PRECIS:Phacoemulsification combined with endoscopic cyclophotocoagulation had a statistically significant reduction in both intraocular pressure and the number of medications compared with phacoemulsification alone. PURPOSE:Comparative evaluation of phacoemulsification combined with endoscopic cyclophotocoagulation (phaco-ECP) versus phacoemulsification (phaco) alone in primary angle closure glaucoma (PACG) with cataract. DESIGN:Prospective, randomized, parallel-group, active-controlled trial. PARTICIPANTS:Patients with PACG and cataract. METHODS:A total of 100 consecutive patients with PACG and cataract were screened, of whom 66 patients who met the inclusion criteria were recruited. Patients were randomized into 2 groups and underwent phaco-ECP or phaco alone. The patients were examined at baseline and at 1 week, 1, 3, 6, 12, 18, and 24 months. The anterior chamber angle parameters on swept-source anterior segment OCT (SS-ASOCT) were noted at baseline and at the 3-, 6-, and 12-month follow-up. The primary outcome measures were reduction in intraocular pressure (IOP) and the number of antiglaucoma medications. RESULTS:The mean baseline IOP was 19.9±5.8 and 19.5±7.2 mm Hg in the phaco-ECP and phaco groups, respectively ( P =0.59). The mean IOP decreased to 14.0±2.6 and 15.7±2.2 mm Hg at 24 months in the phaco-ECP and phaco group, respectively ( P =0.02). The reduction in the number of medications was also significantly higher in the phaco-ECP group (1.8±1.10 vs. 1.0±0.8 mm Hg; P =0.02) as compared with the phaco-alone group. Qualified success with IOP ≤12 mm Hg was obtained in 46.6% of patients in the phaco-ECP group and 13.7% of patients in the Phaco group ( P =0.01). No absolute failures (requiring trabeculectomy) were noted in the phaco-ECP, whereas 6.9% of patients in the phaco group failed ( P =0.23). A significant widening of the angle parameters was noted postoperatively at 3, 6, 12, and 18 months as compared with baseline in both groups. The other secondary outcome parameters, like BCVA, visual field changes, endothelial cell count, pupil diameter, and complication rate, were comparable between the groups. CONCLUSIONS:The phaco-ECP group demonstrated a significant reduction in IOP and the number of medications, along with a notable widening of the nasal anterior chamber angle parameters compared with the phaco-alone group.

PURPOSE:To evaluate the role of corneal biopsy in nonhealing keratitis patients on multiple antimicrobials. METHODS:In a randomized, prospective, interventional study conducted at a tertiary eye center in India, 44 patients with infectious keratitis were recruited from February 2022 to October 2023. The cases that were on ≥2 topical antimicrobial drugs belonging to 2 different classes for ≥1 week with no signs of healing and corneal ulcer size of ≥4 mm were included. They were randomized into two groups: the corneal scraping group and the corneal biopsy group. The primary outcome measure was culture positivity rate, while the secondary outcome measures were smear positivity rate and complication rates in both groups. RESULTS:The culture positivity rate of the corneal scraping group was 59.09% and the corneal biopsy group was 77.27% in cases of bacterial keratitis (P = 0.32). However, in cases of fungal keratitis, the culture positivity rate of the biopsy group was better than the scraping group (P = 0.012). The sensitivity and specificity of the Gram stain of the corneal scraping sample were found to be 55.56% and 92.31%, respectively. The sensitivity and specificity of the potassium hydroxide stain of the corneal scraping sample were found to be 50% and 94.4%, respectively. The sensitivity and specificity of histopathological samples obtained from biopsy to detect fungal elements were 66.6% and 90%, respectively. No complications were noted in both the groups during the procedure. CONCLUSION:In nonhealing keratitis with suspected fungal cause, corneal biopsy may be used as a primary diagnostic modality in a referral center.

