Minimally invasive glaucoma surgery (MIGS) presents substantial challenges due to its intricate procedures and high technical demands, necessitating robust surgical navigation systems. The development of these systems is highly dependent on the availability of precisely annotated datasets. Addressing this need, we have created the first multicenter, large-scale, fine-annotated surgical video dataset for MIGS. This dataset includes millions of frames, extensively annotated with both surgical instruments and anatomical structures. The annotations are organized into two primary tasks: Task I, which involves phase recognition to identify different stages of the surgery, and Task II, which focuses on semantic segmentation of surgical instruments and anatomical details. By providing a foundational resource for training computer vision models, our dataset aims to facilitate the development of advanced computer-assisted interventions that can improve the precision and safety of glaucoma surgeries.

BackgroundGlaucoma secondary to neurofibromatosis type 1 (NF1) is a vision-threatening complication characterized by variable phenotypic expression. The prognostic significance of specific anterior segment signs, particularly ectropion uveae (EU), remains unclear.Case presentationWe report a 7-year-old girl with NF1 who presented with unilateral refractory glaucoma and prominent EU in the affected eye. Despite maximal medical therapy and sequential surgical interventions, including microcatheter-assisted transluminal trabeculotomy, subsequent scar tissue excision with goniotomy, and two sessions of transscleral cyclophotocoagulation, intraocular pressure (IOP) remained uncontrolled. Implantation of a glaucoma drainage device (GDD) resulted in initial IOP reduction, with IOP maintained at 16/18 mmHg during the first 3 months. At 1 year post-GDD, IOP was 23 mmHg, and brinzolamide was subsequently added.ConclusionThis 4-year longitudinal case highlights an association between prominent ectropion uveae and a refractory surgical course in this patient. Traditional angle surgeries appeared to carry a high risk of failure, whereas GDD implantation provided IOP reduction from 42 to 23 mmHg at 1 year, although adjunctive medication was subsequently required. This observation raises the question of whether earlier GDD implantation might prove beneficial in similar patients. However, this hypothesis requires validation in a larger series.

Objective:​ This study aimed to analyse visual quality and its associated factors in patients with primary open-angle glaucoma (POAG) using OPD-Scan III. Methods:​ In this retrospective study, 53 eyes from patients with POAG were enrolled and divided into an early-to-moderate stage group (22 eyes) and an advanced stage group (31 eyes). All subjects underwent optical coherence tomography, visual field testing, and ocular biometry. Higher-order aberrations (HOAs) and the modulation transfer function (MTF) were analysed using OPD-Scan III. Spearman correlation analysis was performed to assess the relationships between MTF values at spatial frequencies of 5–30 cycles per degree (cpd) and visual field mean deviation (MD) as well as average retinal nerve fiber layer thickness (RNFLT). Results:​ At a 4-mm pupil diameter, no statistically significant difference in HOAs was found between the two groups (all P>0.05). However, a significant intergroup difference was observed in MTF values at the 5 cpd spatial frequency (U=4.394, P=0.036), while no significant differences were found at other spatial frequencies (all P>0.05). MTF values at spatial frequencies of 5, 10, and 15 cpd each showed positive correlations with MD (r=0.345, P=0.011; r=0.318, P=0.020; r=0.330, P=0.016, respectively). Conclusion:​ MTF values at the 5 cpd spatial frequency were significantly reduced in advanced POAG patients. The decline in MTF within the 5–15 cpd range was significantly correlated with the progression of visual field defects. These findings highlight the importance of emphasizing the assessment and intervention of visual quality in the management of advanced POAG.

PURPOSE:To evaluate the 3-year efficacy and safety of phacogoniotomy versus phacotrabeculectomy for advanced primary angle-closure glaucoma (PACG) with cataract. DESIGN:Multicenter, randomized controlled, open-label, non-inferiority trial. METHODS:Patients were randomized 1:1 to undergo either phacogoniotomy (65 eyes) or phacotrabeculectomy (59 eyes). Three years retention was 92.3% (60/65) and 83.1% (49/59) for each group, respectively. Primary outcome was 3-year intraocular pressure (IOP) reduction (noninferiority margin: 4 mmHg). Secondary outcomes included surgical success, complications, hypotensive medications used; additional outcomes were changes in visual acuity (BCVA), visual field (VF), and corneal endothelial cell density (ECD). RESULTS:At 3 years, phacogoniotomy reduced mean IOP from 40.2 (10.3) to 14.1 (2.4) mmHg (-26.1 [10.4] mmHg reduction); phacotrabeculectomy, from 39.7 (9.3) to 14.4 (2.5) mmHg (-25.3 [9.2] mmHg reduction). Adjusted between-group difference in IOP change was -0.37 mmHg (95% CI, -1.32-0.58 mmHg; P = 0.44), meeting noninferiority. Complete (78.3% vs 89.8%; P = 0.13) and qualified (90.0% vs 91.8%; P > 0.999) success rates were comparable. Hypotensive medications declined in both groups (phacogoniotomy: 2.1 [1.2] to 0.2 [0.6]; phacotrabeculectomy: 2.1 [1.3] to 0.0 [0.2]; P = 0.06 for 3-year difference). BCVA improvements (0.1 vs 0.0 logMAR; P = 0.49), VF stability (MD difference:1.42 dB, P = 0.26; PSD difference: 0.22 dB, P = 0.75), and ECD loss (difference: 2%; P = 0.53) were similar. No new complications occurred in extended follow-up. CONCLUSIONS:At 3 years, phacogoniotomy remained non-inferior to phacotrabeculectomy in IOP reduction for advanced PACG with cataract.

