Repeat selective laser trabeculoplasty has emerged as a valuable option for managing intraocular pressure in pa-tients with primary open-angle glaucoma or ocular hypertension. This review synthesizes current evidence of the efficacy, safety, and clinical applicability of repeat selective laser trabeculoplasty. Evidence from randomized controlled trials, systematic reviews, and observational studies indicate that repeat selective laser trabeculoplasty effectively sustains significant intraocular pressure reduction with minimal complications. This procedure demonstrates comparable efficacy to that of initial selective laser trabeculoplasty, supporting its role as a sustainable, drop-free management strategy. However, further research is warranted to optimize treatment intervals, assess long-term outcomes, and evaluate cost-effectiveness across different healthcare settings.

In Part II, this paper addresses ocular motions, their causes (forces), and the governing laws, beginning with the fundamental question: Why do the eyes move? Ocular rotations and different types of translations (ocular, orbital, and corporeal) are reviewed. The discussion then turns to how the eyes move, where concepts such as the plane of muscular action, torque, and arc of contact provide possible explanations for the anatomical arrangement of the ocular muscles within the orbit. Sherrington's law of reciprocal innervation is used to explain the distribution of muscular active forces in a conservative mechanical system, but in combination with Hering's law, it may prevent eye rotation (e.g., isometric contractions of antagonist muscles of an asymmetrical convergence). Normally, however, the limitation of an eye rotation is determined by passive forces, evoked by muscular activity itself, particularly natural muscular elasticity. Thus, elongation of an antagonist muscle may passively restrict the active contraction of an agonist. In addition to mechanisms for initiating rotation (active forces) and stopping it (passive forces), the oculomotor system also requires a means of dissipating energy (dissipative forces) to initiate subsequent movements. Hence, it cannot function as a perfectly conservative system of forces. The paper concludes with a review of "selective" effects of muscle function (due to the sparse distribution of fibers), the role of intermuscular membranes (and pulleys), and mechanical considerations of surgical procedures, such as muscular transpositions to alter or abolish actions (e.g., bifid reinsertions). Part III will address the diagnostic complexities of the oculomotor system, general treatment principles, and ocular fixation (eye and head positions). Although the basic concept of the primary position is relativized, the absolute need for referential conditions in defining, qualifying, and measuring strabismus is emphasized. The prim-diopter is challenged due to its lack of "linearity" relative to angular units, and an alternative is proposed. Methods of examining oculomotor disturbances are outlined, including monocular rotations (ductions), and tests to differentiate between muscular deficiencies and opposing forces. Techniques for identifying the site of a rotational restriction are described, followed by approaches to measuring ocular deviations in diagnostic positions. The concepts of muscular overactions and underactions are analyzed before introducing the concept of diagnostic muscle pairs. Classical knowledge about deviations caused by deficient or restricted muscle actions reinforces the theory of distribution of rotational ocular muscles by diagnostic pairs. For vertical deviations, "underactive" muscle pairs must be separately matched (e.g., RSR with LIR, RIO with LSO). Since vertical recti exert stronger vertical actions than oblique muscles, head tilts are recommended to enhance stress on both pairs, mainly by additional stimulation of oblique muscles. Classical diagnostic directions then align with the objective horizontal plane. The article concludes with peropertative oculomotor testing and a broad protocol for evaluating oculomotor imbalance.

