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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.

Background/aimsTo assess baseline ocular parameters in the prediction of long-term intraocular pressure (IOP) control after clear lens extraction (CLE) or laser peripheral iridotomy (LPI) in patients with primary angle closure (PAC) disease using data from the Effectiveness of Early Lens Extraction for the treatment of primary angle-closure glaucoma (EAGLE) tria.MethodsThis study is a secondary analysis of EAGLE data where we define the primary outcome of ‘good responders’ as those with IOP<21 mm Hg without requiring additional surgery and ‘optimal responders’ as those who in addition were medication free, at 36-month follow-up. Primary analysis was conducted using a multivariate logistic regression model to assess how randomised interventions and ocular parameters predict treatment response.ResultsA total of 369 patients (182 in CLE arm and 187 in LPI arm) completed the 36-month follow-up examination. After CLE, 90% met our predefined ‘good response’ criterion compared with 67% in the LPI arm, and 66% met ‘optimal response’ criterion compared with 18% in the LPI arm, with significantly longer drops/surgery-free survival time (p<0.05 for all). Patients randomised to CLE (OR=10.1 (6.1 to 16.8)), Chinese (OR=2.3 (1.3 to 3.9)), and those who had not previously used glaucoma drops (OR=2.8 (1.6 to 4.8)) were more likely to maintain long-term optimal IOP response over 36 months.ConclusionPatients with primary angle closure glaucoma/PAC are 10 times more likely to maintain drop-free good IOP control with initial CLE surgery than LPI. Non-Chinese ethnicity, higher baseline IOP and using glaucoma drops prior to randomisation are predictors of worse long-term IOP response.

Purpose To investigate the postoperative intraocular pressure (IOP) control and identify the factors associated with failure of initial Ex-PRESS surgery in patients with open-angle glaucoma for 3 years. Methods A total of 79 patients with medically uncontrolled open-angle glaucoma (55 normal-tension glaucoma and 24 primary open-angle glaucoma) were enrolled. All patients underwent Ex-PRESS implantation (including combined cataract surgery). The outcome measure was the survival rate using life table analysis, the failure was defined as IOP of > 18 mmHg (criterion A), > 15 mmHg (criterion B) or > 12 mmHg (criterion C) and/or IOP reduction of < 20% from baseline (each criterion) without any glaucoma medications. The Cox proportional hazards model was used to identify risk factors for IOP management defined as the above criterion.  Results The mean preoperative IOP was 19.3 ± 5.8 mmHg. At 36 months, the mean IOP was 11.8 ± 3.6 mmHg with a mean IOP change of 7.5 mmHg (reduction rate 39.0%). The cumulative probability of success was 58% (95%CI: 42–64%) (criterion A), 48% (95%CI: 37–59%) (criterion B) and 30% (95%CI: 20–40%) (criterion C). In multivariate analyses, factors that predicted poor IOP control included the intervention of bleb needling after 6 months after the surgery (HR: 2.43; 95%CI: 1.35–4.37; P  = 0.032). Transient hypotony was observed in 4 patients. Conclusion The implementation of bleb needling after Ex-PRESS surgery in the late postoperative period was suggested to be the main risk factor for achieving lower IOP.

Purpose The aim of this study was to define the capability of ChatGPT-4 and Google Gemini in analyzing detailed glaucoma case descriptions and suggesting an accurate surgical plan. Methods Retrospective analysis of 60 medical records of surgical glaucoma was divided into “ordinary” ( n  = 40) and “challenging” ( n  = 20) scenarios. Case descriptions were entered into ChatGPT and Bard’s interfaces with the question “What kind of surgery would you perform?” and repeated three times to analyze the answers’ consistency. After collecting the answers, we assessed the level of agreement with the unified opinion of three glaucoma surgeons. Moreover, we graded the quality of the responses with scores from 1 (poor quality) to 5 (excellent quality), according to the Global Quality Score (GQS) and compared the results. Results ChatGPT surgical choice was consistent with those of glaucoma specialists in 35/60 cases (58%), compared to 19/60 (32%) of Gemini ( p  = 0.0001). Gemini was not able to complete the task in 16 cases (27%). Trabeculectomy was the most frequent choice for both chatbots (53% and 50% for ChatGPT and Gemini, respectively). In “challenging” cases, ChatGPT agreed with specialists in 9/20 choices (45%), outperforming Google Gemini performances (4/20, 20%). Overall, GQS scores were 3.5 ± 1.2 and 2.1 ± 1.5 for ChatGPT and Gemini ( p  = 0.002). This difference was even more marked if focusing only on “challenging” cases (1.5 ± 1.4 vs. 3.0 ± 1.5, p  = 0.001). Conclusion ChatGPT-4 showed a good analysis performance for glaucoma surgical cases, either ordinary or challenging. On the other side, Google Gemini showed strong limitations in this setting, presenting high rates of unprecise or missed answers.