PURPOSE:To evaluate the visual preservation, safety, and surgical outcomes of phacogoniotomy (phacoemulsification combined with or without goniosynechialysis and goniotomy) in patients with end-stage glaucoma. METHODS:This multicenter retrospective study included 134 eyes of 128 patients (92 primary angle-closure glaucoma [PACG] and 42 primary open-angle glaucoma [POAG]) with end-stage glaucoma (defined as inability to perform perimetry or visual acuity ≤ 20/200). Patients underwent phacogoniotomy and were followed ≥ 12 months. Main outcomes included best-corrected visual acuity (BCVA), intraocular pressure (IOP), medication burden, and complications, with specific attention to the "wipe-out" phenomenon. RESULTS:At a mean follow-up of 19.2 ± 8.0 months, no cases of "wipe-out" (sudden, immediate, irreversible central vision loss) occurred. BCVA improved in 63.1% of eyes and remained stable in 30.3%. The mean IOP decreased significantly from 31.4 ± 9.7 mm Hg to 14.1 ± 3.3 mm Hg (P < 0.001) and mean number of medications dropped from 2.2 ± 1.4-0.6 ± 1.0 (P < 0.001). Complete success rate was 67.9% overall, with 76.1% for PACG and 50.0% for POAG (P = 0.005). Qualified success rate was 97.0% overall, with 96.7% for PACG and 97.6% for POAG (P = 0.695). The most common complications were transient hyphema (11.2%) and IOP spike (3.7%). CONCLUSIONS:In end-stage glaucoma, phacogoniotomy is a safe and effective procedure that significantly lowers IOP while preserving or improving vision in > 90% of cases. The procedure may reduce the risk of "wipe-out" associated with traditional filtration surgery and appears particularly effective in eyes with angle-closure mechanisms.

ObjectiveTo assess the efficacy and safety of goniotomy (GT) and gonioscopy-assisted transluminal trabeculotomy (GATT) with or without phacoemulsification (PEI) for exfoliation glaucoma (XFG).MethodsSearches were conducted in PubMed, Scopus, Embase, Ovid, and the Web of Science. Two independent reviewers performed study selection, data extraction, and quality assessment. The primary outcomes were the reduction in intraocular pressure (IOP) and the number of antiglaucoma medications (AGMs) at 1, 6, and 12 months postoperatively. Safety was assessed by the incidence of complications.ResultsFourteen studies involving 624 eyes were included. The GATT ± PEI group showed significant IOP reductions of 1.96 mmHg (p < 0.01), 2.17 mmHg (p < 0.001), and 2.07 mmHg (p < 0.001) at 1, 6, and 12 months, respectively, with corresponding AGM reductions of 3.28 (p < 0.001), 2.87 (p = 0.003), and 2.54 (p = 0.011). The GT + PEI group demonstrated IOP reductions of 1.95 (p < 0.001), 2.00 (p = 0.040), and 2.13 mmHg (p = 0.013), with AGM reductions of 1.07, 0.96, and 0.96 (all p < 0.001). For standalone procedures, GT significantly reduced AGMs at all timepoints (all p < 0.001) and IOP at 1 and 6 months (both p = 0.002), while standalone GATT significantly reduced IOP only at 1 month (2.39 mmHg, p < 0.001) and AGMs at 6 and 12 months (both p < 0.001). The most common complications were anterior chamber hemorrhage (47.6%) and IOP spike (17.0%).ConclusionThis meta-analysis demonstrates that GT and GATT, particularly when combined with phacoemulsification, are safe and effective in reducing IOP and medication burden in patients with XFG. The evidence for sustained IOP lowering with standalone GATT remains limited, suggesting that combined surgery may offer more reliable long-term pressure control, especially for patients with concurrent cataract.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD420251072295, identifier CRD420251072295.

