PURPOSE:To review contemporary evidence supporting selective laser trabeculoplasty (SLT) as an initial and longitudinal therapy for glaucoma and to examine its implications for clinical outcomes, functional disease control, and health system sustainability. RECENT FINDINGS:Randomized clinical trials and extension studies have demonstrated that SLT-first strategies provide intraocular pressure (IOP) control comparable to medication-first therapy while substantially reducing treatment burden. In the Laser in Glaucoma and Ocular Hypertension (LiGHT) Trial, ∼70% of patients initially treated with SLT remained free from topical therapy and incisional surgery at 6 years. Secondary analyses revealed lower rates of moderate or fast visual field progression among eyes treated with SLT-first pathways compared with medication-first pathways (∼17% vs. 26%). Repeat SLT has been shown to produce IOP reductions similar to initial treatment without increased adverse events. Baseline IOP influences treatment response, with greater absolute pressure reductions observed in eyes with higher pretreatment IOP. SLT-first strategies have also been associated with lower cumulative costs and fewer surgical interventions over long-term follow-up. SUMMARY:SLT has established itself as a cornerstone of early glaucoma management. By providing durable and repeatable IOP control, SLT-first strategies may reduce reliance on daily medications and improve functional disease stability. Ongoing studies will further elucidate the role and optimal timing of repeat SLT, refining its integration into long-term glaucoma care.
Advancements in home-based tonometry and perimetry have enabled glaucoma care to expand beyond the office into the home in recent years. By capturing data that would otherwise be missed during routine office visits, remote glaucoma monitoring provides a more comprehensive clinical picture and leads to more individualized and timely management decisions. In addition, shifting data collection to the home may facilitate patient engagement and reduce strain on office resources. Further validation of existing tools and the introduction of new technologies have the potential to revolutionize glaucoma care delivery in the future.
Glaucoma is a chronic and progressive optic neuropathy, necessitating lifelong monitoring for affected individuals. Traditional surveillance of the disease relies on evaluation of intraocular pressure (IOP), optic nerve anatomy, and visual function at the physician's office, which only provides limited snapshots of a disease characterized by dynamic physiological variation. Developments in portable ophthalmological technologies and digital health platforms have enabled home monitoring of glaucoma. This review synthesizes current evidence on the home monitoring of glaucoma, with a focus on self-tonometry and home-based visual field testing. Handheld tonometers such as iCare HOME and iCare HOME2 allow repeated, anesthesia-free self-measurement of IOP in a real-world setting. These devices have demonstrated good agreement with Goldmann applanation tonometry, the gold standard. Home tonometry captures diurnal variations of IOP, thus providing relevant insights for diagnosis and therapeutic decision-making. Home-based visual field testing (eg, tablet-based platforms, virtual reality-based testing) enables frequent, unsupervised functional assessment with repeatability and sensitivity comparable to standard automated perimetry. Increased testing frequency may facilitate earlier detection of rapid progression, particularly in the early stages of disease. Collectively, evidence suggests the feasibility and clinical relevance of these home monitoring modalities. However, patient compliance with testing schedules and cost-effectiveness remain as challenges.
Hypotony maculopathy, characterized by chorioretinal folds with potential for vision loss, can occur as a complication from overfiltration following trabeculectomy. Its rate has increased in the era of antifibrotics. The challenge in treatment involves raising intraocular pressure to treat hypotony maculopathy while maintaining a level low enough to control glaucoma progression. This review aims to cover the expanse of nonsurgical and surgical management options available. Since a gold standard for hypotony maculopathy treatment is not established, selecting and tailoring treatment options will depend on specific patient and bleb characteristics.
Phosphodiesterase type-5 (PDE5) inhibitors are widely prescribed for erectile dysfunction and exert their pharmacologic effects through augmentation of nitric oxide-cyclic guanosine monophosphate signaling, a pathway with important ocular vascular implications. Given the expression of PDE5 within ocular tissues, increasing attention has been directed toward the effects of these agents on intraocular pressure (IOP), ocular blood flow, and glaucoma-related outcomes. Most clinical and experimental studies evaluating PDE5 inhibitors demonstrate no clinically meaningful or sustained effect on IOP across a range of dosing regimens, exposure durations, and patient populations, including individuals with established open angle glaucoma. Although isolated studies have reported transient or modest IOP elevations, these changes were typically small, transient, and unlikely to be clinically significant. In contrast, substantial evidence indicates that PDE5 inhibition increases ocular blood flow, with effects that appear more pronounced in the choroidal circulation than in the retinal vasculature. Human and animal studies have consistently demonstrated increased choroidal perfusion and thickness after sildenafil administration, supporting a preferential choroidal vascular response. Regarding glaucoma, early concerns were largely based on isolated case reports and postmarketing observations. More recent large-scale observational analyses suggest that PDE5 inhibitor exposure is associated with a lower hazard of being diagnosed as a glaucoma suspect or with open angle glaucoma. Collectively, current evidence supports a neutral effect of PDE5 inhibitors on IOP, a consistent enhancement of choroidal blood flow, and a potential protective association with glaucoma, warranting further mechanistic and prospective investigation. In this review, we examine the available clinical and experimental evidence regarding the effects of PDE5 inhibitors on IOP, ocular perfusion, and glaucoma risk to clarify their ophthalmic safety profile and potential therapeutic implications.