Diabetic retinopathy screening in lowand middle-income countries is limited by restricted access to specialized care. Portable retinal cameras offer a practical alternative; however, image quality - affected by mydriasis - directly influences the performance of artificial intelligence models. This study evaluated the effect of mydriasis on image gradability and AI-based diabetic retinopathy detection in real-world, resource-limited settings. The proportions of gradable images were compared between mydriatic and non-mydriatic groups. Generalized estimating equations were used to identify factors associated with image gradability, including age, sex, race, diabetes duration, and systemic hypertension. A ResNet-200d model was trained on the mobile Brazilian Ophthalmological dataset and externally validated on both mydriatic and non-mydriatic images. Model performance was evaluated using accuracy, F1 score, area under the curve, and confusion matrix metrics. Sensitivity differences were assessed using the McNemar test, and area under the curves were compared using DeLong's test. The Youden index was used to determine optimal classification thresholds. Agreement between maculaand disc-centered images was analyzed using Cohen's κ. The mydriatic group demonstrated a higher proportion of gradable images compared with the non-mydriatic group (82.1% vs. 55.6%; p<0.001). In non-mydriatic images, lower gradability was associated with systemic hypertension, older age, male sex, and longer diabetes duration. The AI model achieved better performance in mydriatic images (accuracy, 85.15%; area under the curve, 0.94) than in non-mydriatic images (accuracy, 79.68%; area under the curve, 0.93). The McNemar test showed a significant difference in sensitivity (p=0.0001), whereas DeLong's test revealed no significant difference in area under the curve (p=0.4666). The Youden index indicated that optimal classification thresholds differed based on mydriasis status. Agreement between image fields was moderate to substantial and improved with mydriasis. Mydriasis significantly improves image gradability and enhances AI performance in diabetic retinopathy screening. Nonetheless, in lowand middle-income countries where pharmacologic dilation may be impractical, optimizing model calibration and thresholding for non-mydriatic images is essential to ensure effective AI implementation in real-world clinical environments.

Glaucoma is a progressive optic neuropathy that can cause irreversible blindness, though it rarely affects women of reproductive age. Its management during pregnancy and lactation is particularly challenging because of the potential impact of intraocular pressure fluctuations on disease progression and the risks of treatment to both the mother and fetus. Physiological changes in pregnancy, such as decreased intraocular pressure and hormonal alterations, may influence disease activity but do not guarantee disease stability. Preconception counseling plays a key role in mitigating risks and tailoring treatment strategies. Many glaucoma medications carry teratogenic risks, with brimonidine being the only US Food and Drug Administration Category B drug. Surgical interventions - including laser trabeculoplasty and minimally invasive glaucoma surgeries - offer alternative options but require careful timing and consideration of fetal safety. Multidisciplinary collaboration is essential to optimize maternal and neonatal outcomes. This review summarizes evidence-based approaches for glaucoma management during pregnancy and lactation, highlighting clinical considerations, therapeutic strategies, and patient-centered care.

This study aimed to evaluate disparities in the distribution of ophthalmologists and the volume of ca-ta-ract surgeries across Brazil, considering public and private health sectors and the country's federative units. Data on ophthalmologists were obtained from the National Medical Residency Commission and the Associação Médica Brasileira. Information on cataract surgeries performed through the Unified Health System was collected from the DATASUS database, while data on procedures covered by private health plans were retrieved from the National Supplementary Health Agency. Population estimates from the 2024 Demographic Census of the Brazilian Institute of Geography and Statistics were used to calculate physician density and surgery rates per 100,000 inhabitants. Associations between the number of ophthalmologists and cataract surgery volume were analyzed using Spearman's correlation coefficient. Brazil has 16,784 ophthalmologists, representing 8.96 specialists per 100,000 inhabitants. Marked disparities were observed: large cities (>500,000 inhabitants) had 18.75 ophthalmologists per 100,000 residents, whereas municipalities with <50,000 inhabitants had fewer than one. Across federative units, physician density ranged from 19.18 per 100,000 in the Federal District to 4.22 in Maranhão. In 2024, cataract surgery rates varied widely, from 1,012.61 per 100,000 inhabitants in the Southeast to 435.00 in the North. Nationally, Unified Health System performed 736.30 surgeries per 100,000 inhabitants, compared with 1,276.79 in the private sector. On average, each ophthalmologist performed 96.92 cataract surgeries annually. Significant inequalities persist in the geographic distribution of ophthalmologists and in cataract surgery provision, with higher surgical volumes concentrated in the private sector. Targeted policies are required to address regional disparities and improve the equity and efficiency of cataract care delivery in Brazil.

