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Background/aimsThis work aims to clarify whether micropulse transscleral cyclophotocoagulation (MPCPC) is gentler in terms of postoperative inflammation and is better tolerated compared with continuous wave cyclophotocoagulation (CWCPC).MethodsProspective, randomised controlled, interventional, single-centre trial performed at the Ludwig Maximilians University Munich from January 2020 to July 2023. In all patients, a laser flare meter was used to measure anterior chamber flare (ACF). Central macular thickness (CMT) was assessed using optical coherence tomography. To quantify pain perception and quality of life (QoL), patients completed the Visual Analogue Scale (VAS) and the Glaucoma Activity Limitation 9 questionnaire.Results60 eyes of 60 patients were included, with 30 eyes in the MPCPC group and 30 eyes in the CWCPC group. A significantly higher increase in ACF was found after CWCPC as compared with MPCPC at 1 day (p=0.004) and 1 week after surgery (p=0). ACF values equalised at week 6 (p=0.270) and month 3 (p=0.610). The increase in ACF at week 1 did not show a significant correlation with the final decrease in intraocular pressure (IOP, p=0.465). Moreover, the CWCPC group showed a markedly higher increase in CMT (165.5 (15–354) µm vs 55.8 (24–141) µm). VAS and QoL scores did not show to be significantly different.ConclusionsCompared with MPCPC, patients treated with CWCPC presented with more marked ACF only in the early postoperative period. ACF did not correlate with final IOP. CWCPC and MPCPC are equally well tolerated in terms of pain perception and QoL, but CWCPC may cause more severe inflammatory macular oedema.

In this manuscript we develop a deep learning algorithm to improve estimation of rates of progression and prediction of future patterns of visual field loss in glaucoma. A generalized variational auto-encoder (VAE) was trained to learn a low-dimensional representation of standard automated perimetry (SAP) visual fields using 29,161 fields from 3,832 patients. The VAE was trained on a 90% sample of the data, with randomization at the patient level. Using the remaining 10%, rates of progression and predictions were generated, with comparisons to SAP mean deviation (MD) rates and point-wise (PW) regression predictions, respectively. The longitudinal rate of change through the VAE latent space (e.g., with eight dimensions) detected a significantly higher proportion of progression than MD at two (25% vs. 9%) and four (35% vs 15%) years from baseline. Early on, VAE improved prediction over PW, with significantly smaller mean absolute error in predicting the 4 th , 6 th and 8 th visits from the first three (e.g., visit eight: VAE8: 5.14 dB vs. PW: 8.07 dB; P < 0.001). A deep VAE can be used for assessing both rates and trajectories of progression in glaucoma, with the additional benefit of being a generative technique capable of predicting future patterns of visual field damage.

To analyze the direct and indirect associations between structural, functional, and systemic variables in patients with primary open-angle glaucoma (POAG), normal-tension glaucoma (NTG), and controls using structural equation modeling (SEM). A cross-sectional observational study was conducted including 156 participants: 55 with POAG, 49 with NTG, and 52 age- and sex-matched controls. Clinical variables included intraocular pressure (IOP), central corneal thickness (CCT), vertical cup-to-disc ratio (VCDR), and visual-field mean deviation (MD). Systemic variables comprised age and cardiovascular risk factors (hypertension, diabetes, and dyslipidemia). SEM was applied to assess direct and indirect effects on the diagnosis of glaucoma. The model showed a good overall fit ( (9) = 15.968; = 0.068; /df = 1.774; CFI = 0.972; RMSEA = 0.071) and explained 46.0% of the variance in glaucoma diagnosis (  = 0.460). The most influential predictors were VCDR (  = 0.40), age (  = 0.14), and cardiovascular risk factors (  = 0.19). A significant negative correlation was observed between CCT and MD (  = -0.29), indicating greater functional damage in eyes with thinner corneas. An inverse association between cardiovascular risk burden and IOP was also identified (  = -0.18). Our findings support the hypothesis of distinct glaucomatous phenotypes, including a vascular subtype with lower IOP and altered perfusion, potentially influenced by systemic comorbidities and chronic treatments. Reduced CCT was also confirmed as an independent marker of advanced functional loss. SEM helps disentangle complex mechanisms and may inform personalized therapeutic strategies, particularly in NTG.