ForewordThe only time is now. Every “now” is unique. Responsible persons ask themselves, “How can I act well now?” The answers will differ for every person, because just as every situation is unique, so is every person different from every other person. But surely there must be some algorithm that will assist us in coming to the right answer. Unfortunately, no, for there is no right answer. There is only an answer that is as appropriate as we can conclude at that moment in that situation. No written guidelines can apply appropriately to every unique situation.Unfortunately we physicians have been suckled on a fallacy: “What’s good for the goose is good for the gander.” Phrased in medical terms, “normal findings are good, and abnormal findings are bad.” This is too simple, and often wrong.Good clinicians know that care must be personalized for it to be optimal. So-called normal findings give rough guidance, sometimes applicable to groups, but frequently wrong for individuals. Consider intraocular pressure (IOP). A normal IOP of 15 mmHg good for some and bad for others, and an abnormal IOP of 30 mmHg is good for some and bad for others. We are so bombarded by the myth of the sanctity of the standard distribution curve that it is hard to think independently and specifically. Also, unfortunately, doctors are prone to decide for patients, often on the basis of normative data that is not relevant or important for the particular patient. That we do this is not surprising, as we want to help, and so we default to what seems to be the easy, safe (non-thinking) way, in which we do not have to hold ourselves accountable for the outcome.Somebody HAS to decide, or else we would be living in an anarchical world. Also true. And because none of us knows as much as we need to know to act appropriately, we seek advice from so-called “experts.”For us to care for people well it is essential that we consider what others recommend. So we look to experts, as we should. However, experts are sometimes right and sometimes wrong. Remember that von Graefe in 1860 recommended surgical iridectomy for all glaucoma, Elliot recommended mustard plaster between the shoulders for glaucoma, Becker based treatment on tonographic findings, Weve reported 100% success with penetrating cyclodiathermy in glaucoma, Lichter advised against laser trabeculoplasty, many thought Cypass was great, and the investigators in the Advanced Glaucoma Intervention Study indicated that an IOP usually around 12 mmHg was better than one usually around 20 mmHg. All wrong. What the authors of these guidelines have done excellently, is to provide a general framework on which ophthalmologists can hang pieces of evidence, so as to be able to evaluate the validity and the importance of that evidence. In doing this meticulously they have provided a valuable service to all ophthalmologists, none of whom individually have either the time or the skill to be fully informed. In their own practices the authors consider whether valid information is relevant for the particular person being considered. That process of considering relevance is essential, always. And relevance is based on the particular unique patient, unique doctor and unique situation. The only guideline the authors can provide in this regard is to remind us all to consider relevance with all patients in all situations, and from the patient’s perspective. Even more important than the service to ophthalmologists is the benefit to patients that will result from thoughtful use of these guidelines.We need, also, to remember that diagnoses are generic, and that within every diagnosis there are differences. For example what does a diagnosis of primary open angle mean? Some of those affected will rapidly go blind despite the most thoughtful treatment and others will keep their sight even without treatment. What does a diagnosis of Chandler’s Syndrome mean? In some, surgery works well, and, in