The purpose of this review is to analyze the molecular mechanisms of postoperative fibrosis of the filtering bleb and critically evaluate pharmacological approaches to modulating its key mediators as a basis for developing more effective and safer strategies to prolong the hypotensive effect of trabeculectomy. This review examines current approaches to the management of reparative processes in open-angle glaucoma surgery aimed at preventing excessive fibrosis of the outflow pathways and prolonging the hypotensive effect. Glaucoma continues to be the leading cause of irreversible blindness, and surgical reduction of intraocular pressure is the most effective treatment when medical therapy is insufficient. However, up to 50% of surgical procedures fail within 5 years because of subconjunctival and episcleral fibrosis. The review considers the key phases and molecular markers of wound healing (inflammation, proliferation, and remodeling) and the role of fibroblasts as effector cells. The article also analyzes the methods used in clinical practice to modulate wound healing, including steroids, mitomycin C, 5-fluorouracil, immunosuppressants, and angiogenesis inhibitors, from the standpoint of the benefit-risk ratio, and discusses various methods of drug delivery. Despite considerable progress, existing approaches do not fully meet the criteria of safety and effectiveness, highlighting the need for further experimental and clinical studies.
The results of numerous randomized clinical trials and clinical practice have demonstrated the effect of angiogenesis inhibitors (anti-VEGF agents) on the activity and growth of the neovascular complex in neovascular age-related macular degeneration (nAMD). At the same time, a reduction in the risk of macular fibrosis has been demonstrated, with its incidence decreasing from 39—100% in the “pre-antiangiogenic era” to 20.4—61.4% during anti-VEGF therapy. The main factors determining the risk of subretinal fibrosis are disease activity, timing of treatment initiation, treatment regimen and regularity, and type of drug. Fluctuations in retinal thickness and volatility of specific fluid compartments lead to an increase in the volume of subretinal hyperreflective material (SHRM) and hinder complete restoration of ellipsoid zone integrity. Extensive investigation of the role of angiopoietin-2 (Ang-2) in the development of fibrosis has shown that it acts not only as a cofactor of angiogenesis but also as an independent regulator of fibrogenesis through vascular destabilization with increased VEGF-mediated permeability and exudation, activation of macrophages and microglia with production of TGF-β and CTGF, as well as cross-talk with classical fibrotic pathways. The synergistic action of Ang-2 and VEGF-A promotes subretinal scarring and underscores the high potential of bispecific therapy for improving clinical outcomes in patients with nAMD. Compensatory activation of Ang-2 during anti-VEGF monotherapy may sustain tissue remodeling, contributing to the development of treatment resistance. Preclinical studies in models of choroidal neovascularization and clinical data on the effectiveness of faricimab 6 mg through dual Ang-2/VEGF-A inhibition have demonstrated not only superiority in controlling exudation and resolving retinal edema, but also a targeted effect on preventing proliferation and the development of subretinal fibrosis, as evidenced by a significant reduction in SHRM volume — a key precursor of fibrotic changes.
Differentiating idiopathic macular telangiectasia (MacTel type 1) from secondary macular telangiectasias remains challenging, and available diagnostic methods such as blue light reflectance (BLR) analysis are still underused. This study presents the case of a 80-year-old man with a visual acuity of 20/800 in the right eye (OD). Multimodal imaging revealed perifoveolar telangiectasias, diffuse loss of the foveal reflex, and hyporeflective intraretinal cystoid spaces consistent with edema. The patient received 18 intravitreal injections of anti-VEGF agents (aflibercept, faricimab), with improvement to 20/40 and subsequent stabilization at 20/50 OD. One year later he was diagnosed with intraretinal cavitations in the inner retinal layers, disorganization of the inner retinal layers, and formation of a lamellar macular hole. BLR analysis demonstrated hyperreflectivity along the temporal vascular arcades, indicating vascular sclerosis characteristic of a branch retinal vein occlusion in the past and increasing the likelihood of secondary macular telangiectasia. BLR analysis is a noninvasive and widely available method that can reveal perivascular changes not evident on color fundus photography or OCT, thereby refining the differential diagnosis and management of macular telangiectasias.
Surgery for advanced stages of primary open-angle glaucoma (POAG) aims to normalize intraocular pressure (IOP). A course of physiotherapy during subsequent stages of surgical treatment may have an additional beneficial effect. Objective. The study evaluated the effect of physiotherapy in patients with glaucomatous optic neuropathy and surgically compensated IOP. Material and methods. This prospective cohort study included 50 patients (64 eyes) with stage II—III POAG and indications for glaucoma surgery — nonpenetrating deep sclerectomy (NPDS). IOP, mean deviation (MD), pattern standard deviation (PSD), visual field index (VFI), average retinal nerve fiber layer thickness (AvgRNFL), and ganglion cell complex (GCC) parameters were assessed before NPDS and at 1, 3, and 6 months after surgery. In the study group, 1 month after NPDS, patients received a 2-week course of adjunctive physiotherapy consisting of three procedures — transcranial magnetic and electrical stimulation, endonasal electrophoresis with the 0.1% retinoprotective agent Semax, and heliox (21/79) inhalation. The control group received 0.1% Semax nasal drops twice daily for 10 days. Results. One month after NPDS, corneal-compensated IOP (IOPcc) decreased significantly (p<0.001), with no subsequent increase. In the study group, MD improved from −8.62±1.86 dB to −7.03±1.36 dB (p<0.01), while adjunctive physiotherapy produced a further improvement to −4.33±0.98 dB (p<0.0001), which persisted for up to 6 months after surgery. In the control group, MD returned to baseline values by month 3. Analysis of VFI, AvgRNFL, and GCC revealed no statistically significant differences. Conclusion. The findings indicate that comprehensive physiotherapy potentiates improvement in retinal function after surgery in patients with advanced POAG, with the effect lasting for up to 6 months.
The review presents the findings of studies on the clinical use of ultrasound biomicroscopy and anterior segment optical coherence tomography in the diagnosis of natural lens dislocation.
