Target pressure—glaucomatologists’ holey grail

To compare intraocular pressure (IOP) control in eyes with or without clear corneal phacoemulsification following trabeculectomy. The study group included 30 eyes that underwent uneventful clear corneal phacoemulsification and foldable intraocular lens implantation following trabeculectomy without antimetabolites. Thirty eyes that had undergone filtering surgery without cataract extraction were selected as controls. Case and control groups were matched with respect to age, gender, IOP, number of glaucoma medications, glaucoma type (primary open-angle glaucoma/pseudoexfoliative glaucoma), trabeculectomy time and follow-up. Comparisons between the study and control groups (intergroup) and within the same group at different time-points (intragroup) were performed for IOP, glaucoma medications and bleb morphology. Success rates were investigated by Kaplan-Meier survival analysis and the factors influencing final success by logistic regression. Intraocular pressure (p = 0.04) and glaucoma medications (p = 0.001) increased during an average follow-up of 26.1 +/- 9.9 months in both groups. Intragroup differences became statistically significant after the 6-month visit, but intergroup differences remained insignificant. Bleb height decreased significantly following phacoemulsification in the study group (p = 0.017). Success rates decreased with time in both groups, with no intergroup difference (p = 0.46). The final success rate was negatively correlated with IOP and number of glaucoma medications used at the study entry, while there was a positive correlation between the baseline and final success rates. Trabeculectomy success decreased in a time-dependent manner in eyes with and without subsequent phacoemulsification. Uncomplicated clear corneal phacoemulsification was not found to have any additional unfavorable influence on IOP control in eyes with filtering blebs.

Aim: to determine a level of "target" intraocular pressure (IOP) in patients with normal-tension glaucoma (NTG), depending on the disease stage. Patients and Methods: a final protocol of a multicenter scientific analytical selective combined study conducted in 6 countries (Russia, China, Belarus, Serbia, Slovakia and Uzbekistan) at 25 clinical centers included data from 269 patients. The stage of glaucoma was confirmed by ophthalmoscopy and/or fundus photography and/or optical coherence tomography and/or Heidelberg tomography, and standard automatic perimetry (SAP). Visual acuity was examined, clinical refraction was determined, a tonometric level of IOP was measured (Maklakov tonometry with a 10 g load, Caucasian population), and Goldman tonometry results (Asian population) were evaluated. Results: at diagnosis, patients with NTG were several years younger than those with primary open-angle glaucoma (POAG). The greatest increase in glaucoma progression was reported in patients with the advanced disease (+91.4%), while a number of patients with stages I and II decreased by 5.5% and 23.4%, respectively. In patients with mild NTG (stage I), IOP level reduced by 19.9% and 16.6% from the initial values when measured by Maklakov and by Goldman methods, respectively. In patients with stages II и III, the parameter values decreased by 17.1% and 9.4% (on average, by 14.1%), as well as by 21.9% and 9.3% (on average, by 15.3%), respectively. Only among patients with advanced NTG, the progression rate was approximately 7 times higher in individuals with the appropriate family history (p=0,016; U=2,416). Conclusion: regardless of the disease stage, the lower an initial IOP level, the less it can be reduced towards the final examination. During the entire follow-up period, an average decrease in the IOP level was 16.5% regardless of the NTG stage. Due to the treatment provided, IOP in NTG patients was on average 2–4 mm Hg lower than that in individuals with POAG. Thus, current guidelines to determine "target" values of the parameter in this group of patients should be amended. KEYWORDS: normal-tension glaucoma, "target" intraocular pressure, glaucoma progression, tonometry. FOR CITATION: Egorov E.A., Kuroyedov A.V., Zavadskiy P.Ch., Vitkov А.А., Bakunina N.A., Baryshnikova D.A., Bulakh I.A., Zvereva O.G., Zubasheva S.A., Galimova A.B., Gaponko O.V., Getmanova A.M., Gusarevich A.A., Korelina V.E., Lanin S.N., Stepanova E.A., Chernyakova T.V., Shakhalova A.P., Razhko Yu.I., Yuan H., Sun X., Wu L., Bozic М., Ferkovа S.L., Zakhidov A.B. Target intraocular pressure level in patients with different stages of low tension glaucoma. Russian Journal of Clinical Ophthalmology. 2025;25(1):9–19 (in Russ.). DOI: 10.32364/2311- 7729-2025-25-1-2