To investigate choroidal structural and vascular changes in patients with mild autonomous cortisol secretion using enhanced depth imaging optical coherence tomography and optical coherence tomography angiography. This cross-sectional study included 60 eyes of 30 patients with mild autonomous cortisol secretion and 60 eyes of 30 subjects with nonfunctional adenoma (controls) between February 2023 and January 2024. Subfoveal choroidal thickness, pachychoroid spectrum disease and choroidal vascularity index were evaluated using spectral-domain optical coherence tomography. Group comparisons were performed, and correlations between subfoveal choroidal thickness and clinical features were analyzed. Pachyvessels were more common in patients with mild autonomous cortisol secretion than in controls (71.4% vs. 42.9%, p=0.002). The frequency of pachychoroidal spectrum disease was significantly higher in the mild autonomous cortisol secretion Group (68.3% vs. 31.7%; p<0.001). Median subfoveal choroidal thickness was 355 μm (range, 150-535) in the mild autonomous cortisol secretion Group and 297 μm (range, 162-597) in controls (p=0.014). Choroidal vascularity index was comparable between groups (p=0.072). Subfoveal choroidal thickness correlated significantly with axial length, spherical equivalent, post-1-mg dexamethasone suppression test cortisol level, and disease duration. Patients with mild autonomous cortisol secretion exhibited greater subfoveal choroidal thickness and a higher frequency of pachychoroidal spectrum disease compared with controls, whereas stromal and vascular structural alterations were proportionally similar between groups.

To evaluate whether specific meibomian gland morphological features can serve as diagnostic indicators of dry eye disease in patients with type 2 diabetes mellitus. This cross-sectional study included patients with type 2 diabetes mellitus and age-matched healthy controls. All participants underwent a comprehensive ocular surface evaluation, including the ocular surface disease index, tear break-up time, Schirmer's I test, corneal staining, eyelid margin scoring, meibum expressibility assessment, meibography scoring, and evaluation of meibomian gland loss area. Meibomian gland morphology was assessed bilaterally. Dry eye severity was determined based on ocular surface disease index scores, tear break-up time, Schirmer's test results, and corneal staining scores. Correlations between meibomian gland features and ocular surface parameters, age, diabetes duration, and hemoglobin A1c levels were analyzed. Receiver operating characteristic analysis was performed to determine the diagnostic value of specific meibomian gland features for dry eye disease. Dry eye disease was diagnosed in 56.6% of patients with diabetes and 22.6% of controls. Compared with controls, patients with diabetes had significantly higher ocular surface disease index scores, greater corneal staining, worse meibum expressibility, increased meibomian gland loss, and lower tear break-up time and Schirmer values (all p<0.05). Meibomian gland dropout, shortening, tortuosity, distortion, overlapping, ghost glands, and lack of extension to the lid margin were significantly more prevalent in patients with diabetes (p<0.05) and showed significant correlations with age, HbA1c levels, and diabetes mellitus duration. Receiver operating characteristic analysis identified meibomian gland dropout, ghost glands, shortening, and lack of extension to the lid margin as the most predictive morphological features for dry eye disease in patients with diabetes. Type 2 diabetes mellitus is associated with distinct meibomian gland morphological alterations that correlate with both dry eye disease severity and systemic diabetic parameters, suggesting potential diagnostic value.

To quantitatively compare eyebrow and eyelid positions in anophthalmic sockets reconstructed with conical or spherical orbital implants combined with customized external ocular prostheses. This cross-sectional observational study included 38 patients with unilateral anophthalmic sockets, of whom 21 received conical implants, and 17 received spherical implants. Eyelid and eyebrow parameters-including margin reflex distance 1 and 2, vertical and horizontal palpebral fissure dimensions, eyebrow-to-upper-eyelid margin distance in primary gaze and infraduction, medial and lateral eyelid angles in primary gaze, and superior eyelid sulcus depth -were quantitatively assessed using standardized digital photographs analyzed with Image J software. The contralateral healthy eye served as the control. Statistical analyses were performed to compare measurements between groups. In the primary gaze position, conical and spherical implants showed comparable margin-reflex distance1, margin-reflex distance2, vertical palpebral fissure height, eyelid margin position, and medial and lateral eyelid angles. During infraduction, the upper eyelid margin was significantly lower in sockets reconstructed with conical implants. Compared with contralateral normal eyes, anophthalmic sockets exhibited a reduced horizontal palpebral fissure and a deeper superior eyelid sulcus, irrespective of implant shape. Anophthalmic sockets reconstructed with conical or spherical implants demonstrate similar eyebrow and eyelid positioning in primary gaze. However, conical implants are associated with a lower eyelid margin during infraduction. Independent of implant format, anophthalmic sockets show a narrower horizontal palpebral fissure and increased superior sulcus depth compared with normal eyes.