Purpose:To evaluate the 2-year outcomes of goniotomy (GT) in patients with prior failed glaucoma surgery. Design:A prospective, observational multicentered study. Participants:Patients who underwent GT after previous failed glaucoma surgery. Methods:Patients were enrolled from May 2021 to October 2022. They underwent comprehensive ophthalmic examination, including medical history review, slit lamp examination, best-corrected visual acuity, and intraocular pressure (IOP) assessments preoperatively and postoperatively. Postoperative complications were also evaluated. Complete success was defined as IOP of 6 to 18 mmHg with ≥20% reduction from baseline, without medication. Qualified success required similar IOP control with medication. Main Outcome Measures:Intraocular pressure change, medication use, treatment success rate, and postoperative complications over 24 months. Results:A total of 61 eyes from 51 patients were included, with 20 eyes (17 patients) diagnosed with primary open-angle glaucoma and 41 eyes (34 patients) with primary angle-closure glaucoma as their primary condition. The mean age was 60.6 ± 10.6 years, with 30 (58.8%) female patients. Prior surgeries included peripheral iridectomy (23 eyes), trabeculectomy (39 eyes), XEN Gel implant (1 eye), Ahmed valve implant (1 eye), and phacoemulsification and intraocular lens implantation (17 eyes). Among these, complete success was achieved in 26 eyes (42.6%) and qualified success in 52 eyes (85.2%). The mean IOP dropped from 26.4 ± 6.2 mmHg preoperatively to 16.3 ± 4.8 mmHg at 24 months (35.8% reduction; P < 0.001). Antiglaucoma medications decreased from 2.6 ± 1.2 to 1.4 ± 1.4 over 24 months (P < 0.001). Best-corrected visual acuity remained stable during the follow-up (P = 0.987). Complications included hyphema (n = 7), IOP spikes (n = 6), mild corneal edema (n = 3), and shallow anterior chamber (n = 2), all within the first postoperative month. Regression analysis showed that older age was positively correlated with complete success (odds ratio = 1.06; 95% confidence interval, 1.00-1.12; P = 0.044) and qualified success (odds ratio = 1.16; 95% confidence interval, 1.05-1.28; P = 0.004). Primary open-angle glaucoma was negatively associated with qualified success (odds ratio = 0.18; 95% confidence interval, 0.04-0.84; P = 0.029). Conclusions:Goniotomy proves to be a safe and effective procedure for patients with previous failed glaucoma surgery over the 24-month study period. Financial Disclosures:Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

PURPOSE:To evaluate the impact of prolonged use of topical glaucoma medications on the surgical outcomes of gonioscopy-assisted transluminal trabeculotomy (GATT) in juvenile open-angle glaucoma (JOAG). PATIENTS AND METHODS:This multicenter retrospective study included 100 eyes of 77 JOAG patients who underwent GATT with at least 12 months of follow-up. Patients were categorized into the short-duration (≤ 1.5 years) and long-duration (> 1.5 years) groups. Intraocular pressure (IOP), glaucoma medications, and complications were recorded at baseline and the final visit. Success was defined as a postoperative IOP ≤ 21 mmHg (criterion A), ≤ 18 mmHg (criterion B), or ≤ 15 mmHg (criterion C). Complete and qualified successes were defined as meeting these criteria without and with medications, respectively. RESULTS:The mean age of the participants was 23.2 ± 8.6 years with a mean follow-up of 14.2 ± 4.1 months. Qualified and complete success rates for the short-duration and long-duration groups were 98.0 % and 92.0 % (P = 0.369), 80.0 % and 66.0 % (P = 0.322) for criterion A; 92.0 %, and 68.0 % (P = 0.006), 78.0 % and 50.0 % (P = 0.021) for criterion B; 66.0 % and 40.0 % (P = 0.013), 58.0 % and 30.0 % (P = 0.015) for criterion C. The short-duration group had a significantly lower final IOP than the long-duration group (P = 0.011). No significant differences were observed in final medication and complications. CONCLUSIONS:Prolonged use of topical glaucoma medications may reduce the efficacy of GATT in achieving lower IOP in JOAG. Early surgical intervention may contribute to better postoperative outcomes.

