Management of glaucoma during pregnancy and lactation: clinical considerations and therapeutic strategies.

Primary Congenital Glaucoma in the Developing World

Update on Microinvasive Glaucoma Surgery.

Glaucoma is recognized as a progressive optic neuropathy and a leading cause of irreversible blindness worldwide. While intraocular pressure (IOP) is considered the only modifiable risk factor, current medical treatments are challenged by issues such as inadequate IOP control and ocular side effects. Rho kinase (ROCK) inhibitors have been developed as a novel pharmacologic class targeting the trabecular meshwork to enhance conventional aqueous humor outflow. In this review, the pharmacokinetics and IOP-lowering efficacy of key ROCK inhibitors are summarized. Beyond IOP reduction, ROCK inhibitors exhibit neuroprotective, anti-inflammatory, antifibrotic, and ocular perfusion-enhancing effects. Finally, we analyzed the limitations and future prospects of ROCK inhibitors in the management of glaucoma.

Glaucoma is a leading cause of irreversible blindness in the world. Currently, glaucoma is diagnosed as a progressive optic neuropathy with characteristic optic disc and nerve fiber layer damage, usually associated with loss of visual function. The intraocular pressure (IOP) is the most important risk factor for the disease, although a significant proportion of patients do not have elevated IOP. Other risk factors include older age, African descent, myopia and family history of the disease. The ophthalmoscopic examination of the optic disc is essential to identify the signs of glaucomatous optic neuropathy, such as increased cupping, neuroretinal rim thinning or optic disc hemorrhages. Glaucomatous visual field loss usually starts in the periphery, and loss of central vision does not occur until late in the course of the disease. Visual function is most commonly assessed by standard automated perimetry; however, as many as 50% of nerve fibers can be lost before the appearance of visual field defects in this test. Newer technologies have been developed to find more sensitive ways to detect early glaucoma using both functional (short-wavelength automated perimetry and frequency-doubling perimetry) and structural (scanning laser topography, optical coherence tomography and scanning laser polarimetry) measurements. The management of glaucoma is based on lowering the intraocular pressure to prevent further optic nerve damage. Currently, there are five major classes of medications that are used to lower the intraocular pressure: Beta-adrenergic antagonists, adrenergic agonists, parasympathomimetics, prostaglandin-like analogues and carbonic anhydrase inhibitors. The goal of therapy is to maintain adequate vision for patients during their lifetime, keeping in mind the possible adverse effects of the drugs. If additional lowering of IOP is indicated or if medication fails to sufficiently lower the IOP, laser trabeculoplasty is usually the next step. If IOP is still not adequately controlled, incisional glaucoma surgery is indicated. Neuroprotective agents, which directly protect the optic nerve in glaucoma, are being evaluated in clinical trials.

Glaucoma is one of the most dreadful ocular conditions that affects millions of people worldwide and is one of the major causes of irreversible blindness. Although glaucoma is a complex and poorly understood disorder, the primary goal of therapy is lowering Intraocular Pressure (IOP), which is not only one of the most significant risk factors in development of the disease, but also the only modifiable one. Therefore, a precise measurement of IOP is essential for accurate diagnosis and effective monitoring of glaucoma. Goldmann applanation tonometry is the gold standard method for IOP measurement. It has been known that IOP measurement by this method is affected by corneal properties; typically, thick corneas overestimate and thin corneas underestimate the IOP. Therefore, several methods had been introduced to correct IOP based on the central corneal thickness. However, those methods had oversimplified the problem, and ignored important factors such as corneal viscosity and elasticity. New generation of devices such as Ocular Response Analyzer (Reicherts®) and CorVis ST (Oculus Inc.®) have been devised that can account for corneal biomechanical properties when measuring IOP. It is claimed that these methods are particularly useful for eyes with inherently abnormal and surgically altered corneal biomechanics such as those who have undergone laser vision correction or keratoplasty [1]. Around two-thirds of patients with glaucoma may have their highest IOP readings beyond regular clinic hours, especially during the night. Actually, these undetected IOP spikes have been suggested to play a role in progressive glaucomatous optic neuropathy in a subset of glaucoma patients with apparent normal office-based IOP readings. Therefore, determining the role of IOP fluctuation in glaucoma warrants more extensive research. Accordingly, a 24 hour continuous (or frequent) IOP monitoring would be a commendable goal, especially for those with unexplained progression [2]. In addition to IOP fluctuation, the potential role of corneal characteristics, pathologies, and prior operations on IOP measurement should be considered when interpreting patients’ IOP. While there is no single method which provides an easy, quick and accurate result in all cases, the practitioner should adopt a patient-oriented strategy to select the most appropriate method, based on established strengths and limitations of each device [1]. Antiglaucoma eye drops comprise the mainstay of treatment in most cases of glaucoma. However, some patients still need laser and surgical procedures to prevent glaucoma progression. Nowadays, similar to other aspects of ophthalmology, utilization of laser plays a tremendous role in glaucoma treatment. Typical laser surgeries for glaucoma include laser peripheral iridotomy, laser iridoplasty, laser trabeculoplasty, and laser cyclophotocoagulation. There are also emerging methods of glaucoma laser therapy using advantages of novel inventions such as micropulse laser and pattern delivery [3]. Several surgical procedures have been introduced to help in achieving normal IOP where topical medications are inappropriate or inadequate. For several decades, filtering surgeries (trabeculectomy and shunt) have been used successfully to control IOP in a variety of cases with glaucoma. Although the primary concept has not been changed since then, recent growing knowledge about wound healing allows using modified techniques and novel adjuvants to achieve more efficient filtering blebs with less associated complications [4]. In contrast to open angle glaucoma, small incision cataract surgery with or without goniosynechialysis may be a good alternative for medications or even filtering surgeries in selected cases with angle-closure glaucoma. It can efficiently widen the iridocorneal angle, evades anatomical predisposition to angle closure, and significantly improves IOP control without long-term complications of trabeculectomy [5]. The 5 solicited review articles of this issue deals with the most recent advancements in glaucoma diagnosis and treatment and update the readers with useful and practical information in this regard.