This study aimed to assess the effectiveness and safety of ab externo canaloplasty over a 3-year follow-up period in Polish Caucasian patients with glaucoma. This retrospective study of a cases series was conducted at the Department of Ophthalmology Medical University of Bialystok, Poland. Primary outcome measures were intraocular pressure and medication burden. Secondary outcome measures were best corrected visual acuity, retinal nerve fiber layer thickness, visual field test results, endothelial cell density, intraoperative and postoperative complications, and additional glaucoma surgery. The study group consisted of 160 eyes diagnosed with early to-moderate primary open-angle glaucoma and treated with ab externo canaloplasty from 2014 to 2020. The criteria for qualified and complete success were intraocular pressure < 18 mmHg or ≥ 20% reduction in intraocular pressure from baseline with or without antiglaucoma medications, respectively. After surgery, the mean intraocular pressure decreased from 19.23 ± 4.33 to 14.52 ± 3.79 mmHg, which constituted a 36.7 ± 7.8% reduction compared to the baseline value. The number of medications decreased by two at the end of the study period (from 2.69 ± 1.05 to 0.32 ± 0.75). Complete and qualified success were achieved in 58.7% and 68.7% of the patients, respectively, at the end of follow-up. An incomplete cannulation of Schlemm's canal was the most common intraoperative complication, occurring in 32 eyes (20%). The most frequent postoperative complications were hyphema, Descemet's membrane detachment, and a transient increase in intraocular pressure. Additional surgical procedure was required in seven cases (4.4%). In 16 patients (10%), medical treatment was re-administered. Overall, our findings suggest that ab externo canaloplasty is a good option for Polish Caucasian patients with primary open-angle glaucoma. It reduces intraocular pressure and has a low postoperative complication rate. Additional glaucoma surgery or re-administration of medications is required if the target intraocular pressure is unsatisfactory.

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Both nonpenetrating deep sclerectomy (NPDS) and iStent inject are safe and effective when combined with phacoemulsification. The NPDS group presented lower final intraocular pressure (IOP); however, more postoperative intervention and longer recovery time was required. The aim of this study was to assess the 1-year efficacy and safety of second-generation trabecular microbypass stent implantation (iStent inject) versus NPDS in association with phacoemulsification (Phaco) for the concomitant surgical treatment of open-angle glaucoma and cataracts. This was a single-center longitudinal retrospective comparative study of eyes treated with Phaco-NPDS, with adjunctive use of collagen matrix implant and mitomycin C (group 1), or Phaco-iStent inject (group 2). The main outcome measures were success rates [absolute success: proportion of eyes with IOP<18 mm Hg without any glaucoma medication; relative success: proportion of eyes achieving different target IOPs (<18; <15; and <12 mm Hg) with or without medication]; mean reduction (%) in IOP and medication use; number of postoperative reinterventions (goniopuncture, needling, and reoperation); and number of complications. The mean age (y) was 69.3 in group 1 and 72.7 in group 2. Groups 1 (n=51) and 2 (n=32) achieved absolute success rates of 74.5% and 81.3%, respectively (P=0.333). Concerning relative success rates, no significant difference was found for IOP<18 mm Hg or an IOP<15 mm Hg between the 2 groups. However, significantly more eyes achieved an IOP <12 mm Hg in the Phaco-NPDS group. The mean percentage of IOP reduction from baseline to the end of follow-up was also statistically higher in group 1 (39.9% vs. 24.5%). Both groups achieved similar results in the mean reduction of medications per eye. No significant complications were found in either group, but patients in group 1 required more postoperative intervention than group 2. Both techniques are safe and effective for the concomitant surgical treatment of open-angle glaucoma and cataracts and presented comparable relative success rates at different target IOP levels (<18 and <15 mm Hg). A larger proportion of patients in group 1 achieved a target IOP <12 mm Hg; however, more postoperative intervention was required.