Importance:The safety and effectiveness of combining surgical peripheral iridectomy (SPI) with goniosynechialysis (GSL) and goniotomy (GT) vs trabeculectomy for intraocular pressure (IOP) reduction remains unknown. Objective:To investigate the safety and effectiveness at 1 year of SPI + GSL + GT vs trabeculectomy in advanced primary angle-closure glaucoma (PACG) without cataract. Design, Setting, and Participants:This noninferiority randomized clinical trial was conducted at 8 tertiary eye centers in China. A total of 88 Chinese patients (88 eyes) with advanced PACG without cataract were enrolled from January 2022 to July 2023. Data were analyzed from August 2024 to September 2024. Mean (SD) patient age was 60.3 (7.3) years, and 52 patients (59.1%) were female. Forty-three patients were randomized to SPI + GSL + GT and 45 were randomized to trabeculectomy; 86 patients (97.7%) completed the 12-month follow-up. Interventions:Participants were randomized 1:1 to receive SPI + GSL + GT or trabeculectomy. Main Outcomes and Measures:The primary outcome was IOP at 12 months (noninferior margin: 4 mm Hg). Secondary outcomes included surgical success (IOP: 5-18 mm Hg, ≥20% reduction from baseline, with or without antiglaucoma medications); postoperative complications and interventions, including bleb massage, suture lysis, or releasable sutures; and number of antiglaucomatous medications prescribed. Results:At 12 months, the SPI + GSL + GT group had a mean (SD) IOP of 15.6 (4.0) mm Hg vs 14.9 (4.2) mm Hg in the trabeculectomy group (difference, 0.5 mm Hg; 95% CI, -1.2 to 2.2; P = .55), which was within the 4-mm Hg noninferiority margin. Qualified success rates were 38 of 43 participants (88.4%) for SPI + GSL + GT and 42 of 45 participants (93.3%) for trabeculectomy (difference, -5.0%; 95% CI, -19.6% to 8.5%; P = .48). However, complete success rates were lower in the SPI + GSL + GT group (26 participants [60.5%]) vs the trabeculectomy group (37 participants [82.2%]; difference, -21.8%; 95% CI, -40.2% to -2.4%; P = .03). Postoperative complications were present for 8 participants (18.6%) in the SPI + GSL + GT group vs 9 participants (20.0%) in the trabeculectomy group (difference, -1.4%; 95% CI, -17.9% to 15.1%; P = .71). Postoperative interventions were lower in the SPI + GSL + GT group (3 participants [7.0%] vs 25 participants [55.6%]; difference, 48.6%; 95% CI, 32.2%-65.0%; P < .001). Median (IQR) numbers of medications used decreased from 2 (0-3) to 0 (0-1) in the SPI + GSL + GT group and from 2 (2-3) to 0 (0-0) in the trabeculectomy group (difference, -0.81; 95% CI, -1.36 to -0.26; P = .004). Conclusions and Relevance:In this randomized clinical trial among patients with advanced PACG without cataract, SPI + GSL + GT demonstrated noninferiority (4-mm Hg margin) to trabeculectomy for IOP at 12 months, with fewer interventions (including bleb massage, suture lysis, or releasable sutures) but no difference in postoperative medication use. This suggests SPI + GSL + GT as a potential alternative to trabeculectomy for similar cases, pending validation in larger sample sizes with smaller noninferiority margins. Trial Registration:ClinicalTrials.gov Identifier: NCT05163951.

Importance:Intraocular pressure (IOP) reduction with phacogoniotomy (phacoemulsification plus goniosynechialysis plus goniotomy) was not less than that of phacotrabeculectomy for advanced primary angle-closure glaucoma (PACG) with cataract at 1-year follow-up, but longer-term outcomes are needed. Objective:To investigate if phacogoniotomy is noninferior to phacotrabeculectomy for advanced PACG with cataract at 2 years. Design, Setting, and Participants:This multicenter, noninferiority, randomized clinical trial took place in 7 ophthalmology centers in China. The trial started May 31, 2021, and 2-year follow-up ended May 31, 2024. Included in this analysis were patients with advanced PACG and cataract. Study data were analyzed from September 2024 to January 2025. Interventions:Random assignment (1:1) to phacogoniotomy or phacotrabeculectomy. Main Outcomes and Measures:The primary outcome measure was reduction in IOP from baseline to the 2-year visit with a noninferiority margin of 4 mm Hg. Results:A total of 124 participants (124 eyes) were randomized (mean [SD] age, 66.4 [8.6] years; 67 female [54.0%]), 65 (52.4%) to the phacogoniotomy group and 59 (47.6%) to the phacotrabeculectomy group. A total of 59 patients (90.7%) in the phacogoniotomy group and 52 patients (88.1%) in the phacotrabeculectomy group completed 2-year visits. All participants were Chinese. Mean (SD) IOP reduction was -25.6 (10.2) mm Hg and -24.7 (9.4) mm Hg in the phacogoniotomy and phacotrabeculectomy groups, respectively, and the upper boundary of the CI for difference in change between groups was lower than the 4-mm Hg noninferiority margin (mean difference, -0.5 mm Hg; 97.5% CI, -1.7 mm Hg to 0.8 mm Hg; P = .42). The mean difference for complete success for phacogoniotomy vs phacotrabeculectomy was -6.7% (95% CI, -21.4% to 8.8%; P = .47) and for qualified success was 1.4% (95% CI, -11.0% to 14.3%, P = .30). Median (IQR) number of antiglaucomatous medication was 0 (0) vs 0 (0; Hodges-Lehmann estimate of location shift, 0; 95% CI, 0; P =.12) with phacogoniotomy vs phacotrabeculectomy, respectively (mean difference, 0.13; 95% CI, -0.36 to 0.63; P = .60). Conclusions and Relevance:Mean IOP reduction with phacogoniotomy was noninferior to phacotrabeculectomy for advanced PACG and cataract at 2-year follow-up with no differences detected in complete or qualified success or mean number of antiglaucomatous medications. These findings support phacogoniotomy as an alternative to phacotrabeculectomy for patients with advanced PACG and cataract. Trial registration:ClinicalTrials.gov Identifier: NCT04878458.

