Search

Introduction: Glaucoma is one of the most common causes of blindness and affects more than 70 million people worldwide. The disease is characterised by the loss of retinal ganglion cells associated with a progressive optic neuropathy, resulting in an impairment of visual functions, for example, visual field loss. Nowadays, the only modifiable risk factor is the increase in intraocular pressure, and its treatment is to lower this pressure by medication, laser treatment or surgery to avoid disease progression. New methods for preventing and reversing vision loss are thus urgently needed. Several small and two multicentre studies have presented evidence that repetitive transorbital alternating current stimulation (rtACS) can lead to long-lasting visual field improvement. This could open a new and inexpensive therapeutic option for optic atrophy. However, the level of evidence for this method is still fairly rather poor, and further trials are needed. Therefore, this clinical trial aims to prove the effectiveness of rtACS compared with sham stimulation in patients with primary open-angle glaucoma (POAG)., Methods and Analysis: VIRON (Vision Restoration in Optic Neuropathy) is a national, multicentre, prospective, randomised, placebo-controlled, double-blind trial with three arms. The primary objective is to assess the effectiveness of rtACS in patients with POAG compared with sham stimulation. The primary outcome is the change in mean defect (MD) in the visual field immediately after 10 sessions of rtACS (days 9, 16 and 23) compared with the values of initial perimetry (days -21 to -14 and 0) after applying electrical stimulation with a classical montage, compared with sham and electrical stimulation using individualised montage. Secondary outcome measures comprise a long-term effect with changes in MD at 24 weeks after stimulation, and data from the National Eye Institute Visual Function-25 and quality of life (Short Form 36) questionnaires. The target population are patients with glaucomatous optic atrophy and significant glaucomatous visual field defects (MD of 5-22 dB) due to POAG.After randomisation, patients received either classical rtACS (group 1), individual rtACS (group 2) or sham stimulation (group 3) in daily 25 min stimulation sessions in two series of five consecutive days separated by a weekend interval. In group 1, active stimulation will be via the routinely applied montage using two electrodes affixed on the right and left side of the head, next to the eyes, with straightforward fixation. In group 2, the current flow will be individually modelled (MRI-based) to target areas of partial visual field defects by optimising electrode positions in conjunction with an optimised visual fixation direction. Group 3 with sham stimulation will serve as control.The calculated sample size required to achieve a statistical power of 80% for a relevant effect size and allow for dropouts was 300 (100 per group). The trial has already begun with the first patient in July 2023. The planned recruitment period is 24 months with an estimated end of the study in November 2025 (last patient out). An adjusted extension of the study period is planned., Ethics and Dissemination: VIRON was approved by the Central Ethics Committee of the University Medical Center Göttingen (19 October 2022) and those of the individual participating centres (Bonn: 446/23-EP, Hamburg: 2023-200889-BO-bet, Cologne: 23-1487 and Mainz: 2023-17399-§23b). The study protocol complies with the Declaration of Helsinki, the national medicine device regulation (MDR) laws and the international standards of good clinical practice (GCP).The study protocol (V.5, 24 November 2023) was designed following the Standard Protocol Items: Recommendations for Interventional Trials guidelines and is registered on https://drks.de/search/de/trial/DRKS00029129.As study initiatior the University Medical Center Göttingen (UMG) is responsible for data ownership and data management of the VIRON study. The study data will be published within 6 months of the study being completed. After the publication of the primary results, all data are anonymised and published in an open-access journal to ensure access to the data for third parties., Trial Registration Number: https://drks.de/search/de/trial/DRKS00029129., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Glaucoma drainage devices (GDD) are used for patients with secondary glaucoma, such as uveitic or neovascular glaucoma, which is uncontrolled under local therapy. They are also used in patients with conjunctival scarring, for example after a previous vitrectomy or after unsuccessful previous glaucoma surgery, such as trabeculectomy. They are also a treatment option for congenital glaucoma, aphakic glaucoma or for the treatment of iridocorneoendothelial syndromes. The conventional GDD were the Baerveldt, Molteno or Ahmed glaucoma implant, whereby the first two were valveless and the latter had a valve. Newer GDD include the PAUL glaucoma implant, the Ahmed Clear Path and the EyeWatch system. Hypotony is a feared complication after GDD surgery, and there are various options for avoiding it: external ligation of the tube or intraluminal suture obstruction. However, low IOP may still occur postoperatively. If early postoperative hypotension occurs in