PRECIS:This study used fNIRS during a Go/No-Go task to reveal altered prefrontal activation in POAG patients, indicating compensatory cortical recruitment and subtle cognitive dysfunction, highlighting glaucoma's broader neurodegenerative and cognitive impact. PURPOSE:To evaluate cognitive function in individuals with primary open-angle glaucoma (POAG) by assessing prefrontal cortical activity during a behavioral inhibition test (Go/No-Go task) using functional near infrared spectroscopy (fNIRS). PATIENTS:Fifteen patients with mild to moderate POAG and fifteen age and gender matched healthy controls. METHODS:In this pilot case-control study, all participants underwent cognitive assessment using Addenbrooke's Cognitive Examination III (ACE-III), and quality-of-life assessment using EuroQol 5-Dimension 5-Level (EQ-5D-5L) questionnaire. Prefrontal cortical activation patterns were assessed in the prefrontal cortex using a 17-channel fNIRS system during a block-design Go/No-Go task assessing sustained attention and response inhibition. Using statistical parametric mapping (SPM) with general linear model (GLM) analysis, the study observed activation/deactivation in prefrontal cortical regions. RESULTS:Mean age and gender ratio were comparable between the two groups. POAG patients demonstrated significantly lower cognitive scores on ACE-III and reduced health-related quality of life compared to healthy controls (P<0.001). fNIRS demonstrated abnormal prefrontal activation in POAG, with significant hyperactivation during Go versus Rest at channels 8, 13, and 14 (P<0.05), not observed in healthy controls. Conversely, in No-Go vs Rest, healthy controls exhibited significant activation at channels 8, 10, and 15 (P<0.05), absent in POAG. Finally, the Go vs No-Go contrast revealed heightened deactivation in POAG at channel 17 (P<0.05), not observed in healthy controls. CONCLUSIONS:Patients with POAG demonstrated altered and less efficient prefrontal cortical activation patterns during tasks requiring attention and inhibition. These fNIRS based findings suggest early cortical dysfunction in glaucoma.

With the increasing prevalence of cardiovascular diseases, it has become common for patients to be on different classes of anticoagulant medications. The blood-thinning characteristic of these drugs makes them essential for the management of long-term comorbidities, but it also raises the possibility of hemorrhagic complications during and after ophthalmic surgery. Although there is some agreement regarding the preoperative use of anticoagulant drugs in cataract surgery, little is known about the continuation or discontinuation of these drugs before surgeries for glaucoma. Regarding the use of anticoagulants before glaucoma surgery, surgeons' practices differ greatly. Anticoagulation therapy must be understood in the context of glaucoma surgery and laser treatment, as the evidence currently available is inconclusive regarding the benefits of continuing/withholding anticoagulation or using bridging therapy. Modifying anticoagulation therapy for glaucoma surgery must be done carefully and after consulting primary care physicians, internists, cardiologists, and neurologists due to the potential serious adverse effects of stopping the treatment.

Précis: Trabecular cutting minimally invasive glaucoma surgery like bent ab interno needle goniectomy (BANG) when performed in baseline aqueous angiography identified low aqueous humor outflow regions, results in greater success of intraocular pressure reduction. Purpose: To study the efficacy of Bent Ab Interno Needle Goniectomy (BANG) in high versus low aqueous humor outflow (AHO) regions as determined by Aqueous Angiography(AA) in patients with primary open angle glaucoma (POAG). Methods: A prospective, single-centre, pilot, randomized control trial recruited 30 eyes of 30 patients of POAG and visually significant cataract (45-80 y) and were randomised into two groups (“A”: BANG performed in the high-flow regions and “B”: BANG performed in the low-flow regions) of 15 each. AA was performed using indocyanine green dye (0.1%) to identify baseline high- and low-flow regions of the AHO pathways followed by BANG in these respective regions as per randomisation. Preoperative and postoperative data on IOP, number of antiglaucoma medications (AGMs) and any complications were noted over 6 months. Overall success was defined as achieving an IOP ≤15 mm Hg and ≥6 mm Hg at 6 months of follow-up with AGMs (qualified success) or without AGMs (complete success). Results: AA revealed high-flow regions of AHO pathways in the nasal quadrant and low-flow regions of AHO pathways in the temporal quadrant in all 30 patients. Both groups had comparable demographic composition [group A age: 65.3±6.48 y and male: female (14:1) and group B age: 64.6±7.08 y and male: female (13:2)]. The mean preoperative IOPs [group A (17.27±3.43 mm Hg); group B (17.60±5.42 mm Hg)] ( P =0.842) and mean postoperative IOP at 6 months [group A (15.6±4.98 mm Hg); group B (13.13±2.29 mm Hg)] ( P =0.09) were similar. However, lower qualified success was seen in group A (40.00%) compared to group B (86.67%; P =0.021). Survival in Kaplan-Meier analysis was higher in group B ( P =0.021). Complications were comparable in both groups. Conclusion: Short-term results of BANG in low-flow AHO regions show enhanced success compared to those in high-flow AHO regions. This study suggests that trabecular cutting minimally invasive glaucoma surgeries (like BANG) may be performed in baseline low-flow AHO regions (temporal quadrant) instead of the high-flow AHO (nasal quadrant) regions.