This study investigated the correlation between pupillary light reflex (PLR) amplitude and visual impairment severity in primary angle-closure glaucoma (PACG). This retrospective case-control study included 35 eyes of 35 PACG patients and 15 eyes of 15 age-/sex-matched controls. Pupillary parameters (photopic/scotopic diameters, PLR amplitude) were measured using the OPD-Scan III wavefront aberrometer. Clinical metrics included best-corrected visual acuity (BCVA), the cup-to-disc ratio (C/D), the visual field mean deviation (MD), and retinal nerve fiber layer thickness (RNFLT) across six optic disc quadrants. Patients were stratified into mild (MD ≥ -6 dB), moderate (-12 dB ≤ MD < -6 dB), and severe (MD < -12 dB) subgroups per HPA criteria. Compared to controls, PACG patients showed significantly reduced PLR amplitude and scotopic diameter (P < 0.001 and P = 0.013, respectively). Significant inter-subgroup differences were observed in PLR amplitude (mild vs. severe; moderate vs. severe) (all P < 0.001). Significant inter-subgroup differences were observed in MD (mild vs. severe: P < 0.001; moderate vs. mild: P = 0.010;moderate vs. severe: P = 0.032), BCVA (mild vs. severe: P = 0.005), C/D (mild vs. severe: P < 0.001; moderate vs. severe: P = 0.013), and average RNFLT (mild vs. severe: P < 0.001; moderate vs. severe: P = 0.032). PLR amplitude negatively correlated with C/D (r=-0.706, P < 0.001) and positively with MD (r = 0.746), nasal (r = 0.527), superonasal (r = 0.449), inferonasal (r = 0.513),Temporal(r = 0.475)inferotemporal(r = 0.483),and average RNFLT (r = 0.526) (all P < 0.05). Multivariable linear regression analysis revealed that only MD was independently associated with PLR amplitude (β = 0.040, P < 0.001) after adjusting for age, IOP, BCVA, ACD, and IT750. Reduced PLR amplitude in PACG correlates with structural and functional deterioration, reflecting disease severity. As a rapid, non-invasive metric, PLR assessment complements conventional methods for objective PACG evaluation.

To evaluate the efficacy and safety of phacoemulsification with intraocular lens implantation (PEI) combined with 120° goniotomy (GT) versus PEI combined with trabeculectomy (Trab) in advanced Pseudoexfoliative glaucoma (PXG) with cataracts. A retrospective study included 68 advanced PXG with cataract patients (68 eyes): 32 underwent PEI + GT and 36 underwent PEI + Trab. The visual acuity, intraocular pressure(IOP), the number of glaucoma medications, surgical success rate, complications, postoperative interventions, surgery duration, and quality of life (EQ-5D-5L) were recorded preoperatively and at 1, 3, 6, and 12 months postoperatively. The PEI + GT group had a higher 1-month IOP than PEI + Trab (15.7 ± 1.7 vs. 13.9 ± 2.3 mmHg; P<0.05). Both groups experienced a significant reduction in the IOP and the number of medications used postoperatively (all P<0.05).The cumulative success rate and early complication incidence were comparable between the groups (P>0.05).PEI + GT demonstrated significantly lower rates of late complications and postoperative interventions, shorter operative time (16.8 ± 3.1 vs. 34.5 ± 5.5 min), and higher postoperative quality of life (EQ-5D-5L) compared to PEI + Trab (all P < 0.05). Both PEI + GT and PEI + Trab effectively reduced IOP and glaucoma medication use in PXG patients with cataract. However, PEI + GT demonstrated shorter surgery duration, fewer late complications, reduced need for postoperative interventions, better surgery safety, and higher postoperative quality of life than PEI + Trab.