others, poorly. So one never directs diagnosis and treatment at a condition, but rather at the person, the objective being the wellness of that person.The previous European Glaucoma Society Guidelines are used internationally. It is good that the EGS is again providing updated, useful information.The Guidelines are a practical, inspirational contribution.George L. Spaeth, BA, MD.Esposito Research Professor, Wills Eye Hospital/Sidney Kimmel Medical College/Thomas Jefferson Universitywww.eugs.orgThe Guidelines writers, authors and contributorsAugusto Azuara-Blanco (Editor)Luca BagnascoAlessandro BagnisJoao Barbosa BredaChiara BonzanoAndrei BrezhnevAlain BronCarlo A. CutoloBarbara CvenkelStefano GandolfiTed Garway HeathIlmira GazizovaGus GazzardFranz GrehnAnders HeijlCornelia HirnGábor HollóAnton HommerMichele IesterIngrida JanulevicieneGauti JóhannessonMiriam KolkoTianjing LiJosé Martínez de la CasaFrances Meier-GibbonsMaria MusolinoMarta PazosNorbert PfeifferSergey PetrovLuis Abegao PintoRiccardo ScottoIngeborg StalmansGordana SunaricMégevandErnst TammJohn ThygesenFotis TopouzisMarc Töteberg-HarmsCarlo E. Traverso (Editor)Anja TuulonenZoya VeselovskayaAnanth ViswanathanIlgaz YalvacThierry ZeyenGuidelines CommitteeAugusto Azuara-Blanco (Chair)Carlo E. Traverso (Co-chair)Manuele Michelessi (NGP Co-chair)Luis Abegao PintoMichele IesterJoao BredaCarlo A. CutoloPanayiota FountiGerhard GarhoeferAndreas KatsanosMiriam KolkoFrancesco OddoneMarta PazosVerena Prokosch-WillingCedric SchweitzerAndrew TathamMarc Toteberg-HarmsAcknowledgementsAnja TuulonenTed Garway HeathRichard WormaldTianjing LiManuele MichelessiJenny BurrAzuara-Blanco for their methodological oversight.Tianjing Li and Riaz Qureshi (US Cochrane Eye and Vision Group) and Manuele Michelessi (EGS) for leading the evidence review.Manuele MichelessiGianni VirgiliJoao Barbosa BredaCarlo A. CutoloMarta PazosAndreas KatsanosGerhard GarhoferMiriam KolkoVerena ProkoschPanayota FountiFrancesco OddoneAli Ahmed Al RajhiTianjing LiRiaz Qureshi and Azuara-Blanco for their contribution to the evidence review.Karen Osborn and Joanna Bradley from Glaucoma UK charity for their contribution to the section: ‘What matters to patients’ (https://glaucoma.uk)Additional contributions were made by the following people on specific topicsEleftherios AnastasopoulosPanayiota FountiGus GazzardFranz GrehnAnders HeijlGábor HollóFotis TopouzisAnja TuulonenAnanth ViswanathamThe team of Clinica Oculistica of the University of Genoa for medical editing and illustrationsLuca BagnascoAlessandro BagnisChiara BonzanoCarlo A. CutoloMichele LesterMaria MusolinoRoberta ParodiRiccardo ScottoWe would like to thank the following colleagues for their help in reviewing/editing section I.7. Landmark randomised controlled trials for glaucomaJoe CaprioliTed Garway Heath Gus Gazzard Divakar Gupta Anders Heijl Michael Kass Stefano Miglior David Musch Norbert Pfeiffer Thierry ZeyenExternal reviewsWe would like to thank the following societies and experts:World Glaucoma Association:Parul IchhpujaniMonisha NongpiurTanuj DadaSola OlawoyeJayme ViannaMin Hee SuhFarouk GarbaSimon SkalickyAlex HuangFarouk GarbaPradeep RamuluVerena ProkoschCarolina Gracitelli;American Glaucoma Society:Josh Stein;and Latin-American Glaucoma Society:Daniel GrigeraWe would like to thank the external reviewers whose comments are listed on https://www.eugs.org/eng/guidelines.aspThe EGS executive committeeTed Garway Heath (President)Fotis Topouzis (Vice President)Ingeborg Stalmans (Treasurer)Anja Tuulonen (Past President)Luis Abegao PintoAndrei BrezhnevAlain BronGauti JóhannessonNorbert PfeifferThe board of the European Glaucoma Society FoundationCarlo E. Traverso (Chair)Fotis Topouzis (Vice Chair)Franz GrehnAnders HeijlJohn ThygesenThierry ZeyenGlossary5-FU 5-fluorouracilAAC Acute angle closureACG Angle closure glaucomaAGIS Advanced glaucoma intervention studyAH Aqueous humourAI Artificial intelligenceALT Argon laser