combination with a shallow anterior chamber, the injection of a viscoelastic can be helpful. Late hypotension is usually treated with permanent occlusion or removal of the tube. Furthermore, GDD erosion and migration can occur postoperatively, in such cases a surgical revision is required. Corneal decompensation can also occur after GDD; Descemet's membrane endothelial keratoplasty (DMEK) is the treatment of choice in many centers and is performed more frequently than a penetrating keratoplasty. Finally, double vision is a possible complication after GDI. Most patients have short-term, self-limited diplopia or can be adequately treated with prism glasses; a few require strabologic surgery., Competing Interests: Erklärung zu finanziellen Interessen Forschungsförderung erhalten: nein; Honorar/geldwerten Vorteil für Referententätigkeit erhalten: ja, von einer anderen Institution (Pharma- oder Medizintechnikfirma usw.); Bezahlter Berater/interner Schulungsreferent/Gehaltsempfänger: nein; Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an Firma (Nicht‐Sponsor der Veranstaltung): nein; Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an Firma (Sponsor der Veranstaltung): nein Erklärung zu nichtfinanziellen Interessen Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Introduction: The aim of this study was to report clinical outcomes from a single-center cohort undergoing PAUL® glaucoma implant (PGI) surgery for secondary glaucoma after vitreoretinal surgery (VR)., Methods: Retrospective review of patients undergoing PGI surgery at the University Eye Hospital Bonn, Germany, from April/2021 to May/2023 was conducted., Results: Thirty-three eyes of 33 patients were included. Mean number of preoperative VR surgeries was 2 (1-4), the majority following retinal detachment (23 eyes, 69.7%). 18 eyes had previous silicone oil tamponade (54.4%). Complete (without drops) and qualified (with or without drops) success rates (95% CI) after 1 year were 69.7% (54.5-84.8) and 97% (90.9-100) for criterion A (IOP ≤21 mm Hg), 66.7% (51.5-81.8) and 87.9% (51.5-81.8) for criterion B (IOP ≤18 mm Hg), 54.5% (39.4-72.7) and 72.7% (54.5-87.9%) for criterion C (IOP ≤15 mm Hg), and 24.2% (9.1-39.4) and 30.3% (15.2-48.4) for criterion D (IOP ≤12 mm Hg), respectively. Mean IOP decreased from 25.64 mm Hg (14-49 mm Hg) to 13.59 mm Hg (8-20 mm Hg) (reduction of 41.1%) after 12 months with a reduction of IOP-lowering agents from 3.21 (1-5) to 0.38 (0-3). Seven eyes (21.2%) developed postoperative complications, most of which eventually resolved. Two eyes had a tube flushing because of high postoperative IOP with silicone oil obstruction. Postoperative non-glaucoma-related procedures were performed in 10 eyes (24.4%). None of these led to high IOP or further complications in the postoperative phase., Conclusion: PGI surgery is an effective procedure for reducing both IOP and topical therapy in patients with uncontrolled secondary glaucoma following vitreoretinal surgery. Non-glaucoma-related procedures can be safely performed after PGI implantation with good IOP control., (© 2025 S. Karger AG, Basel.)

Prcis: Deep sclerectomy (DS) and canaloplasty provide better intraocular pressure (IOP) control than viscocanalostomy. DS required less glaucoma medications but more interventions to reach target IOP., Purpose: To compare real-world outcomes of three non-penetrating glaucoma surgery (NPGS) techniques., Methods: Retrospective, cohort study of consecutive patients undergoing canaloplasty (CP), deep sclerectomy (DS), and viscocanalostomy (VC), across nine European glaucoma units. Four intraocular pressure (IOP) criteria were used to define success at 2-year follow-up: (A)IOP≤21 mmHg and ≥20% reduction; (B)IOP≤18 mmHg and ≥20% reduction; (C)IOP≤15 mmHg and ≥25% reduction; (D)IOP≤12 mmHg and ≥30% reduction. Secondary outcomes included IOP control, BCVA, number of medications over time, risk factors for failure, complications, and post-operative interventions. Success was distinguished as qualified or complete, if reached with or without antiglaucoma medications, respectively., Results: 600 eyes (545 patients) undergoing standalone CP (201 eyes), DS (200 eyes), and VC (199 eyes) were included. Qualified success rates of CP, DS, and VP at 24 months were, respectively: (Criterion A) 85.1%, 67.6% and 64.6%; (Criterion B) 85.1%, 66.1% and 58.6%; (Criterion C) 76.6%, 55.5% and 39.0%; (Criterion D) 27.7%, 28.5% and 22.1%. Success rates were significantly different across the three techniques (P=0.04 or below), except for complete success according to criterion A (P=0.07). Mean IOP(±SD) reduced from 25.2(±6.9), 20.5(±6.7), and 22.7(±7.2)mmHg pre-operatively to 13.1(±3.1), 12.9(±4.5), and 14.7(±4.6)mmHg at post-operative year 2 in the CP, DS, and VC groups respectively (P<0.001 between pre-operative and post-operative time points for all groups)., Conclusions: All three NPGS provide sustained IOP reduction, but DS and CP provide better success rates and IOP control. Success rates were low for the most stringent cut-offs, suggesting that other techniques such as trabeculectomy may be indicated when a very low target IOP is demanded., Competing Interests: CONFLICTS OF INTEREST: No conflicting relationship exists for any author., (Copyright © 2025 Wolters Kluwer Health, Inc. All rights reserved.)