Background/AimsTo compare intraocular pressure (IOP) measurements using a prototype smartphone tonometer with other tonometers used in clinical practice.MethodsPatients from an academic glaucoma practice were recruited. The smartphone tonometer uses fixed force applanation and in conjunction with a machine-learning computer algorithm is able to calculate the IOP. IOP was also measured using Goldmann applanation tonometry (GAT) in all subjects. A subset of patients were also measured using ICare, pneumotonometry (upright and supine positions) and Tono-Pen (upright and supine positions) and the results were compared.Results92 eyes of 81 subjects were successfully measured. The mean difference (in mm Hg) for IOP measurements of the smartphone tonometer versus other devices was +0.24 mm Hg for GAT, −1.39 mm Hg for ICare, −3.71 mm Hg for pneumotonometry and −1.30 mm Hg for Tono-Pen. The 95% limits of agreement for the smartphone tonometer versus other devices was −4.35 to 4.83 mm Hg for GAT, −6.48 to 3.70 mm Hg for ICare, −7.66 to −0.15 mm Hg for pneumotonometry and −5.72 to 3.12 mm Hg for Tono-Pen. Overall, the smartphone tonometer results correlated best with GAT (R2=0.67, p<0.001). Of the 92 videos, 90 (97.8%) were within ±5 mm Hg of GAT and 58 (63.0%) were within ±2 mm Hg of GAT.ConclusionsPreliminary IOP measurements using a prototype smartphone-based tonometer was grossly equivalent to the reference standard.

PurposeTo describe the results of darkroom prone provocative testing (DRPPT) in primary angle closure suspects (PACS) and to compare the findings to controls with open angles.Methods889 subjects with PACS in the Zhongshan Angle Closure Prevention Trial (a randomised controlled trial to compare prophylactic laser iridotomy to no treatment in PACS) and 89 with open angles in the 5-year follow-up of Liwan Eye Study were placed in a darkroom face down for 15 min. Intraocular pressure (IOP) was measured immediately before and after DRPPT.ResultsPACS participants were of similar age than controls (59.3 vs 60.5), more often female (82.9% vs 58.4%) and had lower IOP (14.3 vs 15.2 mm Hg). The average IOP increases after DRPPT was 4.3±3 mm Hg in PACS and 5.2±2.8 in controls (p<0.05). 20.5% of controls and 13.9 % of those with PACS developed an IOP spike ≥8 mm Hg after DRPPT (p<0.05). Among PACS, 15.8 % of those with all four quadrants closed had an IOP elevation of ≥ 8 mm Hg as opposed to 10.0%–12.4 % with two or three closed quadrants (p<0.05). DRPPT failed to predict who would reach a clinical trial endpoint over 6-year follow-up of those with PACS.ConclusionsA modified DRPPT failed to separate PACS from those with open angle. Although the test resulted in greater IOP elevation among those PACS participants with all four quadrants closed than in those with two or three closed quadrants, it did not offer any insight into the risk of developing acute or chronic angle closure disease over 6-year follow-up.

Background/aimsTo compare the accuracy of self-obtained, partner-obtained and trainer-obtained measurements using the handheld Icare Home rebound tonometer with Goldmann applanation tonometry (GAT), and to evaluate the acceptability to subjects of Icare Home measurement.Methods76 subjects were trained to use Icare Home for self-measurement using a standardised protocol. A prespecified checklist was used to assess the ability of a subject to perform self-tonometry. Accuracy of Icare Home self-measurement was compared with GAT using one eye per subject, randomly selected. Bland-Altman difference analysis was used to compare Icare Home and GAT intraocular pressure (IOP) estimates. Acceptability of self-tonometry was evaluated using a questionnaire.Results56 subjects (74%, 95% CI 64 to 84) were able to correctly perform self-tonometry. Mean bias (95% limits of agreement) was 0.3 mm Hg (−4.6 to 5.2), 1.1 mm Hg (−3.2 to 5.3) and 1.2 mm Hg (−3.9 to 6.3) for self-assessment, partner-assessment and trainer-assessment, respectively, suggesting underestimation of IOP by Icare Home tonometry. Differences between GAT and Icare Home IOP were greater for central corneal thickness below 500 µm and above 600 µm than data points within this range. Acceptability questionnaire responses showed high agreement that the self-pressure device was easy to use (84%), the reading was quick to obtain (88%) and the measurement was comfortable (95%).ConclusionsIcare Home tonometry can be used for self-measurement by a majority of trained subjects. IOP measurements obtained using Icare Home tonometry by self-assessment and third party-assessment showed slight underestimation compared with GAT.

Background/AimsTo determine if selective laser trabeculoplasty (SLT) is superior to topical medication as a first-line treatment for glaucoma on quality of life (QoL) and clinical outcomes.MethodsIn this international, longitudinal, multisite randomised controlled trial, treatment naïve mild-to-moderate primary open angle or exfoliation glaucoma patients were randomised 1:1 to SLT or topical medication. Glaucoma-specific QoL (primary outcome) was measured using the Glaucoma Outcomes Assessment Tool (GOAT; 342 items, 12 domains). Secondary outcomes included rate of successful intraocular pressure (IOP) reduction (>25% reduction from baseline) and presence of ocular surface disease including conjunctival hyperaemia and eyelid erythema. Our intention-to-treat analysis was performed at months 12 and 24.ResultsOf 167 enrolled patients, 83 and 84 were randomised to SLT and topical medication, respectively; and 145 (n=75 SLT, n=70 medication) completed 24-month follow-up. While both treatment arms achieved significant within-group gains in GOAT outcomes at both endpoints, SLT patients reported a greater between-group improvement in ‘social well-being’ compared with medication patients (mean±SE=0.28±0.13; p=0.034) at 24 months. At month 24, the rate of successful IOP reduction was 18.6% (95% CI 3.0% to 34.3%, p=0.022) higher (absolute difference) in the medication compared with SLT group. More individuals in the medication group had conjunctival hyperaemia and eyelid erythema compared with SLT at 24 months.ConclusionOverall, we did not find evidence that SLT was superior to medication in improving glaucoma-specific QoL. While we found superior IOP reduction in the medication arm, eyelid erythema and conjunctival hyperaemia were more prevalent in these patients compared with the SLT group.Trial registrationACTRN12611000720910.