trabeculoplastyBAC Benzalkalonium chlorideCCT Central corneal thicknessCDR Cup to disc ratioCIGTS Initial glaucoma treatment studyCNTGS Collaborative normal tension glaucoma studyDCT Dynamic contour tonometryEAGLE Effectiveness of early lens extraction for the treatment of primary angle closure glaucomaEGPS European glaucoma prevention studyEGS European glaucoma societyEMA The european medicines agencyEMGT Early manifest glaucoma trialFC Flow chartFDT Frequency doubling technologyFC Fixed combinationFL Fixation lossesFN False negativesFP False positiveGAT Goldmann applanation tonometryGHT The glaucoma hemifield testGRADE Grading of recommendations, assessment, development and evaluationsHRT Heidelberg retina tomographyICE Irido-corneal endothelial syndromeIOL Intraocular lensIOP Intraocular pressureITC Iridotrabecular contactIV IntravenousLIGHT Laser in glaucoma and ocular hypertension trialLPI Laser peripheral iridotomyLV Loss varianceMD Mean defect or mean deviationMMC Mitomycin CNCT Non-contact tonometryNd:YAG Neodymium-doped yttrium aluminum garnetNTG Normal tension glaucomaOAG Open angle glaucomaOCT Optical coherence tomographyOHT Ocular hypertensionOHTS The ocular hypertension treatment studyONH Optic nerve headORA Ocular response analyserOSD Ocular surface diseasePAC Primary angle closurePACG Primary angle closure glaucomaPACS Primary angle closure suspectPAS Peripheral anterior synechiaePCG Primary congenital glaucomaPDS Pigment dispersion syndromePGA Prostaglandin analoguePOAG Primary open angle glaucomaPG Pigmentary glaucomaPSD Pattern standard deviationPXF Pseudoexfoliation syndromePXFG Pseudoexfoliation glaucomaRCT Randomised controlled trialRNFL Retinal nerve fiber layerRoP Rate of progressionSAP Standard automated perimetrySITA Swedish interactive threshold algorithmSLT Selective laser trabeculoplastySWAP Short-wavelength automated perimetryTLPI Thermal laser peripheral iridoplastyTM Trabecular meshworkUBM Ultrasound biomicroscopyUGH Uveitis-glaucoma-hyphema syndromeUKGTS United Kingdom glaucoma treatment studyVEGF Vascular endothelial grow

Background/Objective Management of concomitant cataract and glaucoma depends on the stage of glaucoma and the patient’s situation. There are different surgical options for handling visually significant cataract and mild-to-moderate open-angle glaucoma (OAG). We aimed to compare the one-year results of phacoemulsification alone versus phacoviscocanalostomy in these patients. Subjects/Methods This was a parallel-arm, single-masked, randomized-controlled trial, conducted at Farabi Eye Hospital, Tehran, Iran between January 2016 and January 2018. We enrolled 89 eyes from 89 patients with mild-to-moderate primary OAG or pseudoexfoliative glaucoma (PEXG) with visually significant age-related cataract. They randomly underwent phacoemulsification alone ( n  = 44) or combined phaco-viscocanalostomy ( n  = 45). All patients had a 12-month follow-up period, and the mean intraocular pressure (IOP), the number of antiglaucoma medications, and complete and qualified success rates were compared. Results After the 1st and 3rd months, the mean IOP showed significantly decreased in the phaco-visco group compared to the phaco group ( P  < 0001 and P  = 0.004, respectively), but it was not statistically significant at 6th and 12th months ( P  = 0.540 and P  = 0.530). The need for antiglaucoma medication and the complete and qualified success rates were significantly in favour of the phaco-visco group in all postoperative visits ( P  < 0.05). Conclusions Although both phacoemulsification alone and phacoviscocanalostomy procedures can be considered for patients with mild-to-moderate OAG, we found better success rates using phacoviscocanalostomy. Therefore, if the surgeon is an expert in performing this technique, this non-penetrating procedure can be applied in patients with visually significant cataract and earlier stages of OAG, especially in patients with PEXG.