Background : The PreserFlo™ MicroShunt (PFMS) is a bleb-forming device considered to be less invasive than traditional glaucoma surgery such as trabeculectomy. This study evaluates the 1-year success rates as well as safety profile of PFMS in patients having high intraocular pressure (IOP) and/or glaucoma refractory to drop therapy with a history of prior intravitreal dexamethasone therapy. Methods : A total of 16 eyes after PFMS implantation due to elevated IOP after intravitreal dexamethasone implant (DEX-I) administration were included in this retrospective cohort study. Success rates and secondary outcomes were evaluated. Results : Qualified and complete success rates at 12 months, respectively, were 14/16 and 12/16 eyes for criterion A, 13/16 and 11/16 eyes for B, 13/16 and 11/16 eyes for C, and 6/16 and 6/16 eyes for D. The overall mean (range) preoperative IOP decreased from 27 (16-38) mmHg to 13 (10-17) mmHg at 12 months. BCVA was not significantly different up to 12 months ( p = 0.63). The preoperative mean (range) number of medications decreased from 3.56 (2-4) to 0.31 (0-3) at 12 months. One eye underwent needling twice, and two eyes were revised surgically. One patient needed replacement of the PFMS. There were no hypotony-related complications. Conclusions : The PFMS is an effective surgical option for patients with steroid-induced IOP elevation. It demonstrates satisfactory short-term success rates, a reduced need for pressure-lowering eye drops, an excellent safety profile with minimal postoperative care, and a low complication rate. Additional interventions such as needling or revisions were infrequently necessary. However, PFMS may not be the ideal choice for cases requiring a low target pressure (≤12 mmHg).

Aim: To evaluate a useful, non-contact method for the follow-up of pericardium patch graft changes in patients undergoing PAUL ® Glaucoma Implant (PGI) surgery using high-resolution anterior segment optical coherence tomography (OCT) to predict tube erosions., Methods: Prospective analysis over six months of tube pericardium patch graft thickness of PGI surgical cases at the University Eye Hospital Bonn, Germany, from November 2021 to August 2022. In all eyes, Tutopatch ® (RTI Surgical, United States) pericardium was used to cover the implant intra-operatively. Anterior segment OCT (AS-OCT, Heidelberg ANTERION ® Swept-Source-OCT) examinations were performed following a standardized protocol to measure quantitative and qualitative aspects of the patch grafts before surgery, and at three and six months after surgery., Results: Twenty-six eyes of 26 patients were included. Thickness of the patch material was 1188 µm (IQR 415 µm) directly after implantation and decreased over time to 1068 µm (IQR 478 µm) at 3 months and 846 µm (IQR 677 µm) at 6 months. No significant differences between groups were shown concerning gender (p = 0.128), ethnicity (p = 1.000), age (p = 0.741), glaucoma type (p = 0.173), other concurrent diseases (p = 0.302), former glaucoma surgeries (p = 1.000) and the quadrant of implantation (p = 0.555). Five eyes developed implant exposure. When comparing eyes with and without tube exposure, no significant differences were shown in average patch thickness above the tube directly after implantation (p = 0.476). However, significant differences in average thickness were observed at 3 months (p = 0.013) and 6 months (p = 0.005)., Conclusions: Pericardial patch grafts tend to thin over time which can be assessed by AS-OCT, the latter proving to be a useful method to follow-up patients who undergo patch graft implantation during PGI surgery. This investigation could potentially help identify patients at risk of tube exposure which in turn could lead to modification of patient management. It could also possibly be used in future studies to find more suitable patch materials., Competing Interests: Declarations. All procedures performed in studies involving human participants were in accordance with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the Ethics Committee of the University Hospital Bonn. Informed consent: Informed consent was obtained from all individual participants included in the study and the authors affirm that human research participants provided informed consent for publication of the images used in Figs. 1 and 3., (© 2024. The Author(s).)

Background/aims: Bleb characteristics in the area around the plate following glaucoma drainage device (GDD) surgery are difficult to evaluate on slit lamp examination. Ultrasound sonography could be used for more detailed visualisation. The aim of this study was to describe bleb configuration after PAUL glaucoma implant (PGI) surgery and evaluate the possible correlation with intraocular pressure (IOP) in order to derive new markers for evaluating GDD function., Methods: Patients underwent a 15 MHz ultrasound examination (Compact Touch, Quantel Medical) after undergoing PGI implantation. The filtering bleb dimensions were measured and bleb configuration was assessed along with documentation of all clinical data., Results: A total of 70 eyes from 65 patients were included. 