Normal tension glaucoma is a progressive optic neuropathy that poses technical complexity in management to prevent vision loss. Surgical intervention is necessary when visual field progression is noted or imminent. Trabeculectomy with adjunct use of the anti-scarring agent mitomycin-C is the treatment of choice in achieving a target intraocular pressure to preserve vision in normal tension glaucoma patients. This subset of patients is at a relatively higher risk for dense visual field defects and postoperative surgical management is key to success for the patient and the surgeon. Other surgical interventions can be of aid in combination with each other or with traditional trabeculectomy and antimetabolite treatment to prevent fibrosis; however, these surgeries have not definitively resulted in intraocular pressures low enough to reach a desired target in normal tension glaucoma patients.

To estimate the effect of reducing intraocular pressure (IOP) on: (i) the incidence of primary open-angle glaucoma (POAG) in patients with ocular hypertension (OH), and (ii) the progression of glaucoma. A meta-analysis of relevant randomized controlled trials was conducted. A literature search was performed to identify trials with: a randomized comparison of IOP-lowering intervention versus placebo or no treatment; visual field loss or optic disc changes as outcome; and follow-up >6 months. A pooled relative risk (RR) was calculated by a random effects model. Risk reduction of glaucoma conversion per mmHg of IOP reduction was quantified in a meta-regression model. We identified nine OH and one POAG trials. A meta-analysis of OH trials gives a pooled RR of 0.61 [95% confidence interval (CI) 0.45-0.83]. A meta-regression shows a decrease of the RR of glaucoma conversion by 14% with each mmHg extra IOP reduction (P = 0.045). No meta-analysis of POAG trials was performed because only one study has been identified. There is sufficient evidence that OH therapy reduces the risk of conversion to glaucoma. This risk reduction increases with greater IOP reduction.

Homozygous Familial hypercholesterolemia (HoFH) is a rare genetic disease characterized by very high levels of low-density lipoprotein cholesterol (LDL-C). Owing to LDL receptor activity being completely or nearly all lost in HoFH, LDL-C levels greatly exceed normal levels, and are even higher than in heterozygous (HeFH), which can cause fatal cardiovascular disease even in infancy. The current study updates differences in clinical characterization, therapeutic strategies and cardiovascular outcomes between HoFH and HeFH. A total of 157 patients who were genetically or clinically diagnosed with FH (HoFH: 15, HeFH: 142) were retrospectively analyzed. Clinical characteristics, lipid profiles and atherosclerotic prognosis were evaluated between HoFH and HeFH patients. Age and sex were similar between the two groups. Untreated LDL-C in HoFH was about double that in HeFH (498.4±164.3 vs. 232.0±60.5 mg/dL, p＜0.001), while on-treatment LDL-C with lipid lowering therapies did not differ significantly (83.8±59.1 vs. 127.1±59.6 mg/dL, p = 0.15). There was wide diversity in lipid lowering therapies between the two groups and a significantly higher prevalence of coronary artery and valvular disease in HoFH. Consequently, HoFH patients were more likely to receive percutaneous and surgical interventions at a younger age compared to HeFH patients. The findings of this observational study show the clinical relevance of FH. Although both HeFH and HoFH are inherited disorders of lipoprotein metabolism, HoFH should be treated with a different, stricter therapeutic strategy to prevent premature ASCVD.