Purpose To clarify recent trends in glaucoma surgery in Japan, including minimally invasive glaucoma surgery. Study design Retrospective cohort study. Methods We used the Diagnostic Procedure Combination database, a nationwide administrative database in Japan. Patients who underwent glaucoma-related procedures were included. We calculated the number of surgeries stratified by procedures and age categories. We also investigated the number of glaucoma-related procedures in combination with cataract surgery. Results From fiscal years 2011 to 2019, we identified 134,331 glaucoma-related procedures at 720 hospitals. The total number of glaucoma-related procedures increased by 215% from 6516 in 2011 to 20,569 in 2019. The numbers of filtering surgeries, trabeculotomies, and glaucoma drainage devices with plates [GDD(p +)] procedures significantly increased ( P  = 0.002, 0.002, and 0.006, respectively), whereas the number of cyclocryotherapy procedures significantly decreased ( P  = 0.002). The number of iStent procedures increased by 49% from 371 in 2018 to 551 in 2019. The ≥ 65 year age group accounted for > 80% of the iStent procedures. In the 0 to 14 year age group, trabeculotomy accounted for about 70% of the procedures, and the GDD(p +) procedure became the second most common procedure after trabeculotomy because of the decrease in filtering surgeries. Among combination surgeries, trabeculotomy was most frequently performed. The proportion of combination surgery increased, especially in trabeculotomy. Conclusions The total number of glaucoma-related procedures increased throughout the observation period. Before 2017 filtering surgery was the most common procedure, whereas trabeculotomy was most common after 2018. The proportion of trabeculotomies performed in combination with cataract surgery continuously increased.

Minimally invasive glaucoma surgery aims to provide a medication-sparing, conjunctival-sparing, ab interno approach to intraocular pressure reduction for patients with mild-to-moderate glaucoma that is safer than traditional incisional glaucoma surgery. The current approaches include: increasing trabecular outflow (Trabectome, iStent, Hydrus stent, gonioscopy-assisted transluminal trabeculotomy, excimer laser trabeculotomy); suprachoroidal shunts (Cypass micro-stent); reducing aqueous production (endocyclophotocoagulation); and subconjunctival filtration (XEN gel stent). The data on each surgical procedure for each of these approaches are reviewed in this article, patient selection pearls learned to date are discussed, and expectations for the future are examined.

This study investigates vessel density (VD) changes in the lamina cribrosa (LC) and peripapillary sclera (PPS) after glaucoma surgery and their association with visual field (VF) progression. Primary open-angle glaucoma patients undergoing surgery for uncontrolled intraocular pressure (IOP) at Seoul St. Mary’s Hospital were included. Optical coherence tomography angiography (OCT-A) assessed VD changes in the LC and PPS one month post-surgery. VF progression was evaluated using mean deviation (MD) values from serial VF tests over six months. Of 80 enrolled eyes, 74 were analyzed. Laminar VD recovery occurred in 12 eyes (16.2%), with a 21.92% ± 7.37% increase, linked to shorter axial length (P = 0.005), thinner corneal thickness (P = 0.016), and less PPS VD change (P < 0.001). PPS VD recovery occurred in 14 eyes (18.9%), with an 18.50% ± 7.28% increase, associated with younger age (P = 0.043), longer axial length (P = 0.010), and lower preoperative PPS VD (P < 0.001). Multivariate analysis showed that both laminar and PPS VD recovery significantly reduced VF progression risk (P < 0.001). VD recovery, particularly in the LC, predicts better glaucoma outcomes. The distinct responses of LC and PPS to IOP reduction highlight the need to consider individual anatomical factors in glaucoma management.