Minimally invasive glaucoma surgeries (MIGS) targeting the trabecular meshwork are emerging as a new modality in the management of primary angle closure glaucoma (PACG). Aqueous angiography (AA) allows in vivo, real-time assessment of conventional aqueous humor outflow (AHO) using tracer dyes. Herein, we discuss a novel case of AA demonstrating changes seen in AHO post-trabecular MIGS in a PACG patient. This case provides evidence that supports the hypothesis of using trabecular MIGS in treating PACG patients and encourages further research to innovate and study the efficacy of trabecular MIGS in the management of primary angle closure disease.

The emergence and advancements in glaucoma treatment modalities have expanded the options available to clinicians, particularly for patients with mild to moderate glaucoma. These newer approaches, such as minimally invasive glaucoma surgeries and selective laser trabeculoplasty, aim to effectively reduce intraocular pressure and potentially improve patient outcomes. 'Interventional glaucoma' reflects a paradigm shift in the glaucoma management strategies and involves adopting a more proactive approach and offering these interventions at earlier stages of the disease. By administering them earlier, these interventions can modulate the course of the disease and prevent significant visual loss, thereby reducing or delaying the need for subsequent filtering surgeries. In this review, we discuss the need for interventional glaucoma and the evidence behind these interventional techniques. We highlight key considerations that should be considered when implementing interventional glaucoma approaches in the Asian context.

PRECIS:Netarsudil shows promise as a second-line drug in early glaucoma patients with an increase in most OCTA parameters as compared with Dorzolamide, with comparable rates of side effects. OBJECTIVE:To compare the effect of Netarsudil and Dorzolamide on macular and optic nerve head (ONH) perfusion changes on Optical Coherence Tomography Angiography (OCTA), and macular ganglion cell layer (mGCL) and peripapillary retinal nerve fiber layer (pRNFL) thickness on OCT in preperimetric/early glaucoma patients. PARTICIPANTS AND METHODS:In this prospective, randomized, parallel group, active-controlled trial 90 preperimetric/early glaucoma eyes were recruited. The primary outcome measure was change in macular and ONH perfusion, and intraocular pressure (IOP). A total of 95 patients were randomized and 45 were prescribed Netarsudil 0.02% (group 1) and 45 were prescribed Dorzolamide 2% (group 2). The IOP, ONH perfusion, ONH flux index (FI), and macular vessel density (mVD) on OCTA; pRNFL thickness and mGCL thickness on OCT of the 2 groups were recorded at baseline, 4 months, 8 months, and 12 months. RESULTS:The mean baseline IOP in group 1 was 19.52±3.2 mm Hg and in group 2 it was 19.5±2.97 mm Hg. Group 1 showed 2.77 mm Hg (13.23%±8.27%) decrease in IOP ( P <0.001), while group 2 showed 1.85 mm Hg (8.98%±7.32%) decrease in IOP ( P <0.001) at 12 months. Group 1 showed 1.58 mm/mm 2 increase in mVD ( P <0.001), and 0.03 (7.6%) increase in ONH FI ( P <0.001) at 12 months. However, no trend in mVD or ONH FI was seen in group 2. Group 1 showed 1.03% increase in ONH perfusion ( P <0.001), while group 2 showed 1.16% increase in ONH perfusion ( P <0.001). There was no significant difference in ONH perfusion between the 2 groups. The OCT (pRNFL and mGCL) showed normal variability in both the groups. Congestion (40%) was the most common side effect observed in the Netarsudil group, while metallic taste (42.5%) was the most common side effect in the Dorzolamide group. The side effect profile of the 2 drugs was comparable ( P =0.65). CONCLUSION:Netarsudil causes an increase in all the OCTA parameters-mVD, ONH perfusion, and ONH FI-whereas Dorzolamide causes an increase only in ONH perfusion in preperimetric/early glaucoma patients. Netarsudil monotherapy also showed a higher decrease in IOP as compared with dorzolamide therapy.

