affected and 3 million people blind from glaucoma [1] . Early diagnosis is critical for sight preservation and imaging modalities such as optical coherence tomography assist with the identification and quantification of glaucomatous changes. While widely used in the clinical setting, optical coherence tomography (OCT) has only more recently been optimized for use intraoperatively, in both portable and microscope-integrated forms. Intraoperative OCT (iOCT) provides visualization of both anterior and posterior structures in the eye. Gaining prominence in corneal and vitreoretinal surgery, iOCT has been shown to enhance surgical decision-making and improve outcomes in these fields. In glaucoma, iOCT has uses during tube shunt placement, minimally invasive glaucoma surgery, and trabeculectomy. This review highlights recent updates in iOCT use for glaucoma surgery.

Purpose of review: Conventional glaucoma drainage devices (GDDs), such as the Ahmed Glaucoma Valve and Baerveldt Glaucoma Implant, are widely used in childhood glaucoma. Recently, newer surgical options, including the PRESERFLO microshunt, Paul Glaucoma Implant (PGI), eyePlate-S, and ClearPath, have emerged with potential advantages to childhood glaucoma patients. This review summarizes current evidence regarding the design, outcomes, and safety profiles of these newer implants in childhood glaucoma patients.

Recent findings: The PRESERFLO offers a minimally invasive approach with favorable safety and intraocular pressure (IOP)-lowering outcomes in small pediatric case series, including eyes with prior GDD implantation. It is typically used with adjunctive mitomycin C. Technical modifications, such as ripcord insertion, reduce the risk of postoperative hypotony.The PGI features a valveless design that enables controlled flow via a 6-0 Prolene ripcord without external ligation. Additionally, its design reduces contact with the corneal endothelium and extraocular muscles. Retrospective series and early randomized data suggest good IOP control with an acceptable safety profile. The eyePlate-S features a valveless design that allows controlled flow through a 5-0 Prolene ripcord, eliminating the need for external ligation. Its tube has an external diameter comparable to the PGI (0.47 mm) but a larger internal diameter (0.18 mm in the eyePlate-S vs. 0.13 mm in the PGI). The eyePlate-200S can also be positioned between extraocular muscles, which may reduce the risk of postoperative diplopia. In addition, the thin, flexible silicone plate can be folded to facilitate implantation.The ClearPath enables flexible implantation in complex pediatric anatomy. Early multiyear results show sustained IOP reduction and decreased medication burden, with a success rate of 79% at 4 years.

Summary: Newer devices such as the PRESERFLO, PGI, and ACP demonstrate encouraging mid-term efficacy and safety in the management of childhood glaucoma, particularly in refractory cases or eyes with prior surgeries. While early outcomes are promising, larger comparative studies with extended follow-up are needed to better establish their long-term role relative to conventional GDDs in childhood glaucoma management.