55 eyes (78.6%) had a double-layered bleb whereas 15 eyes (21.4%) had a bleb with only one compartment (six eyes, 8.6% above; nine eyes, 12.9% below the plate). The total height of both compartments averaged 3.52 mm. The average IOP was 13.03 mm Hg. There was a significant correlation between single and double-layered blebs (p<0.01) with regard to IOP (one compartment: 16.47 mm Hg vs two compartments: 12.09 mm Hg). There was no significant correlation between total bleb height (p=0.143) or bleb extension (T: p=0.629; L: p=0.742). However, total bleb height showed an inverse association with IOP. Blebs with a height >2 mm had significantly lower mean IOP than those having <2 mm bleb heights (p=0.041)., Conclusions: Sonography is a suitable modality to evaluate bleb characteristics after PGI implantation. Blebs with a double fluid layer are significantly correlated with lower IOP values. Bleb height has an inverse association with IOP, with higher blebs (>2 mm) showing a significantly lower IOP., Competing Interests: Competing interests: CW, LW, MP and RL certify that they have no affiliations with or involvement in any organisation or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership or other equity interest and expert testimony or patent-licensing arrangements) or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript. KM has received honoraria or research grants from the following: Allergan/Abbvie (C,H,R) and Glaukos (C,H,R), but none of this is related to the current study. FGH has received honoraria or research grants from the following: Acucela (C,F), Allergan (F), Apellis (C, F), Bayer (C, F), Boehringer-Ingelheim (C), Bioeq/ Formycon (F,C), CenterVue (F), Ellex (F), Roche/Genentech (C,F), Geuder (C,F), Graybug (C), Gyroscope (C), Heidelberg Engineering (C,F), IvericBio (C, F), Kanghong (C,F), LinBioscience (C), NightStarX (F), Novartis (C,F), Optos (F), Oxurion (C), Pixium Vision (C,F), Oxurion (C), Stealth BioTherapeutics (C), Zeiss (F,C), but none of this is related to the current study., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Prcis: This prospectively collected case series of 56 eyes having PAUL glaucoma implant (PGI) surgery is the first to demonstrate its medium-term safety and effectiveness in what is essentially an exclusively Caucasian population., Background: To report 2-year outcomes from a single-center cohort undergoing PGI surgery., Methods: Prospectively collected data on patients undergoing PGI surgery at the University Eye Hospital Bonn, Germany, from April 2021 to September 2021., Results: Of 53 patients, 56 eyes were included. Complete and qualified success rates (95% CI) were 52% (37-66) and 89% (80-96) for criterion A ( intraocular pressure [IOP]≤21 mm Hg), 48% (36-61) and 79% (67-88) for criterion B (IOP≤18 mm Hg), 45% (32-57) and 64% (52-77%) for criterion C (IOP≤15 mm Hg) and 27% (16-40) and 38% (25-50) for criterion D (IOP≤12 mm Hg), respectively. Mean IOP decreased from 25.43 mm Hg (7-48 mm Hg) to 11.25 mm Hg (3-24 mm Hg) (reduction of 50%) after 24 months with a reduction of IOP-lowering agents from 3.50 (1-5) to 0.46 (0-3). One eye needed an injection of viscoelastic due to significant hypotony with AC shallowing; 3 eyes received a Descemet membrane endothelial keratoplasty because of persistent corneal decompensation; 9 eyes developed tube exposure which required conjunctival revision with additional pericardial patch graft, with 5 of these eyes eventually needing tube explantation. An intraluminal prolene stent was removed in 24 eyes (42.9%) after a mean time period of 5.67 months (2-15 m). Mean IOP before removal was 21.4 mm Hg (12-40 mm Hg) and decreased to 11.15 mm Hg (6-20 mm Hg)., Conclusions: PGI surgery is an effective procedure for reducing IOP and pressure-lowering therapy. The use of an intraluminal prolene stent impedes hypotony in the early postoperative phase and enables further noninvasive IOP lowering during the postoperative course., Competing Interests: Disclosure: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The eyeWatch System (EWS) (Rheon Medical, Lausanne, Switzerland) was developed as a glaucoma drainage device (GDD) to precisely control intraocular pressure (IOP) and thus prevent the development of postoperative hypotension and its complications., Objective: To report 1‑year outcomes from a single-center cohort undergoing EWS surgery., Material and Methods: Retrospective review of patients undergoing EWS surgery at the University Eye Hospital Bonn, Germany from May 2021 to September 2022., Results: A total of 5 eyes of the first 5 consecutive patients treated with the EWS were included in this study. The mean preoperative IOP was 34.6 mm Hg (23-45 mm Hg) which was reduced to 12.2 mm Hg (9-18 mm Hg) with a mean reduction of 60%. Local pressure-lowering therapy was reduced from 2.8 agents preoperatively (1-4) to 0.6 agents after 1 year. All patients achieved the target IOP of below 21 mm Hg including 4 patients without any medication. The complication rate was low. One patient had to undergo two surgical revisions as the IOP was elevated to over 30 mm Hg after surgery and tube exposure became apparent during the course of the follow-up so that a second donor patch was sutured on. The same patient had an elevated IOP >30 mm Hg after a cMRI examination, so that a reduction of IOP by adjusting the EWS using the eyeWatch pen (EWP) was performed. IOP adjustments with the eyeWatch pen (EWP) were performed in 4 of 5 patients in the first year after surgery; the mean IOP before adjustment was 21.33 mm Hg (15-37 mm Hg) which was reduced to a mean of 8.58 mm Hg (4-16 mm Hg)., Conclusion: The EWS effectively lowers IOP and the amount of necessary pressure-lowering therapy. With the EWP postoperative adjustments of IOP are possible without further invasive measures., (© 2024. The Author(s).)