PRÉCIS:Evaluation of aqueous humor outflow (AHO) pathways shows a segmental pattern with the nasal quadrant having the maximum and the temporal quadrant having the least AHO pathways in nonglaucomatous subjects. AIM:To evaluate circumferential aqueous humor outflow (AHO) pathways in nonglaucomatous subjects using aqueous angiography (AA). METHODS:A cross-sectional, observational, single-center study recruited 30 subjects with visually significant age-related cataract planned for phacoemulsification. AA was performed using indocyanine green (ICG) dye 0.1% just before phacoemulsification. Images were analyzed at 60 seconds from the injection of ICG dye for angiographic signal intensity in 4 quadrants and 8 sectors, circumferentially (360 degrees) along the limbus. Signal intensities were evaluated and compared between quadrants and sectors as the primary outcome measure. Signal intensities between males and females, right and left eyes were assessed as secondary outcome measures, using appropriate statistical tests. RESULTS:The mean age of the patients was 61.53±5.5 years (range: 49-68 y) with 16 males and 14 females; 16 right eyes and 14 left eyes. Segmental AHO was noted in all patients. The median signal intensity was highest in the nasal quadrant [45.95(35.59-54.34)] followed by the inferior [31.56 (24.82-41.71)], superior [30.16 (28.2-37.43)], and temporal [26.66 (22.92-34.33)] quadrants, and their difference was statistically significant (P<0.0001). Median signal intensity among 8 sectors was highest in the nasosuperior sector [23.05 (17.14-29.20)] and least in the temporoinferior sector [12.98 (10.82-17.51)] (P<0.0001). No significant difference was observed in median signal intensities between males [132.83 (115.82-174.18)] and females [143.74 (122.43-166.00)] (P=0.771) and right eyes [143.74 (118.53-170.6)] and left eyes [133.51 (122.43-153.86)] (P=0.967). Anterior capsule rupture and vitreous staining were noted in one patient each. CONCLUSION:Nonuniform, segmental AHO pathways were seen in nonglaucomatous subjects using AA. The nasal quadrant had the maximum AHO functional channels, followed by the inferior, superior, and least in the temporal quadrant. Within the sectors, the nasosuperior sector had the highest signal intensity.

Aims and background:To describe cases of primary angle closure glaucoma (PACG) with neovascularization of iris/angle (NVI/NVA) with no obvious retinal pathology. Case description:We provide a description of three patients with a diagnosis of PACG with NVI/NVA. Detailed history taking along with ophthalmic and systemic examination including slit lamp examination, gonioscopy, and fundus fluorescein angiography (FFA) was done in all patients. FFA revealed peripheral hyperfluorescence and capillary nonperfusion (CNP) areas in periphery in all three eyes. Carotid Doppler and tests for blood coagulation profile were done and no apparent cause of NVI/NVA could be found. Secondary causes of NVI such as proliferative diabetic retinopathy, central retinal vein occlusion, ocular ischemic syndrome (OIS), vasculitis, branch retinal vein occlusion, central retinal artery occlusion, branch retinal artery occlusion, and ocular tumors were ruled out. All these patients had features of angle closure and were hence diagnosed with PACG with NVI/NVA. We hypothesize that chronically raised intraocular pressure (IOP) can result in peripheral retinal ischemia, leading to elevated vascular endothelial growth factor (VEGF) production resulting in NVI/NVA. Conclusion:PACG with NVI/NVA in absence of an obvious retinal pathology is a separate clinical entity. NVI without any obvious retinal pathology may occur in cases of PACG on account of development of peripheral retinal nonperfusion. Clinical significance:PACG with NVI/NVA as per our series seem to have better prognosis than other causes of neovascular glaucoma (NVG). This distinction would help in management and follow-up. Caution should be taken to rule out all other causes. How to cite this article:Angmo D, Wajiri GB, Verma S, et al. Neovascularization of the Iris/Angle in Primary Angle Closure Glaucoma: A Distinct Entity!. J Curr Glaucoma Pract 2025;19(4):229-233.