PurposeThe study reported here investigated the efficacy, tolerability, and safety of the preservative-free prostaglandin analog tafluprost 0.0015% in treatment-naive patients.Patients and methodsData were collected in two non-interventional, prospective, multicenter, observational, open-label studies of identical design that were conducted in Germany and the Czech Republic. All subjects received preservative-free tafluprost 0.0015% once daily. Intraocular pressure (IOP) levels were recorded for each eye at untreated baseline and 3 months after initiation of medical treatment. The primary outcome was change in mean IOP from baseline to month 3. In the primary open-angle glaucoma (POAG) and ocular hypertension (OH) patient subgroups, analyses were stratified by the level of baseline IOP: ≥20 to 23 mmHg versus ≥24 mmHg. In addition, responder rates and the achievement of pre-specified IOP levels at month 3 were evaluated. Local tolerance of preservative-free tafluprost was evaluated by the patients at final visit. Overall satisfaction with the medical treatment was evaluated by both patients and physicians. All adverse events were recorded.ResultsA total of 579 treatment-naive patients with POAG (n = 349), OH (n = 105), normal tension glaucoma (n = 71), exfoliative glaucoma (n = 27), or other glaucomas (n = 27) were included in this observational study. Mean IOP level at baseline for all patients was 23.6 ± 4.0 mmHg. Mean IOP at month 3 was 16.8 ± 2.9 mmHg (−28.8% vs baseline). At month 3, significant reductions in mean IOP (P < 0.001) were seen in all patients and all subgroups. Preservative-free tafluprost lowered mean IOP significantly in patients with POAG and OH with IOP levels ≥ 20 to 23 mmHg from 21.9 ± 1.1 mmHg at baseline to 16.5 ± 2.2 mmHg, and in the subgroup with IOP levels ≥ 24 mmHg from 26.2 ± 2.4 mmHg to 17.9 ± 2.4 mmHg. In the subgroups of patients with POAG and OH, an IOP response ≥20%, ≥30%, and ≥40% was achieved by 83.4%, 44.1%, and 12.8%, respectively. Overall, patients with higher baseline IOP values showed a better response than patients with lower baseline IOP levels. Preservative-free tafluprost was well tolerated and safe. After 3 months, 97.9% of all patients remained on therapy.ConclusionIn this real-world observational study, treatment with once-daily preservative-free tafluprost proved efficacious, well tolerated, and safe in treatment-naive patients.

AimsTo investigate if eyes presenting intraocular pressure (IOP) within the limits of current guideline-driven target IOP indeed experience slow rates of glaucomatous visual field (VF) progression.MethodsA total of 8598 24-2...

We Are Different, Some Much More than Others

To describe patterns of care for primary open-angle glaucoma (POAG) and assess conformance with the American Academy of Ophthalmology's Preferred Practice Pattern (PPP). We obtained administrative, survey, and eye care records data on 395 working-age patients with POAG enrolled in 6 managed care plans between 1997 and 1999. We assessed processes of care at the initial and follow-up visits, control of intraocular pressure (IOP), intervals between visits and visual field tests, and adjustments in therapy. We found high rates of performance on most recommended processes during initial evaluations, although only 53% of patients received an optic nerve head photograph or drawing and only 1% had a target IOP level documented. Recommended processes were performed at 80% to 97% of follow-up visits. Using loose criteria for control, IOP was controlled in 66% of follow-up visits for patients with mild glaucoma and 52% of visits for patients with moderate to severe glaucoma. Intervals between visits and visual field tests were generally consistent with PPP recommendations. Adjustments in therapy were more likely with worse control of IOP, although adjustments occurred in only half of visits where the IOP was 30 mm Hg or higher. Our study suggests that, in many respects, patients with POAG are receiving care that is consistent with the PPP. However, care is falling short on several key aspects, and POAG may be undertreated relative to standards for IOP control established in recent clinical trials.