This study aimed to analyze ocular sur-face parameters and evaluate meibomian gland dys-function using meibography in newly diagnosed patients with atopic dermatitis compared with healthy controls. This cross-sectional clinical study included 51 newly diagnosed patients with atopic dermatitis and 45 ageand sex-matched healthy controls. Disease severity was assessed using the Eczema Area Severity Index. The Ocular Surface Disease Index questionnaire, Schirmer test, tear meniscus height, noninvasive tear break-up time, conjunctival redness grading, and meibography staging were performed. Meibomian gland dropout was graded for each eyelid from 0 (no loss) to 3 (loss of >2/3 of the total gland area). Schirmer test values, tear meniscus height, and noninvasive tear break-up time were significantly lower in the atopic dermatitis group than in the control group (p<0.001, p<0.001, and p<0.001, respectively). In contrast, Ocular Surface Disease Index scores, conjunctival redness grades, and total meiboscores were significantly higher in the atopic dermatitis group than in the control group (p<0.001, p<0.001, and p<0.001, respectively). Moreover, in the atopic dermatitis group, a significant positive correlation was observed between the Eczema Area Severity Index score and total meiboscore (rₛ=0.390, p=0.005), while a significant negative correlation was found between the Eczema Area Severity Index score and Schirmer test results (rₛ=-0.301, p=0.032). Newly diagnosed patients with atopic dermatitis exhibit significant alterations in tear film parameters and meibomian gland morphology compared with healthy individuals. These patients should be monitored for early development of dry eye disease and meibomian gland dysfunction to prevent associated complications.

This cross-sectional study compared best-corrected visual acuity obtained using Cloudscaper symbols, a novel optotype developed according to ETDRS specifications for children's virtual screening, with that obtained using LEA symbols. A total of 560 children aged 3-16 yr underwent visual acuity test with both Cloudscaper symbols and LS. The test application was standardized using the EyeSpy algorithm. Additionally, 147 participants were tested with the standard Snellen E paper chart. Paired t tests were performed to assess the clinical significance of logMAR visual acuity differences. The mean logMAR visual acuity with LEA symbols was 0.12 (standard deviation [SD]=0.18; range, -0.10 to 0.80), while with Cloudscaper symbols it was 0.18 (SD=0.19; range, -0.10 to 0.80). The mean difference between Cloudscaper symbols and LEA symbols was 0.099 logMAR (approximately 0.5 optotypes; SD=0.08; range, 0.0-0.14; p<0.0001). Cloudscaper symbols slightly underestimated visual acuity compared to LEA symbols. Visual acuity measured by both methods was highly correlated (Spearman's r=0.74, p<0.0001). The mean visual acuity difference between Cloudscaper symbols and the Snellen E chart was 0.0045 (p=0.805; 95% confidence interval [95% CI]), whereas the difference between LEA symbols and Snellen E was 0.0883 (p<0.001; 95% CI). Cloudscaper symbols provide a reliable tool for visual screening in children. Although they slightly underestimate visual acuity compared to LEA symbols - a finding also reported when comparing ETDRS letters with LEA symbols - Cloudscaper symbols show strong agreement with Snellen E chart measurements. This suggests that Cloudscaper symbols allow precise visual acuity assessment comparable to the gold standard.