Purpose:To critically evaluate the current evidence on the influence of lifestyle factors on glaucoma risk and progression. Glaucoma, a leading cause of irreversible vision loss globally, poses a significant clinical challenge. The pathogenesis of glaucoma is multifactorial, involving mechanisms beyond intraocular pressure (IOP). Effective treatments for reducing IOP exist, yet progressive vision loss remains a common occurrence among glaucoma patients, underscoring the need for further research. Age, ethnicity, family history, and high myopia are recognized risk factors; however, they are difficult to modify. In contrast, lifestyle factors such as physical activity, smoking, and diet may offer opportunities for risk reduction, but the relationships between these factors and glaucoma are not yet well understood. Methods:A narrative review of literature was conducted by searching multiple databases, including PubMed, Google Scholar, Scopus, and the Cochrane Library, focusing on peer-reviewed studies published between August 2009 and October 2024. An extensive range of keywords, such as glaucoma, intraocular pressure, lifestyle factors, diet, sleep pattern, alcohol consumption, smoking, anxiety, stress, body mass index, and caffeine, were employed individually and in combination to ensure a comprehensive search. Results:Lifestyle factors, such as mindfulness-based stress reduction, cognitive-behavioral therapy, and sleep apnea management, may be efficacious in reducing intraocular pressure fluctuations and neuroinflammatory damage. In addition, a healthy diet, body mass index, and regular physical activity may contribute to reduced glaucoma risk. Conclusions:This review underscores the potential of lifestyle modifications as a complementary strategy in glaucoma management. Further research is necessary to explore evidence-based associations between lifestyle factors and glaucoma.

Précis: Cognitive impairment in multiple domains was observed in primary open angle glaucoma patients as compared to age and gender matched healthy controls. Objective: Evaluation of cognitive impairment in individuals with Primary Open Angle Glaucoma (POAG). Methods: In this case-control study, individuals with POAG (cases, n=70) were compared with age- and sex-matched healthy individuals (controls, n=70) using detailed ophthalmological evaluation, cognitive assessment and serum cortisol level. A multitude of tests were employed to comprehensively assess various domains of cognitive function: Addenbrooke Cognitive Examination (ACE-III; attention/orientation, memory, language, verbal fluency, and visuospatial skills), Post Graduate Institute Memory Scale (PGIMS; verbal and non verbal memory), Wisconsin Card Sorting Test (WCST; nonverbal executive functions), Go No-Go task (GNG; inhibitory control), and Trail Making Test (TMT; attention and working memory). Results: Intraocular pressure and cup disc ratio were significantly higher (P <0.001) while retinal nerve fibre layer (RNFL) thickness and mean deviation were significantly lower in cases as compared to controls. Cases had significantly lower scores on ACE-III and PGIMS (P<0.001) and longer test completion time in TMT-A (P=0.001). The performance of cases was also significantly worse on most parameters of the WCST and GNG tasks. Serum cortisol level was significantly higher in cases (11.75±7.41 mcg/dl) compared to controls (7.93±2.39 mcg/dl; P=0.02). A significant correlation was observed between serum cortisol level and WCST correct response (P=0.04), WCST error response (P=0.002) and total time taken in TMT-A (P=0.03).Visual field mean deviation also exhibited a significant correlation with serum cortisol level (P<0.001) and total time taken on WCST (P=0.03) and TMT-A (P=0.03). Conclusion: Individuals with POAG exhibited higher cognitive impairment and raised serum cortisol levels than age-matched healthy controls. Early recognition and management of cognitive impairment are pivotal for enhancing the quality of life and implementing comprehensive glaucoma care.