To report the 2-year effective and safety profile of integrated phacoemulsification with intraocular lens implantation (PEI), goniosynechialysis (GSL) and 120° goniotomy (GT) in advanced primary angle-closure glaucoma (PACG) and cataracts. Multicentre prospective study. 201 eyes of 196 patients who received combined PEI+GSL+ GT were assessed at baseline and re-evaluated at days 1, 7, and at 1, 3, 6, 12 and 24 months postsurgery. The intraocular pressure (IOP), the number of topical hypotensive medications, surgical complications and achievements of surgery success were also evaluated. All participants were followed up for a 2-year period. The average IOP declined from 33.0±10.7 mm Hg to 13.6±2.9 mm Hg, and the number of topical hypotensive medication decreased from an average of 2.4 types to 0.4 at month 24. For the safety profile, the major complications were hyphema (n=14, 7.0%), IOP spike (n=9, 4.9%) and transit corneal oedema (n=23, 11.4%). The complete success was achieved in 72.6% of the eyes (146 out of 201), and the qualified success rate was 91.5% (184 out of 201). Only one eye required tube shunt surgery while no one developed severe vision-threatening complications. The best-corrected visual acuity increased from 0.80±1.08 to 0.54±0.78 LogMAR. PEI+GSL+GT is shown to be effective and safe in treating advanced PACG with cataract over a 2-year follow-up period. The combined surgery may be considered as an alternative for patients with advanced PACG.

Introduction Acute primary angle closure (APAC) is a common ophthalmic emergency for Chinese patients causing potential visual disabilities. According to current guidelines published by developed countries, a stepwise protocol (medication laser or paracentesis surgery) is recommended for emergency management of APAC. However, patients with APAC in China and developed countries differ in disease characteristics as the Chinese have longer attack duration and lower success rate in breaking the attack with solely medication or laser therapy. It has been proved that long attack duration is a risk factor for failed medical or laser therapies in subsiding APAC. Since prompt and effective treatment is pivotal in preserving visual function as well as avoiding APAC-induced blindness, direct trabeculectomy may largely benefit long-attacking patients with APAC in China.Purpose The Long-Attacking Acute Angle Closure study aims to compare long-term visual function and safety after different initial treatment strategies: direct surgery (trabeculectomy) or stepwise protocol for patients with APAC with attack duration longer than 72 hours.Methods and analysis This is a pragmatic, multicentre, randomised controlled trial targeting Chinese patients with APAC duration longer than 72 hours. Eligible participants will be identified at either emergency department or glaucoma clinics, then randomised into stepped treatment group or trabeculectomy group using a computer central randomisation service. The patients will be followed up for 1 year after initial treatment.Main outcomes and measures The primary outcome is logMAR BCVA 1 year post initial treatment. Secondary outcomes consist of complete success rate in breaking the attack, intraocular pressure value, mean deviation on Humphrey visual field testing and vision-related quality of life collected using the National Eye Institute Visual Function Questionnaire (25 items) 1 year post initial treatment.Trial registration number ChiCTR2200057289.

PURPOSE:To evaluate the two-year outcomes of combined surgical peripheral iridectomy (SPI), goniosynechialysis (GSL), and goniotomy (GT) for advanced primary angle-closure glaucoma (PACG) without cataract. DESIGN:Multicenter prospective study. METHODS:The study included patients who received a combined SPI + GSL + GT for advanced PACG without cataract, all completed a 24-month follow-up. Outcome measures included changes in intraocular pressure (IOP), best-corrected visual acuity (BCVA), use of anti-glaucoma medications, surgical success, and postoperative complications over the 24-month period. RESULTS:A total of 63 eyes from 51 patients with advanced PACG were included in the study. Among these, 37 eyes (58.7 %) achieved complete success, and 55 eyes (87.3 %) achieved qualified success. The mean IOPs at baseline and after 24 months were 28.8 ± 7.51 mm Hg and 15.8 ± 4.40 mm Hg, respectively (P < 0.001). The average number of anti-glaucoma medications decreased from 1.9 ± 1.4-0.8 ± 1.2 over the 24-month period (P < 0.001). The overall BCVA was stable during the follow-up period (P = 0.225). The primary complications observed included IOP spike (n = 9), hyphema (n = 7), and shallow anterior chamber (n = 3), all of which occurred within the first month postoperatively. Regression analysis showed that older age was positively associated with both complete success [odds ratio (OR) = 1.05; P = 0.030] and qualified success (OR = 1.08; P = 0.024). CONCLUSIONS:SPI + GSL + GT demonstrated safety and effectiveness in treating advanced PACG without cataract over the 24-month study period. This combined surgical approach should be considered a viable alternative to trabeculectomy for these patients.