This study investigated the relationship between thin central corneal thickness (CCT) and lamina cribrosa (LC) morphology in patients with normal-tension glaucoma. Thin CCT was defined as a corneal thickness of less than 500 μm in both eyes, and all included patients had a corrected intraocular pressure of less than 20 mmHg. To investigate the LC-morphological characteristics observed in the Thin-CCT group (N = 60) , the Normal-CCT group (N = 36) was set as the control. A subgroup analysis was performed on Progressors and Non-progressors using the visual field’s progression rate to identify progression-related risk factors. The LC posterior displacement index was higher in the Thin-CCT group and the temporal anterior laminar insertion depth (ALID) was deeper in Progressors . In multivariate analyses, the risk of glaucoma progression increased with older age, thinner CCT, worse visual filed, deeper temporal ALID, and deeper mean LC depth. Notably, ALID showed a significant correlation with CCT. These findings suggest that in patients with normal-tension glaucoma, thinner CCT is associated with a more pronounced posterior displacement and deeper insertion of the LC, even under similar intraocular pressure conditions. The altered LC morphology observed in thin CCT may help explain the higher rate of glaucoma progression in this patient population.

Background To compare the success and safety of microcatheter-assisted 360° trabeculotomy (MCAT) with conventional probe trabeculotomy in a large, heterogeneous cohort of children with primary or secondary glaucoma. Methods In this prospective, multicenter, observer-blinded, randomized controlled trial, 76 children (152 eyes) with bilateral primary or secondary childhood glaucoma aged ≤ 12 years will be included. Each child acts as own control using a paired-eye design: One eye is allocated to MCAT (experimental intervention), achieving a 360° trabeculotomy, the other eye to the probe trabeculotomy (control intervention) which enables a trabeculotomy over 90 to 120°. Each child receives both procedures (paired-eye design). The worse eye is treated first; the surgical method is randomized. Patients and observers are masked to the procedures. The patients are followed up for 24 months. The primary endpoint is complete success (IOP < 18 mmHg at 24 months without medication and revision surgery; with MCAT: successful probing of > 120° is also required for success) at 24 months of follow-up. The primary analysis is performed in the intention-to-treat population using McNemar test stratified by center. Discussion The PIRATE study is a multicenter randomized controlled study comparing MCAT with conventional probe trabeculotomy in a large and heterogeneous childhood glaucoma population. It will provide data on the success and safety of both techniques and clarify if MCAT is superior to probe trabeculotomy. Trial registration German Clinical Trials Register, DRKS-ID: DRKS00034139. Registered on April 24, 2024. https://drks.de/search/en/trial/DRKS00034139 . https://trialsearch.who.int/Trial2.aspx?TrialID=DRKS00034139 .

Background This study aimed to evaluate the incidence and risk factors for early transient intraocular pressure (IOP) elevation after penetrating canaloplasty (PCP) in patients with primary open-angle glaucoma (POAG), primary angle-closure glaucoma (PACG) and secondary glaucoma (SG). Methods This retrospective study included 198 eyes of 198 patients with glaucoma. Participants were classified as normal IOP, early transient high IOP (E-HIOP [Tst]), early persistent IOP elevation, late transient high IOP, and late persistent IOP elevation, based on the period and persistence of postoperative IOP elevation. Results E-HIOP (Tst) developed in 34.8%, 33.3%, and 40.9% of eyes with POAG, PACG, and SG, respectively. In comparison with normal IOP group, we observed the following variations in E-HIOP (Tst) cohorts: 8 − 10 years younger in patients with POAG and PACG; higher prevalence of hyphema (45.5% vs. 20.5%) in POAG; higher baseline IOP in PACG and SG (7 − 8 mmHg); higher preoperative IOP maximum (IOP pre−max ) in SG (all p  < 0.05). Higher IOP pre−max was a risk factor for E-HIOP (Tst) in PACG and SG ( p  < 0.05). Conclusions Nearly 30 − 40% of eyes developed E-HIOP (Tst) after PCP. E-HIOP (Tst) tended to develop in younger participants and those with higher preoperative IOP. A higher IOP pre−max was a risk factor for E-HIOP (Tst) in PACG and SG.