PURPOSE:The objective of this study was to compare the clinical outcomes of intrastromal keratoplasty using biosynthetic corneas with human donor corneas in cases of advanced keratoconus. METHODS:A prospective nonblinded randomized controlled study was conducted at a tertiary eye center in India. Treatment-naïve patients with advanced keratoconus aged 18 years or older were included. Twenty eyes were randomized into 2 groups-group 1 (human donor corneal lenticule, n = 10) and group 2 (biosynthetic corneal lenticule, n = 10). Efficacy analyses included an increase in the thinnest pachymetry and a decrease in the maximum keratometry (Kmax). Safety analyses included any adverse events in the postoperative period. RESULTS:At 6 months postoperatively, the rise in the thinnest pachymetry in group 1 was 346.8 ± 40.82 to 486.7 ± 15.7 μm ( P < 0.001) and in group 2 was 366.2 ± 31.3 to 548.3 ± 59.1 μm ( P < 0.001). The biosynthetic group exhibited a significant increase in the thinnest pachymetry ( P = 0.005). However, both groups showed a similar decrease in Kmax (71.06 ± 7.95 to 63.3 ± 3.74 D in group 1 and 69.13 ± 8.54 to 61.5 ± 6.2 D in group 2; P = 0.44). No adverse events were seen at 6 months of follow-up. CONCLUSION:Femtosecond-assisted intrastromal implantation of biosynthetic corneas is a safe and effective alternative to human donor corneas in cases of advanced keratoconus.

Aims:A review of the published literature was done to understand the role of endocannabinoids in glaucoma. Background:As evidence mounts that intraocular pressure (IOP) is not the only factor in the pathogenesis and progression of glaucoma, a look into other aspects is the need of the hour. From the first instance of a drop in IOP linked to marijuana in the 1970s to the present, research has been ongoing, mostly in animals and in vitro models, with a scarcity of human studies, to delve into the world of the endocannabinoid system (ECS). Methods:PubMed, ScienceDirect, and Google Scholar were searched for studies relating to endocannabinoids and their role in glaucoma. Results:The ECS comprises ligands, receptors, and the synthesizing and degrading enzymes and is ubiquitous throughout the human body, including the visual system, from the eye to the occipital lobe. Apart from the IOP-lowering effect of the system, another property being investigated and implicated as an attribute of its receptors is neuroprotection. This neuroprotection seems to be mediated by excitotoxicity reduction and changes in vascular tone by acting on cannabinoid receptors. Conclusion:The possibilities are indeed immense, and further research into the complex relationship between ECS and glaucoma is imperative to enable us to develop therapies for this otherwise chronic, progressive neuropathy, where the only armament in our hands is early diagnosis and maintenance therapy. Clinical significance:We still do not have drugs for the prevention of retinal ganglion cell loss and for neuroprotection in glaucoma. Drugs that target cannabinoid receptors can revolutionize glaucoma management owing to their IOP-lowering action and neuroprotective effects. Based on the findings, we argue that further studies on the ECS and its implications in glaucoma are warranted to develop newer, effective, and better-targeted treatment strategies. How to cite this article:Warjri GB, Gowtham L, Venkatraman V, et al. Role of Endocannabinoids in Glaucoma: A Review. J Curr Glaucoma Pract 2025;19(1):28-37.

Netarsudil shows promise as a second-line drug in early glaucoma patients with an increase in most OCTA parameters as compared with Dorzolamide, with comparable rates of side effects. To compare the effect of Netarsudil and Dorzolamide on macular and optic nerve head (ONH) perfusion changes on Optical Coherence Tomography Angiography (OCTA), and macular ganglion cell layer (mGCL) and peripapillary retinal nerve fiber layer (pRNFL) thickness on OCT in preperimetric/early glaucoma patients. In this prospective, randomized, parallel group, active-controlled trial 90 preperimetric/early glaucoma eyes were recruited. The primary outcome measure was change in macular and ONH perfusion, and intraocular pressure (IOP). A total of 95 patients were randomized and 45 were prescribed Netarsudil 0.02% (group 1) and 45 were prescribed Dorzolamide 2% (group 2). The IOP, ONH perfusion, ONH flux index (FI), and macular vessel density (mVD) on OCTA; pRNFL thickness and mGCL thickness on OCT of the 2 groups were recorded at baseline, 4 months, 8 months, and 12 months. The mean baseline IOP in group 1 was 19.52±3.2 mm Hg and in group 2 it was 19.5±2.97 mm Hg. Group 1 showed 2.77 mm Hg (13.23%±8.27%) decrease in IOP ( P <0.001), while group 2 showed 1.85 mm Hg (8.98%±7.32%) decrease in IOP ( P <0.001) at 12 months. Group 1 showed 1.58 mm/mm 2 increase in mVD ( P <0.001), and 0.03 (7.6%) increase in ONH FI ( P <0.001) at 12 months. However, no trend in mVD or ONH FI was seen in group 2. Group 1 showed 1.03% increase in ONH perfusion ( P <0.001), while group 2 showed 1.16% increase in ONH perfusion ( P <0.001). There was no significant difference in ONH perfusion between the 2 groups. The OCT (pRNFL and mGCL) showed normal variability in both the groups. Congestion (40%) was the most common side effect observed in the Netarsudil group, while metallic taste (42.5%) was the most common side effect in the Dorzolamide group. The side effect profile of the 2 drugs was comparable ( P =0.65). Netarsudil causes an increase in all the OCTA parameters—mVD, ONH perfusion, and ONH FI—whereas Dorzolamide causes an increase only in ONH perfusion in preperimetric/early glaucoma patients. Netarsudil monotherapy also showed a higher decrease in IOP as compared with dorzolamide therapy.