GATT significantly reduced intraocular pressure and reduced medication use in POAG and PXG patients over 5 years, with high success rates. Previous glaucoma surgeries and early intraocular pressure spikes were risk factors for failure. To evaluate the long-term outcomes of gonioscopy-assisted transluminal trabeculotomy (GATT) in managing primary open angle glaucoma (POAG) and pseudoexfoliation glaucoma (PXG) over 5 years. This retrospective study involved 51 eyes of 42 patients who underwent GATT using prolene suture by a single surgeon with a follow-up duration of at least 5 years. Mean follow-up duration was 69.0±12.1 months. Mean intraocular pressure (IOP) significantly reduced in POAG patients (n=26), from 27.4±5.6mmHg to 14.5±1.9mmHg ( P <0.001), and in PXG patients (n=25), from 26.4 ± 6.6mmHg to 13.3±2.1mmHg ( P <0.001) at the final visit. Correspondingly, the average number of antiglaucomatous medications decreased from 3.2±0.7 to 2.1±1.5 in POAG ( P =0.019) and from 3.5±0.7 to 1.5±1.4 in PXG ( P <0.001). The qualified cumulative surgical success rates at a target IOP ≤18mmHg were 83.1% (95% CI: 72.5%-93.7%) for POAG and 91.2% (95% CI: 84.7%-97.7%) for PXG, and at a target IOP ≤15mmHg were 68.2% (95% CI: 55.0%-81.4%) and 83.5% (95% CI: 74.4%-92.7%), respectively. Factors such as prior incisional glaucoma surgery and higher IOP levels during the first postoperative week were identified as risks for surgical failure. GATT showed promising long-term efficacy and safety in POAG and PXG patients followed for 5 years, achieving significant reductions in IOP and medication dependence. Prior incisional glaucoma surgery and early postoperative IOP elevations were identified as risk factors for failure.

Selective laser trabeculoplasty can be used as a substitute for medications in patients with mild-to-moderate glaucoma, reducing the cost of eye drop distribution in the Brazilian public health system. To observe the effectiveness of selective laser trabeculoplasty (SLT) as a substitute for eye drops in patients with open angle glaucoma in the Brazilian Public Health System. SLT was performed bilaterally after medication washout. This is a prospective interventional study comparing intraocular pressure (IOP) when using eye drops at baseline (post-washout), and at 12-month follow-up after SLT. Medication was added if the target IOP was not achieved, following the Brazilian Public Health System eye drops protocol, based on medication costs. Absolute (without eye drops) and qualified (with eye drops) success were measured with IOP ≤ 21, IOP ≤ 18, IOP ≤ 15 and IOP ≤ 12 mm Hg. Besides IOP evolution, the ability to reduce IOP (in %), and eye drops reduction were evaluated. Ninety-two eyes of 46 patients were included, 70 eyes with mild glaucoma and 22 with moderate glaucoma; the mean number of eye drops was 2.26±1.06 (82.6% were using a prostaglandin analogue), and post-washout IOP of 21.10±5.24 mm Hg. There was relative success at IOP ≤18 mm Hg, where the mild group had greater success than the moderate group (88.1% vs. 71.4%, P =0.824). The average IOP reductions were 23.04% and 25.74% at 6 and 12 months, respectively. The average number of eye drops was 1.02, with 1.1% using a prostaglandin analogue. Furthermore, 68.19% of the patients had a decrease in the quantity of eye drops used. SLT is effective in reducing IOP and replacing eye drops in patients in the Brazilian Public Health System. Moreover, there was a significant reduction in the use of prostaglandin analogues.