Purpose: To evaluate risk factors for failure of Microshunt in glaucoma patients., Design: Multicenter retrospective cohort study., Methods: The study included 220 eyes from 220 consecutive glaucoma patients undergoing Microshunt implantation at six glaucoma units. Four intraocular pressure (IOP) success criteria were defined: (A) IOP ≤21 mm Hg with ≥20% IOP reduction; (B) IOP ≤18 mm Hg with ≥20% IOP reduction; (C) IOP ≤15 mm Hg with ≥25% IOP reduction; and (D) IOP ≤12 mm Hg with ≥30% IOP reduction from baseline. Kaplan-Meier analysis was used to estimate success rates according to the criteria above, and multivariable Cox models were used to identified risk factors for failure according to criterion A., Results: Success rates varied based on different criteria, ranging from 43.3% to 62.5% (overall success for criteria D and A, respectively) and from 35.3% to 44.4% (complete success for criteria D and A, respectively) at 1-year follow-up. Higher intraoperative MMC concentration was associated with reduced risk of failure to maintain complete (0.4 vs 0.2 mg/mL: hazard ratio [HR] = 0.441, P < .001) and overall (0.4 vs 0.2 mg/mL: HR = 0.360, P = .004) success. For complete success, other risk factors for failure were pseudoexfoliation glaucoma/pigmentary glaucoma (HR = 1.641, P = .004), primary angle closure glaucoma (HR = 1.611, P < .001), and previous non-glaucomatous ocular surgeries (HR = 2.301, P = .002). For overall success, other risk factors for failure were lower preoperative IOP (for 1-mm Hg increase, HR = 0.934, P = .005), higher number of preoperative antiglaucoma agents (HR = 1.626, P < .001), and Microshunt combined with cataract surgery (HR = 1.526, P = .033)., Conclusions: This study identified risk factors for Microshunt failure, highlighting the importance of high intraoperative MMC dose and careful patient selection to optimize surgical success., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: With a rising prevalence of age-related eye diseases, prevention and early diagnosis of these conditions are key goals of public eye health. Disease-related knowledge in the general public supports these goals but there is little data available. Thus, we have assessed knowledge of cataract, glaucoma, age-related macular degeneration (AMD) and diabetic eye disease in the German adult general population in a cross-sectional study and identified target groups for health education interventions., Methods: Knowledge assessment content was identified based on a literature review, expert input, and a list of items was generated after a qualitative selection process. The resulting 16-item instrument (4 items per condition) was administered to 1,008 participants from a survey panel, demographically representative of the adult German population. Test properties were evaluated based on a Rasch model and multiple correspondence analysis (MCA). Binary-logistic regression analysis was performed to investigate associations with age, sex, education level, employment status, marital status, income, reported health status, visual difficulties, and recent general practitioner (GP) and ophthalmologist consultations., Results: Replies were correct for a median of 9 out of 16 (range 2 - 16) items, which differed between conditions (p < 0.0001). Most responses were correct for cataract items (median: 3 / 4) and least were correct for AMD items (median: 2 / 4). 27%, 9%, 1% and 19% of respondents replied correctly to all cataract, glaucoma, AMD and diabetic eye disease-related items, respectively. Rasch analysis suggested an adequate targeting of items and in MCA, no evidence of multidimensionality was present. Older age, being retired, decreased general health and recent GP or ophthalmology consultations were significantly associated with more knowledge about common eye conditions (p ≤ 0.005). GP or ophthalmology consultations remained significant in a multivariable model (p ≤ 0.011)., Conclusions: Knowledge gaps regarding eye health are considerable in the German general population and should therefore be addressed in educational interventions targeting the public. Special attention when designing such campaigns needs to be paid to infrequent users of the healthcare system. Knowledge of AMD seems to be poorer compared to other eye conditions., (© 2024. The Author(s).)

Purpose: This study aimed to report on glaucoma patients' beliefs and illness perceptions and to investigate their opinion on ocular drug delivery devices (ODD)., Methods: We performed a cross-sectional study in a large tertiary-referral outpatient glaucoma clinic, with 102 patients. Validated anonymized questionnaires were used. We investigated the awareness and acceptance regarding ODD (contact lenses (CLs), punctal plugs (PPs), subconjunctival implants, anterior chamber (AC) injections, and drug-emitting stents) and looked at factors that could influence a patient's decision for having an ODD., Results: Sixty-three patients (61.8%) confirmed they would rather have ODD than keep their eye-drops (38.2%). The most important factors influencing their decision were effectiveness and long-lasting effect. A large proportion of patients reported a preference for CLs (48.0%), PPs (52.9%), or drug-emitting stents (44.1%). When comparing patients who preferred ODD (group-1) versus eye-drops (group-2), significantly more patients in group-1 were worried (p < 0.001) or felt disrupted (p < 0.001) by their use of eye-drops. A significantly greater share of patients in group-1 showed acceptance towards CLs (60.3% vs. 38.5%; p = 0.032), AC injections (38.1% vs. 12.8%, p = 0.006), or drug-emitting stents (54% vs. 28.2%, p = 0.023), whilst there were no significant differences regarding the acceptance of PPs (p = 0.363) or subconjunctival implants (p = 0.058)., Conclusion: ODD for the treatment of glaucoma were broadly deemed acceptable by patients in this study. Effectiveness and long-lasting effect were the most important factors for a decision towards having an ODD. The majority of patients who preferred an ODD felt severely affected by their disease and were negatively influenced by their glaucoma medication intake., (© 2023. The Author(s).)