A cyclodialysis cleft develops when the meridional fibers of the ciliary muscle detach from the scleral spur, creating an aberrant aqueous drainage pathway between the anterior chamber and suprachoroidal space. Blunt ocular trauma and intraocular surgery have been identified as the most frequent causes. Cyclodialysis has been documented after phacoemulsification, extracapsular cataract extraction, secondary intraocular lens (IOL) implantation, goniotomy, trabeculotomy, trabeculectomy, and other intraocular surgeries. The new aqueous drainage pathway may lead to persistent severe ocular hypotony and its associated complications, which include cataract, choroidal detachment, retinochoroidal folds, disk edema, macular edema, and rarely, irreversible vision loss. The potentially blinding nature of this condition warrants early identification and appropriate management. Restoration of the attachment of the ciliary body (CB) to the sclera and closure of the cleft are the primary objectives of treatment. The etiology, pathophysiology, and surgical treatment of cyclodialysis cleft are discussed in this review. How to cite this article:Sethi A, Udenia H, Beri N, et al. Surgical Management of Cyclodialysis Cleft: An Update. J Curr Glaucoma Pract 2025;19(3):143-152.

PRÉCIS:Trabecular cutting minimally invasive glaucoma surgery like bent ab interno needle goniectomy (BANG) when performed in baseline aqueous angiography identified low aqueous humor outflow regions, results in greater success of intraocular pressure reduction. PURPOSE:To study the efficacy of bent ab interno needle goniectomy (BANG) in high versus low aqueous humor outflow (AHO) regions as determined by aqueous angiography (AA) in patients with primary open angle glaucoma (POAG). METHODS:A prospective, single-centre, pilot, randomized control trial recruited 30 eyes of 30 patients of POAG and visually significant cataract (45-80 y) and were randomised into 2 groups ("A": BANG performed in the high-flow regions and "B": BANG performed in the low-flow regions) of 15 each. AA was performed using indocyanine green dye (0.1%) to identify baseline high-flow and low-flow regions of the AHO pathways followed by BANG in these respective regions as per randomisation. Preoperative and postoperative data on IOP, number of antiglaucoma medications (AGMs), and any complications were noted over 6 months. Overall success was defined as achieving an IOP ≤15 and ≥6 mm Hg at 6 months of follow-up with AGMs (qualified success) or without AGMs (complete success). RESULTS:AA revealed high-flow regions of AHO pathways in the nasal quadrant and low-flow regions of AHO pathways in the temporal quadrant in all 30 patients. Both groups had comparable demographic composition [group A age: 65.3±6.48 y and male:female (14:1) and group B age: 64.6±7.08 y and male:female (13:2)]. The mean preoperative IOPs [group A (17.27±3.43 mm Hg); group B (17.60±5.42 mm Hg)] ( P =0.842) and mean postoperative IOP at 6 months [group A (15.6±4.98 mm Hg); group B (13.13±2.29 mm Hg)] ( P =0.09) were similar. However, lower qualified success was seen in group A (40.00%) compared with group B (86.67%; P =0.021). Survival in Kaplan-Meier analysis was higher in group B ( P =0.021). Complications were comparable in both groups. CONCLUSION:Short-term results of BANG in low-flow AHO regions show enhanced success compared with those in high-flow AHO regions. This study suggests that trabecular cutting minimally invasive glaucoma surgeries (like BANG) may be performed in baseline low-flow AHO regions (temporal quadrant) instead of the high-flow AHO (nasal quadrant) regions.