Introduction:Primary open angle glaucoma is an insidious and chronic vision-threatening eye ailment due to neuro-retino-optic nerve degeneration, which may be due to the raised intraocular pressure (IOP) or due to independent factors. Management of glaucoma is mainly concentrated on lowering IOP that requires lifetime topical medication, different ocular medicaments for lowering of IOP, and surgical interventions, but it has its own limitations to control the progression of glaucomatous optic neuropathy (GON), and this is the reason behind the use of alternative neuroprotective adjuvants.Aim:To evaluate the neuroprotective effect of Ayurvedic line of management of progressive GON.Materials and Methods:Ingredients of trial drug Vara Fort powder (Chakshushya Rasayana) were procured from the Institute Pharmacy, except Swarnamakshika Bhasma, which was purchased from Dhootapapeshwar Pharmaceuticals. The patients fulfilling inclusion criteria, attending outpatient and inpatient departments, irrespective of their sex, race, religion, occupation, etc., were selected and divided into two groups with open-labeled randomization. In Group A, in addition to betaxolol (0.1%) or timolol (0.5%) (non-iobrim), Chakshushya Rasayana 6 g/day orally with Triphala Ghrita and honey along with Koshtha-Shuddhi (body-microchannel clearing treatment) protocol was tried. Nasya (oleation through nasal route) with Jeevantyadi Taila and Tarpana (eye satiation) with Go-Ghrita were also performed. In Group B (control), brimonidine (iobrim) 0.2% eye drop was used for 3 months.Results:Significant improvement was observed in subjective parameters in Group A such as blurred vision, frequent change of presbyopic glasses, and delayed dark adaptation.Conclusion:Chakshushya Rasayana, if administered in a systematic approach along with a modern topical betaxolol or timolol eye drops, has a definite role in improving the lost retinal sensitivity as much as up to 12 dB in 3 months duration.

Primary open-angle glaucoma (POAG) is a major cause of irreversible blindness worldwide, characterized by progressive optic neuropathy and loss of retinal ganglion cells (RGCs). Although lowering intraocular pressure (IOP) remains the mainstay of glaucoma management, many patients continue to experience vision loss, underscoring the need for adjunctive neuroprotective approaches. In Ayurveda, Rasayana therapies are believed to slow degenerative processes. One such intervention is a Rasayana Formulation (RF) comprising three oral preparations; Rasayana Churna (RC), Saptamrita Lauha (SL), and Yashada Bhasma (YB). Additionally, topical Arka (distilled extract) of Shigru Pallava (SP) has been used traditionally for glaucoma and may have an IOP-lowering effect. This is an open-label, two-arm, parallel-group randomized controlled trial with a 2:3 (control: intervention) allocation ratio. A total of 50 previously or newly diagnosed POAG patients (IOP < 30 mmHg) are planned for enrollment. The control group receives the conventional standard of care alone, whereas the intervention group receives standard care plus RF (2.5 g, taken orally twice daily) and SP eye drops (1 drop, four times daily), administered for 90 days with a further 90-day follow-up. Primary outcomes include changes in optic nerve function measured by visual field indices (mean deviation (MD), pattern standard deviation (PSD), visual field index (VFI)) and retinal nerve fiber layer (RNFL) thickness, while secondary outcomes include IOP changes. Participant recruitment and data collection are ongoing. Final outcomes will be disseminated in peer-reviewed journals. If shown to be effective, the combined RF and SP eye drops could enhance neuroprotection and further control IOP in POAG, thereby addressing a significant need in current glaucoma therapy. This trial may provide a foundation for larger-scale investigations into integrative treatments for glaucoma management. Clinical Trial Registry of India (CTRI) no. CTRI/2023/06/053681, dated 08.06.2023.Available from: https://trialsearch.who.int/Trial2.aspx?TrialID=CTRI/2023/06/053681 Protocol Version: 3.0, dated 05.01.2023.

Optic disc haemorrhages are associated with active glaucomatous neurodegeneration and ongoing visual field loss. We sought to determine whether automated alternation flicker enhances the detection of disc haemorrhages in serial images from patients with glaucoma when compared to side-by-side photographic evaluation and single-image display. Serial sets of optic nerve photographs of 394 eyes from 234 patients followed for glaucoma at the authors' institutions were included in this study. Eyes with disc haemorrhages were graded for difficulty level and randomized along with nondisc haemorrhage control images into one of three presentation groups (automated alternation flicker, side-by-side or single image). Seven graders viewed all images and assessed for the presence or absence of disc haemorrhages. The sensitivity of automated alternation flicker for disc haemorrhage detection (0.878) was higher than side-by-side (0.705; p = 0.002) and single photographs (0.757; p = 0.01). There was no specificity difference between pairs of presentation groups (all p ≥ 0.7). Automated alternation flicker was a more sensitive method for disc haemorrhage detection than the current clinical standards and may have an important role in the management of glaucoma.