PROLOGUE: Glaucoma surgery has been, for many decades now, dominated by the universal gold standard which is trabeculectomy augmented with antimetabolites. Tubes also came into the scene to complement what we use to call conventional or traditional glaucoma surgery. More recently we experienced a changing glaucoma surgery environment with the "advent" of what we have become used to calling Minimally Invasive Glaucoma Surgery (MIGS). What is the unmet need, what is the gap that these newcomers aim to fill? Hippocrates taught us "bring benefit, not harm" and new glaucoma techniques and devices aim to provide safer surgery compared to conventional surgery. For the patient, but also for the clinician, safety is important. Is more safety achieved with new glaucoma surgery and, if so, is it associated with better, equivalent, or worse efficacy? Is new glaucoma surgery intended to replace conventional surgery or to complement it as an 'add-on' to what clinicians already have in their hands to manage glaucoma? Which surgery should be chosen for which patient? What are the options? Are they equivalent? These are too many questions for the clinician! What are the answers to the questions? What is the evidence to support answers? Do we need more evidence and how can we produce high-quality evidence? This EGS Guide explores the changing and challenging glaucoma surgery environment aiming to provide answers to these questions. The EGS uses four words to highlight a continuum: Innovation, Education, Communication, and Implementation. Translating innovation to successful implementation is crucially important and requires high-quality evidence to ensure steps forward to a positive impact on health care when it comes to implementation. The vision of EGS is to provide the best possible well-being and minimal glaucomainduced visual disability in individuals with glaucoma within an affordable healthcare system. In this regard, assessing the changes in glaucoma surgery is a pivotal contribution to better care. As mentioned, this Guide aims to provide answers to the crucial questions above. However, every clinician is aware that answers may differ for every person: an individualised approach is needed. Therefore, there will be no uniform answer for all situations and all patients. Clinicians would need, through the clinical method and possibly some algorithm, to reach answers and decisions at the individual level. In this regard, evidence is needed to support clinicians to make decisions. Of key importance in this Guide is to provide an overview of existing evidence on glaucoma surgery and specifically on recent innovations and novel devices, but also to set standards in surgical design and reporting for future studies on glaucoma surgical innovation. Designing studies in surgery is particularly challenging because of many subtle variations inherent to surgery and hence multiple factors involved in the outcome, but even more because one needs to define carefully outcomes relevant to the research question but also to the future translation into clinical practice. In addition this Guide aims to provide clinical recommendations on novel procedures already in use when insufficient evidence exists. EGS has a long tradition to provide guidance to the ophthalmic community in Europe and worldwide through the EGS Guidelines (now in their 5th Edition). The EGS leadership recognized that the changing environment in glaucoma surgery currently represents a major challenge for the clinician, needing specific guidance. Therefore, the decision was made to issue this Guide on Glaucoma Surgery in order to help clinicians to make appropriate decisions for their patients and also to provide the framework and guidance for researchers to improve the quality of evidence in future studies. Ultimately this Guide will support better Glaucoma Care in accordance with EGS's Vision and Mission. Fotis Topouzis EGS President, (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Despite the human ocular surface being easily accessible, ocular drug delivery can be challenging. When applied improperly, topical medications, the most popular first-line treatment used to treat glaucoma, can have a very brief contact time with the ocular surface and may not have the desired therapeutic impact. Drug delivery devices are gadgets that can address some of these problems. This study aims to determine patients' opinions on ocular drug delivery devices used in the treatment of primary open-angle glaucoma (POAG)., Methods: A pretested interviewer-administered questionnaire was used in a cross-sectional study of 115 POAG patients recruited from outpatient clinics in two Nigerian tertiary health institutions. Participants were asked about their understanding and acceptance of five Ocular drug delivery systems (ODD), namely drug-emitting contact lenses (CL), punctual plugs, subconjunctival injections, intracameral implants, and trabecular meshwork micro-stents, for the treatment of POAG., Results: Sixty (52.2%) participants, whose average age was 50 ± 9.8 years, were men. Self-pay was used for eye health treatments by 65% of participants. Of the participants, 68.7% admitted to using eye drops on their own. 57% of people were said to take their glaucoma medications consistently. CL and subconjunctival implants were seen to be most acceptable according to 39% and 30% of participants, respectively. Major factors determining the acceptability of ODD for POAG treatment were observed to be cost and effectiveness., Conclusion: Patients in our cohort who are being treated for POAG have a fairly positive attitude towards ODD. The prospective use of these devices for POAG treatment in Nigeria will depend on their efficacy and cost, as well as how ophthalmologists will weigh ODD options., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Middle East African Journal of Ophthalmology.)

Aim: To assess the efficacy and safety of non-penetrating deep sclerectomy (NPDS) with uveoscleral implant plus subconjunctival and intrascleral collagen matrix overcoming the superficial scleral flap lips (modified deep sclerectomy technique, DS) and minimal use of mitomycin C in glaucoma surgery., Methods: A retrospective review of 47 consecutive glaucoma patients who underwent NPDS with DS between January 2017 and May 2018. Best-corrected visual acuity, intraocular pressure (IOP), post-operative need for glaucoma medications, visual field mean deviation (MD), re-interventions, needling revisions and laser goniopuncture were noted. Absolute success was defined as IOP≤18 mm Hg without topical medication. Relative success was defined as the same criteria but with the addition of any antihypertensive medication. IOP over 18 mm Hg on two consecutive follow-up visits was considered as a failure., Results: Fifty-two eyes of 47 patients were evaluated. Mean preoperative IOP was 25.37±6.47 mm Hg, and decreased to 15.04±4.73 at 12mo and 12.21±4.1 at 24mo (all P <0.0001). Requirement for topical medications dropped from a mean of 3.06±0.25 per patient to 0.51±0.99 and 1.11±1.23 respectively after 12 and 24mo (all P <0.0001). No medications were required in 45.5% of patients after 24mo. Relative and absolute success rate at 24mo were 85.5%±5% and 48.5%±7.4%, respectively., Conclusion: DS is a safe and effective non-penetrating glaucoma surgery variation. It aims to retain the patency of all pathways created for aqueous humor drainage: the intrascleral bleb, the supraciliary space and the open communication between intrascleral and subconjunctival compartments., (International Journal of Ophthalmology Press.)