The safety and effectiveness of combining surgical peripheral iridectomy (SPI) with goniosynechialysis (GSL) and goniotomy (GT) vs trabeculectomy for intraocular pressure (IOP) reduction remains unknown. To investigate the safety and effectiveness at 1 year of SPI + GSL + GT vs trabeculectomy in advanced primary angle-closure glaucoma (PACG) without cataract. This noninferiority randomized clinical trial was conducted at 8 tertiary eye centers in China. A total of 88 Chinese patients (88 eyes) with advanced PACG without cataract were enrolled from January 2022 to July 2023. Data were analyzed from August 2024 to September 2024. Mean (SD) patient age was 60.3 (7.3) years, and 52 patients (59.1%) were female. Forty-three patients were randomized to SPI + GSL + GT and 45 were randomized to trabeculectomy; 86 patients (97.7%) completed the 12-month follow-up. Participants were randomized 1:1 to receive SPI + GSL + GT or trabeculectomy. The primary outcome was IOP at 12 months (noninferior margin: 4 mm Hg). Secondary outcomes included surgical success (IOP: 5-18 mm Hg, ≥20% reduction from baseline, with or without antiglaucoma medications); postoperative complications and interventions, including bleb massage, suture lysis, or releasable sutures; and number of antiglaucomatous medications prescribed. At 12 months, the SPI + GSL + GT group had a mean (SD) IOP of 15.6 (4.0) mm Hg vs 14.9 (4.2) mm Hg in the trabeculectomy group (difference, 0.5 mm Hg; 95% CI, −1.2 to 2.2; P = .55), which was within the 4-mm Hg noninferiority margin. Qualified success rates were 38 of 43 participants (88.4%) for SPI + GSL + GT and 42 of 45 participants (93.3%) for trabeculectomy (difference, −5.0%; 95% CI, −19.6% to 8.5%; P = .48). However, complete success rates were lower in the SPI + GSL + GT group (26 participants [60.5%]) vs the trabeculectomy group (37 participants [82.2%]; difference, −21.8%; 95% CI, −40.2% to −2.4%; P = .03). Postoperative complications were present for 8 participants (18.6%) in the SPI + GSL + GT group vs 9 participants (20.0%) in the trabeculectomy group (difference, −1.4%; 95% CI, −17.9% to 15.1%; P = .71). Postoperative interventions were lower in the SPI + GSL + GT group (3 participants [7.0%] vs 25 participants [55.6%]; difference, 48.6%; 95% CI, 32.2%-65.0%; P < .001). Median (IQR) numbers of medications used decreased from 2 (0-3) to 0 (0-1) in the SPI + GSL + GT group and from 2 (2-3) to 0 (0-0) in the trabeculectomy group (difference, −0.81; 95% CI, −1.36 to −0.26; P = .004). In this randomized clinical trial among patients with advanced PACG without cataract, SPI + GSL + GT demonstrated noninferiority (4-mm Hg margin) to trabeculectomy for IOP at 12 months, with fewer interventions (including bleb massage, suture lysis, or releasable sutures) but no difference in postoperative medication use. This suggests SPI + GSL + GT as a potential alternative to trabeculectomy for similar cases, pending validation in larger sample sizes with smaller noninferiority margins. ClinicalTrials.gov Identifier: NCT05163951

PRÉCIS:The combination of surgical peripheral iridectomy, goniosynechialysis, and goniotomy is a safe and effective surgical approach for advanced primary angle closure glaucoma without cataract. PURPOSE:To evaluate the efficacy and safety of surgical peripheral iridectomy (SPI), goniosynechialysis (GSL), and goniotomy (GT) in advanced primary angle closure glaucoma (PACG) eyes without cataract. PATIENTS AND METHODS:A prospective multicenter observational study was performed for patients who underwent combined SPI, GSL, and GT for advanced PACG without cataract. Patients were assessed before and after the operation. Complete success was defined as achieving intraocular pressure (IOP) between 6 and 18 mm Hg with at least a 20% reduction compared with baseline, without the use of ocular hypotensive medications or reoperation. Qualified success adopted the same criteria but allowed medication use. Factors associated with surgical success were analyzed using logistic regression. RESULTS:A total of 61 eyes of 50 advanced PACGs were included. All participants completed 12 months of follow-up. Thirty-six eyes (59.0%) achieved complete success, and 56 eyes (91.8%) achieved qualified success. Preoperative and postsurgical at 12 months mean IOPs were 29.7±7.7 and 16.1±4.8 mm Hg, respectively. The average number of ocular hypotensive medications decreased from 1.9 to 0.9 over 12 months. The primary complications included IOP spike (n=9), hyphema (n=7), and shallow anterior chamber (n=3). Regression analysis indicated that older age (odds ratio [OR]=1.09; P =0.043) was positively associated with complete success, while a mixed angle closure mechanism (OR=0.17; P =0.036) reduced success rate. CONCLUSIONS:The combination of SPI, GSL, and GT is a safe and effective surgical approach for advanced PACG without cataract. It has great potential as a first-line treatment option for these patients.