Retinal ganglion cell death in glaucoma leads to progressive and irreversible vision loss. Investigating lipidomic profiles of aqueous humor and plasma from primary glaucoma patients may reveal novel lipid signaling pathways and biomarkers. Plasma lipidomics was included to assess systemic alterations, enabling comparison with ocular changes and explore accessible, minimally invasive biomarker sources. This study included patients with primary open-angle glaucoma (POAG), angle-closure glaucoma (PACG), and cataract controls (n = 20 in each group). Serum lipid screening was conducted via biochemical analyzer. Aqueous humor and plasma samples were collected, and lipids were extracted and analyzed using high-resolution mass spectrometry (HRMS). Spectral identification and relative quantification of lipid species were performed with LipidSearch™ver_4.1. The percentage of altered species within each lipid class was analyzed with a log2fold change (FC) threshold ≥1/≤-1. Data normalization and multivariate statistical analyses were conducted using MetaboAnalyst 5.0 with significance criteria (log2 FC ≥ 1/≤-1, p < 0.05 and variable importance in projection (VIP) > 1). No significant changes were observed in routine serum lipid profiles of glaucoma patients versus controls. In aqueous humor, phosphatidylcholines and lysophosphatidylcholines (>50 %) were elevated in aqueous humor of both glaucoma groups, while sphingomyelins (>85 %) and ceramides (18.75 %) were specifically elevated in PACG. Of 301 lipid species identified in aqueous humor, 51 met significance (POAG: 24, PACG: 27). In plasma, diglycerides (>20 %), triglycerides and cholesterol esters (>10 %, log2FC ≤ -1) were declined in both glaucoma groups than controls. Of 1762 plasma lipids identified, 100 met significance (POAG: 47, PACG: 53). Sphingomyelin and ceramide alterations in PACG aqueous humor suggested disrupted mechanosignaling mechanisms. Altered phosphatidylcholines, lysophosphatidylcholines and glycerides linked with retinal-degeneration and apoptosis in both glaucomatous conditions.

PURPOSE:To evaluate the safety and efficacy of needle-assisted circumferential goniotomy (NAG) in primary congenital glaucoma (PCG). METHODS:This is a hospital-based prospective interventional study. Patients diagnosed with PCG, aged <2 years with good corneal clarity, who underwent NAG procedure in a single tertiary eye care center, were included in the study and were followed up regularly in the post-operative period. The pre- and post-operative intraocular pressure (IOP), number of anti-glaucoma medications (AGMs), corneal diameter, axial length, fundus findings, and any complications were recorded at 3, 6, 9, and 12 months. Success was defined as IOP ≤ 18 mmHg with or without two topical AGMs. RESULTS:A total of 52 eyes (14 bilateral and 24 unilateral) of 31 children were included in the study. A total of 80.6% were males and 19.4% were females, with a mean age of 1.14 ± 1.04 years. The baseline IOP was 23.28 ± 5.98 mmHg, which decreased to 11.03 ± 5.06 mmHg at 3 months, 12.08 ± 3.80 mmHg at 6 months, and 12.54 ± 5.09 mmHg at 12 months, P value < 0.001. The mean number of topical AGMs reduced from 2.48 ± 1.03 to 1.35 ± 1.23 at 12 months follow-up, P value < 0.001. Complete success was seen in 88.46% (46/51) eyes. Failure was noted in 11.52% (10/51) eyes, out of which 9.61% (9/51) eyes required trabeculectomy. There were no significant vision-threatening intraoperative or post-operative complications. CONCLUSION:A 24G NAG is a safe and effective surgical procedure to control the IOP in PCG with good corneal clarity. NAG is a single-sitting, minimally invasive, circumferential angle surgery that spares the conjunctiva completely for future surgeries, if needed.