The development of minimally invasive glaucoma surgeries (MIGSs) was intended to provide safe and modestly efficacious modalities for early intervention of mild-to-moderate glaucoma, with minimal trauma and rapid recovery. They were mainly ab interno procedures that reduce intraocular pressure by facilitating the aqueous outflow by bypassing the trabecular meshwork resistance, reinforcing the uveoscleral flow via the supraciliary space, and reducing aqueous production by the ciliary body. While the cumulating evidence helps shape the role of the available MIGS, the exponential new development and advancement in this field has expanded the territory of MIGS. Apart from developing subconjunctival MIGS filtration devices (Xen gel stent and PRESERFLO MicroShunt), there is a tendency to revisit the "traditional" MIGS for alternative use and to modify the procedures with consideration of the fundamental aqueous outflow physiology. Combined MIGS has also been suggested, based on the theory that their different mechanisms may provide additive or synergistic effects. The advancement of laser procedures is also promising and could supplement unmet needs along the glaucoma treatment algorithm. This review examines the broad array of MIGS, updates the recent findings, discusses their potential alternative applications, and explores future challenges., Competing Interests: J.E.D. and A.H. are employees of Sight Sciences, Inc. T.W.S. is a consultant and an investigator for Glaukos, as well as other canal device conflicting companies such as Alcon Surgical, Ivantis, Sight Science, Vialase, Elios, Belkin Vision, and New World Medical. The remaining authors have no funding or conflicts of interest to declare., (Copyright © 2023 Asia-Pacific Academy of Ophthalmology. Published by Wolters Kluwer Health, Inc. on behalf of the Asia-Pacific Academy of Ophthalmology.)

Glaucoma is a leading cause of irreversible blindness worldwide. While intraocular pressure (IOP) presents a major risk factor, the underlying pathophysiology still remains largely unclear. The correlation between vascular abnormalities and glaucoma has been deliberated for decades. Evidence for a role played by vascular factors in the pathogenesis of glaucomatous neurodegeneration has already been postulated. In addition, the fact that glaucoma causes both structural and functional changes to retinal blood vessels has been described. This review aims to investigate the published evidence concerning the relationship between vascular abnormalities and glaucoma, and to provide an overview of the "chicken or egg" dilemma in glaucoma. In this study, several biomarkers of glaucoma progression from a vascular perspective, including endothelin-1 (ET-1), nitric oxide, vascular endothelial growth factor (VEGF), and matrix metalloproteinases (MMPs), were identified and subsequently assessed for their potential as pharmacological intervention targets.

Background: To report one-year outcomes from a single-centre cohort undergoing PAUL® Glaucoma Implant (PGI) surgery., Methods: Retrospective review of patients undergoing PGI surgery at the University Eye Hospital Bonn, Germany, from April 2021 to September 2021., Results: Forty-five eyes of 41 patients were included. Qualified and complete success rates (95% CI) were 95.6% (88.9%-100%) and 73.3% (60%-86.7%) for Criterion A (IOP ≤ 21 mmHg), 84.4% (73.3%-93.3%) and 74.4% (51.1%-80.0%) for Criterion B (IOP ≤ 18 mmHg), 62.2% (48.9%-75.6%) and 46.7% (31.2%-62.2%) for Criterion C (IOP ≤ 15 mmHg) and 26.7% (13.3%-40.0%) and 22.2% (11.1%-33.3%) for Criterion D (IOP ≤ 12 mmHg), respectively. Mean IOP decreased from 26.1 mmHg (7-48 mmHg) to 12.0 mmHg (3-24 mmHg) (reduction of 48.83%) after 12 months with a reduction of IOP-lowering agents from 0.5 (0-3). One eye (2.2%) needed an injection of viscoelastic due to significant hypotony with AC shallowing, and four eyes (8.9%) developed choroidal detachments due to hypotony which resolved without further interventions after 6 weeks. Three patients (6.7%) developed tube exposure which required conjunctival revision with an additional pericardial patch graft. An intraluminal prolene stent was removed in 19 eyes (42.2%) after a mean time period of 8.4 months (2-12 m). Mean IOP before the removal was 21.9 mmHg (12-38 mmHg) and decreased to 11.3 mmHg (6-16 mmHg)., Conclusions: PGI surgery is an effective procedure for reducing IOP and pressure-lowering therapy. An intraluminal prolene stent impedes hypotony in the early postoperative phase and enables further IOP lowering without additional interventions during the postoperative course., (© 2023 The Authors. Clinical & Experimental Ophthalmology published by John Wiley & Sons Australia, Ltd on behalf of Royal Australian and New Zealand College of Ophthalmologists.)