Current management of uveitis-associated ocular hypertension and glaucoma

The times they are a‐changin’: time to change glaucoma management

Glaucoma is a family of diseases commonly characterised by progressive optic neuropathy with associated visual field deficits for which elevated intraocular pressure (IOP) is one of the primary risk factors. For more than a century the main goal of glaucoma management has been to eliminate the risk associated with elevated IOP. In recent years, accumulating evidence of pressure-independent causes of glaucomatous optic neuropathy has led to the recognition that lowering IOP alone may often be insufficient for the long-term preservation of visual function. An innovative therapeutic approach is now emerging to prevent progression of glaucomatous optic neuropathy and preserve vision, irrespective of disease aetiology: direct protection of the optic nerve. In addition to reducing the risk associated with elevated IOP, this neuroprotective approach will augment the overall goal of preserving the optic nerve through direct promotion of retinal ganglion cell (RGC) survival and/or prevention of RGC death. Although no currently available compounds have been clinically demonstrated to provide neuroprotective benefit in glaucoma, recent preclinical studies have shown that alpha-adrenergic agonists, such as brimonidine, provide neuroprotective benefits, as well as excellent IOP lowering efficacy. In addition, new agents with promising neuroprotective utility that are emerging from other studies are now being investigated for efficacy in glaucoma. The review discusses recently introduced compounds and new drugs in development with regard to their potential value in conventional and/or neuroprotective strategies for vision sparing in glaucoma.

Introduction: Normal tension glaucoma (NTG) represents a significant diagnostic and therapeutic challenge within the spectrum of open-angle glaucomas. Characterized by progressive optic neuropathy and visual field loss despite intraocular pressure (IOP) measurements consistently within the statistically normal range, its management remains complex and debated. The central question persists: is IOP reduction beneficial in NTG, and if so, what is the optimal therapeutic strategy? (Anderson et al., 2003). Methods: This comprehensive systematic review was conducted in strict accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. A thorough literature search and screening process identified 80 eligible studies, including randomized controlled trials, cohort studies, and meta-analyses. Inclusion criteria focused on studies evaluating therapeutic interventions (medical, laser, surgical) for NTG with a minimum follow-up of 6 months. Data extraction encompassed management approaches, clinical outcomes (IOP, visual fields, optic disc), patient characteristics, and adverse effects. Results: The synthesis of evidence reveals that IOP reduction, even from normal baseline levels, is beneficial in slowing NTG progression. Medical therapy, particularly prostaglandin analogues (PGAs) like latanoprost, provides an average IOP reduction of 16-24% (Cheng et al., 2009; Ang et al., 2004). Selective laser trabeculoplasty (SLT) achieves comparable efficacy, with first-line use showing superior outcomes (Nitta et al., 2024; Naito et al., 2025). Surgical interventions, including trabeculectomy and minimally invasive glaucoma surgery (MIGS), offer greater and more sustained IOP lowering (30-40%) and reduce medication burden (Chin Lai et al., 2022; Hnin P Oo et al., 2024). Critically, a ≥25% IOP reduction from baseline is associated with significant suppression of visual field progression (Yoshikawa et al., 2018). Evidence also supports pressure-independent neuroprotective effects, notably with brimonidine (Sena &amp; Lindsley, 2017; Krupin et al., 2005) and nilvadipine (Koseki et al., 2008). Discussion: The findings advocate for a stratified, patient-centric management paradigm. Treatment efficacy is strongly influenced by baseline IOP; patients with higher baseline IOP (&gt;15 mmHg) respond better to conventional IOP-lowering therapies. In contrast, patients with lower baseline IOP require consideration of adjunctive neuroprotective strategies and management of vascular risk factors like disc hemorrhage and nocturnal blood pressure dipping (Lee et al., 2014; Bowe et al., 2015). Long-term safety considerations, such as prostaglandin-induced central corneal thinning (Kim &amp; Cho, 2011; Hyungwoo Lee &amp; Cho, 2015) and surgical complication profiles (Andrea Gabai et al., 2019), must be balanced against therapeutic benefits. Conclusion: Effective management of NTG necessitates a multifaceted approach centered on achieving substantial IOP reduction, with a target of ≥25% being clinically meaningful. Treatment selection should be individualized based on baseline IOP, risk factor profile, disease severity, and patient tolerance. Future research should prioritize long-term outcomes of novel interventions, refined patient stratification biomarkers, and the integration of neuroprotection into standard care protocols.