We enjoyed reading the article ‘trabeculectomy versus canaloplasty (TVC) in the treatment of patients with open-angle glaucoma: a prospective randomized clinical trial’ by Matlach et al (2015). The study is well designed and addresses important questions. In particular, the prospective and randomized character makes this an excellent and important article for the ophthalmological community showing that canaloplasty has a comparable intraocular pressure (IOP)-lowering effect to trabeculectomy after 2 years (Matlach et al. 2015). Trabeculectomy, although being a rather invasive and unphysiological procedure is still perceived as the first-line surgical therapy for glaucoma. Disadvantages include the postoperative need of antiproliferative substances and vision-threatening complications like long-term hypotony, choroidal detachment or bleb related infections (Rulli et al. 2013; Kim et al. 2015); therefore, less invasive surgical options have been evaluated in the past. The most promising is the canaloplasty that yields the advantages of a sufficient IOP reduction without the risks of severe complications. The excellent study by Matlach et al. supports our recent findings, where we retrospectively analysed 78 eyes operated with a modified canaloplasty technique. Mean IOP dropped from 19.10 to 13.5 mmHg with 52.6% of patients not using any topical therapy. The main variation of this novel technique is the creation of a second deep scleral flap facilitating orientation and probing of Schlemm's canal and creating an additional aqueous outflow and drainage into the suprachoroidal space (Szurman et al. 2015). We could also show that an additional IOP reduction of 41.2% can be achieved by microinvasive 360° trabeculotomy under topical anaesthesia in cases where target IOP was not achieved (Seuthe et al. 2015). Some points in the article by Matlach et al. are in our eyes misleading and should be addressed: Therefore, in our eyes, the main findings of this study are that canaloplasty is not inferior to trabeculectomy considering absolute IOP reduction with/without topical medication and that trabeculectomy yields higher chances of reaching drop-free IOP reduction <18 mmHg. This changes the dynamics of the surgical approach for treating glaucoma patients: It makes canaloplasty the first-line surgical strategy yielding the same IOP-lowering potential with less severe side-effects than trabeculectomy and more attractive postoperative strategies if target IOP is not reached. Trabeculectomy will in our eyes remain an attractive second line therapy besides deep sclerectomy. We should be asking ourselves the question: which of the two equal IOP-lowering procedures is preferable - the one with 50% chance of having to use additional topical therapy or the one with a 25% possibility for additional topical therapy but with high chances of severe intra- and postoperative complications and failure. The answer is given by Mattlach et al. in this excellent article but could be emphasized with less subtlety.

Aim: to assess the effects of prostaglandin F2a analogues on intraocular pressure (IOP) fluctuations when changing body position. Patients and Methods: thirty-eight patients (50 eyes) with newly diagnosed primary open-angle glaucoma (POAG). Patients were examined before and one month after prescribing travoprost, a prostaglandin F2a analogue. During the examination, IOP was measured by Icare pro rebound tonometry and applanation tonometry (corneal-compensated IOP/ccIOP and Goldmann-correlated IOP/IOPg) in a sitting position. Next, IOP was measured by Icare tonometer twice with a 5-min interval in a supine position. Finally, IOP was measured by Icare tonometry and applanation tonometry (IOPcc, IOPg) in the sitting position. Results: baseline IOPcc, IOPg, and IOP measured by Icare were 25.4±3.2 mm Hg, 25.7±2.3 mm Hg, and 22.9±3.4 mm Hg, respectively. IOP levels (Icare tonometry) in the supine position were 23.7±3.3 mm Hg and 24.0±3.3 mm Hg, respectively. In repeated measurements in the sitting position, IOPcc, IOPg, and IOP measured by Icare were 25.4±3.2 mm Hg, 25.7±2.4 mm Hg, and 22.3±3.4 mm Hg. One month after starting treatment with travoprost, IOPcc, IOPg, and IOP measured by Icare reduced to 18.2±2.7 mm Hg, 18.2±1.8 mm Hg, and 16.6±2.5 mm Hg, respectively. IOP levels (Icare tonometry) in the supine position were 17.3±2.8 mm Hg and 17.2±2.7 mm Hg, respectively. In repeated measurements in the sitting position, IOPcc, IOPg, and IOP measured by Icare were 18.0±2.3 mm Hg, 18.4±1.8 mm Hg, and 16.2±2.5 mm Hg, respectively. When transiting in a supine position, the differences in IOP levels were 0.83±1.04 mm Hg at baseline and 0.77±1.41 mm Hg after one month. When transiting in a sitting position, the differences in IOP levels were 1.66±1.24 mm Hg at baseline and 0.99±0. 98 mm Hg after one month. Conclusion: travoprost as a starting monotherapy for POAG provides a long-lasting IOP reduction and minimizes its fluctuations when changing body position Keywords: glaucoma, intraocular pressure, body position, rebound tonometry, prostaglandin analogue, travoprost. For citation: Antonov A.A., Vostrukhin S.V., Volzhanin A.V. et al. Influence of prostaglandin analogues on intraocular pressure fluctuations in body position change. Russian Journal of Clinical Ophthalmology. 2022;22(2):103–107 (in Russ.). DOI: 10.32364/2311-7729-2022- 22-2-103-107.