Prcis: This retrospective study of 264 eyes having inferior quadrant trabectome surgery confirms its safety and relative effectiveness. Most patients however still require IOP-lowering agents, and a considerable proportion may need additional glaucoma surgery., Purpose: To report outcomes from a large single-center cohort of inferiorly-applied trabectome surgery., Patients and Methods: Retrospective review of patients undergoing trabectome surgery for chronic open angle glaucoma (COAG) at the University Eye Clinic Bonn, Germany, from 2012 to 2020., Results: Two hundred sixty-four eyes of 206 patients with COAG were included. The mean review period was 45.43 (range 12-101) months. One hundred five eyes (39.8%) underwent standalone surgery, of which 74 were pseudophakic and 31 phakic. The mean preoperative IOP was 17.58 mm Hg (range 12-50 mm Hg). One hundred five eyes (39.8%) developed a 'failure event' according to pre-defined criteria at a mean interval of 14.8 months postoperative. In absolute terms, 211 patients (79.9%) had a long-term IOP >14 mm Hg at 7.6 months, 174 patients (65.9%) >16 mm Hg at 10.6 months, 127 patients (48.1%) >18 mm Hg at 10.9 months, and 77 patients (29.2%) >21 mm Hg at 11.1 months. Over a five-year period, overall mean IOP remained stable at 13 mm Hg. The majority of patients were still on glaucoma drops (the mean number reduced from 2.9 to 2.7 agents). Subgroup analyses showed that a higher preoperative IOP was a positive predictor for failure, whereas combined surgery (with phaco) had better IOP outcomes (16.5 mm Hg vs. 19.3 mm Hg, respectively). Forty-one patients (15.5%) developed minor complications: 22 had high postoperative IOP within 3 months, 11 developed a self-resorbing hyphema, and 6 had fibrinous uveitis., Conclusions: Trabectome surgery is a safe and relatively effective procedure for lowering IOP, but most patients still need IOP-lowering agents, and a considerable proportion may need additional glaucoma surgery within a relatively short time. Inferior quadrant treatment may result in inferior IOP outcomes when compared with nasal quadrant surgery., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To assess and describe current utilisation, characteristics and perspectives on virtual glaucoma clinics (VGCs) amongst European glaucoma specialists., Methods: Cross-sectional, anonymized, online questionnaire distributed to all European Glaucoma Society-registered specialists. Questions were stratified into five domains: Demographics, Questions about VGC use, Questions for non-VGC users, COVID-19 effects, and VGC advantages/disadvantages., Results: 30% of 169 participants currently use VGCs, with 53% based in the United Kingdom. Of those using VGCs, 85% reported higher patient acceptance compared to traditional care. The commonest virtual model was asynchronous remote monitoring (54%). Nurses (49%) and ophthalmic technicians (46%) were mostly responsible for data collection, with two-thirds using a mixture of professionals. Consultant ophthalmologists were the main decision-makers in 51% of VGCs. Preferred cohorts were: ocular hypertension (85%), glaucoma suspects (80%), early/moderate glaucoma in worse eye (68%), stable glaucoma irrespective of treatment (59%) and stable glaucoma on monotherapy (51%). Commonest investigations were: IOP (90%), BCVA (88%), visual field testing (85%) and OCT (78%), with 33 different combinations. Reasons for face-to-face referral included: visual field progression (80%), 'above-target' IOP (63%), and OCT progression (51%). Reasons for not using VGCs included: lack of experience (47%), adequate systems in place (42%), no appropriate staff (34%) and insufficient time/money (34%). 55% of non-VGC users are interested in their use with 38% currently considering future implementation. 83% stated VGC consultations have increased during the COVID-19 pandemic; 86% of all participants felt that the pandemic has highlighted the importance of VGCs., Conclusions: A significant proportion of European glaucoma units are currently using VGCs, while others are considering implementation. Financial reimbursement and consensus guidelines are potentially crucial steps in VGC uptake., (© 2022. The Author(s).)

Purpose: Low corneal hysteresis (CH) is associated with an increased risk of glaucoma. Prostaglandin analogue (PGA) eye drops may exert their intraocular pressure (IOP)-lowering effect partially by increasing CH., Methods: Twelve pairs of organ-cultured human donor corneas were used in an ex vivo model. In each case, one cornea was treated with PGA (Travoprost) for 30 days, whereas the other served as an untreated control. IOP levels were simulated in an artificial anterior chamber model. CH was measured using the Ocular Response Analyzer (ORA). Corneal expression of matrix-metalloproteinases (MMPs) was assessed by immunhistochemistry and real-time polymerase chain reaction (RT-PCR)., Results: Increased CH was observed in the PGA-treated corneas. However, at IOP between 10 and 20 mm Hg, CH was increased in PGA-treated corneas (13.12 ± 0.63 mm Hg; control: 12.34 ± 0.49 mm Hg), although not significantly (P = 0.14). CH was significantly increased at higher IOP levels (21-40 mm Hg; PGA-treated: 17.62 ± 0.40 mm Hg; control: 11.60 ± 0.39, P < 0.0001). Treatment with PGA resulted in increased expression of MMP-3 and MMP-9., Conclusions: CH was increased after exposure to PGA. However, this increase was significant only in eyes with higher IOP (>21 mm Hg). A significant increase in MMP-3 and -9 was observed in PGA-treated corneas, indicating structural changes in corneal biomechanics caused by PGA., Translational Relevance: PGAs alter biomechanical structures by directly upregulating MMP-3 and -9, and the increase in CH is dependent on the level of IOP. Therefore, PGAs may have a greater effect when baseline IOP is higher.