PRÉCIS:The combination of phacoemulsification, goniosynechialysis and goniotomy is an effective treatment for primary angle closure glaucoma patients with cataract, and this is not linked to the extent of preoperative peripheral anterior synechiae. PURPOSE:To evaluate the impact of the extent of peripheral anterior synechiae (PAS) on the effectiveness and safety of combined phacoemulsification (PEI), goniosynechialysis (GSL), and goniotomy (GT) in eyes with primary angle closure glaucoma (PACG) and cataract. PATIENTS AND METHODS:This study included patients diagnosed with PACG and cataracts who underwent combined PEI and 120 degrees GSL plus GT (PEI+GSL+GT) between April 2020 and October 2022 at 10 ophthalmic institutes. Eligible patients were divided into 3 groups based on the extent of PAS: 180°≤PAS<270°, 270°≤PAS<360°, and PAS=360°. Data on intraocular pressure (IOP), the number of ocular hypotensive medications, and complications were collected and compared. The study defined complete success as postoperative IOP within the 6-18 mm Hg range and a 20% reduction from baseline without the use of topical medications. Qualified success was defined in the same way as complete success, but it allowed for the use of ocular hypotensive medications. RESULTS:Three hundred four eyes of 283 patients were included. The mean follow-up was 12.50±1.24 months. All groups experienced a significant reduction in IOP after the surgery ( P <0.05). There were no significant differences in final IOP, number of medications, and cumulative complete and qualified success rates among the 3 groups ( P >0.05). The groups with 270°≤PAS<360°had a higher frequency of hyphema compared with 180°≤PAS<270° ( P = 0.044). CONCLUSIONS:PEI+GSL+GT has proven to be an effective treatment for PACG with cataracts over a 1 year period. However, the outcome was not correlated with the preoperative extent of PAS.

Objective To compare the 24-hour intraocular pressure (IOP) fluctuation slope curve between newly diagnosed patients with ocular hypertension (OHT) and primary open-angle glaucoma (POAG).Methods and analysis Newly diagnosed and untreated OHT and POAG patients who underwent 24-hour IOP monitoring were consecutively enrolled in the study. IOP measurements were taken every 2 hours from 8:00 to 6:00 hours the following day using an iCare PRO tonometer. Patients maintained their daily routines, with IOP measured in a seated position during the day and supine at night. The 24-hour IOP fluctuation indices, including peak, trough and overall fluctuation, were calculated. Differences in the 24-hour IOP fluctuation slope curves over time between groups were analysed using a generalised additive mixed model.Results 46 patients with OHT and 41 with POAG were included. From 2:00 to 10:00 hours, mean IOP increased by 0.69 mm Hg every 2 hours in the POAG group (p<0.0001) and by 0.40 mm Hg in the OHT group (p<0.0001). After 10:00, the IOP showed a downward trend, decreasing by 0.31 mm Hg in the POAG group (p<0.0001) and by 0.17 mm Hg in the OHT group (p=0.0003) every 2 hours. The rate of slope change in the upward phase differed significantly between the groups (0.30 mm Hg per 2 hours; p=0.02), as did the rate in the downward phase (0.14 mm Hg per 2 hours; p for interaction=0.04). Multivariate models showed that each 1 mm Hg increase in circadian and diurnal IOP fluctuation was associated with a 27% and 21% higher likelihood of POAG presence, respectively.Conclusion The 24-hour IOP slope curve differed between POAG and OHT, with a steeper slope observed in the POAG group. However, the study is limited by potential confounding factors, reliance on a single 24-hour measurement period and the need for further longitudinal studies to validate these findings.

IntroductionAcute primary angle closure (APAC) is an emergency ophthalmic presentation and a major cause of irreversible blindness in China. However, only a few studies have focused on the characteristics of optic disc hemorrhage (ODH) during an APAC attack, including its shape, depth, location, scope, and duration after intraocular pressure (IOP) control, along with changes in the optic nerve. This study aimed to analyze the characteristics of ODH and optic nerve changes in patients during their first APAC episode.MethodsThis retrospective study involved 32 eyes from 32 patients with APAC who received sequential treatment and analyzed the following parameters: the highest IOP and its duration, ODH, retinal nerve fiber layer thickness (RNFLT), and mean deviation (MD). We compared parameters obtained from the affected eye (ODH group) and contralateral unaffected eye (control group), as well as intragroup comparisons.ResultsThe mean IOP in the ODH group was 64.28 ± 10.36 mmHg, with a duration of 4.44 ± 2.35 days. Flame and splinter shapes accounted for 84.38% of the ODH. The mean ODH duration was 4.81 ± 3.25 weeks. ODH during APAC was isolated to one sector in 59.38% of cases, mostly occurring in the temporal superior and temporal inferior (each accounting for 21.88% of the cases). There was a positive correlation between the extent of hemorrhage and the highest IOP duration (p < 0.001). RNFLT was significantly thickened within 72 h post-IOP control but was thinned by 2 weeks. By 6 months, the thinning stabilized, and there was no difference noted between the ODH and control groups at 12 months. MD partly improved at 6 months post-IOP control, and ODH scope significantly affected the MD (p < 0.001). The duration of high IOP was positively correlated to the ODH scope and MD damage.DiscussionTimely and effective IOP management is essential for recovering visual function following an APAC attack.