To evaluate the effectiveness of the PRESERFLO MicroShunt (PFM) in reducing intraocular pressure (IOP) ex vivo in porcine eyes using an infusion pump system and to simulate various IOP conditions, In this study, porcine eyes received increasing flows between 2 and 20 μL/min. IOP measurements were taken under conditions with and without the PFM [PFM (+) and PFM (-), respectively]. In the PFM (-) group, IOP increased from 7.4 mmHg to 46.3 mmHg as the flow rate increased from 2 μL/min to 20 μL/min. The rate of IOP reduction (%ΔIOP) rose with increasing flow rates, although the absolute IOP values achieved with the PFM insertion also increased. The correlation between IOPs in the PFM (-) conditions and the %ΔIOP was modeled as %ΔIOP = 22.4 Ln [PFM(-) IOP] - 41.7. According to this equation, IOP reduction by PFM insertion is 0% at IOPs of 6.4 mmHg or lower. IOP reductions of 10%, 20%, 30%, and 40% were observed when the pre-insertion IOPs were 10.1, 15.7, 24.6, and 38.4 mmHg, respectively. Achievable post-insertion IOP levels of ≤21 mmHg, ≤18 mmHg, ≤15 mmHg, and ≤12 mmHg corresponded to the initial IOPs of 33 mmHg, 26 mmHg, 20 mmHg, and 14.8 mmHg, respectively. In conclusion, the PFM effectively reduced IOP within a specific range of IOP values in an ex vivo experimental system. In clinical situations, the PFM is unlikely to be effective at low IOP levels. At higher levels, the PFM reduces IOP, but it may be insufficient to achieve the target IOP.

Treatment of glaucoma is aimed at reducing intraocular pressure (IOP) to prevent further damage to the optic nerve. For patients who do not respond to monotherapy, combination treatment may be effective in achieving therapeutic reduction or target IOP. To evaluate the effectiveness and safety of dorzolamide 2% with timolol 0.5% alone or combined with latanoprost in reducing IOP in a real-world setting. A prospective, open-label, multicenter, nonrandomized interventional study was designed. Three hundred fifty patients with primary open-angle glaucoma or ocular hypertension and uncontrolled IOP after latanoprost monotherapy for 4 or more weeks were treated with combination dorzolamide-timolol twice daily added to their existing latanoprost therapy (D/T-Add-On; n = 280) or dorzolamide-timolol twice daily monotherapy (D/T-Switch; n = 70). The primary effectiveness outcome measure was the change in IOP after 6 and 12 weeks of treatment. Of the total population, 313 patients completed this trial (248 D/T-Add-On; 65 D/T-Switch). After 12 weeks, the mean +/- SD IOP decrease was -6.3 +/- 3.6 mm Hg (-28.1%) and -5.8 +/- 4.9 mm Hg (-23.5%) in the D/T-Add-On and D/T-Switch groups, respectively (both p < 0.001). Therapeutic response rates (defined as IOP reduction >20%) after 12 weeks of treatment for the D/T-Add-On and the D/T-Switch groups were 66.4% (186/280) and 52.9% (37/70), respectively. There were 116 predominantly mild, nonserious adverse events attributed to the study drugs, reported by 86 (24.6%) patients. The most frequent adverse events were eye irritation (n = 42; 12.0%) and taste perversion (n = 15; 4.3%). No serious adverse events related to the study medications were reported. In patients with primary open-angle glaucoma or ocular hypertension and elevated IOP while on monotherapy with latanoprost, switching to dorzolamide-timolol or combining dorzolamide-timolol with latanoprost are effective and safe treatment options for reducing IOP and achieving therapeutic response.