Tiago Santos Prata

Précis: In this randomized multicenter trial, both TRAB and CPC lowered IOP at 12 months as primary glaucoma surgeries, with TRAB yielding lower final IOP with fewer medications, while both procedures demonstrated meaningful clinical effectiveness. Purpose: To compare the efficacy and safety of trabeculectomy (TRAB) and slow-burn transscleral cyclophotocoagulation (CPC) as primary surgical treatments for glaucoma. Methods: Prospective, randomized, multicenter trial including one eye per patient from July 2020 to July 2023, with 12-month follow-up. Participants were allocated to TRAB (GI) or CPC (GII). The primary endpoint was surgical success at 12 months, defined by intraocular pressure (IOP) between 6 and 18 mm Hg without non-protocol glaucoma surgery or serious complications. Results: Eighty-six eyes were included; nine were excluded (four in GI; five in GII). Baseline demographics were similar between groups. Both significantly reduced IOP at 12 months (GI: 22.97±8.23 mm Hg to 10.14±2.89 mm Hg; GII: 23.47±6.34 mm Hg to 14.58±3.66 mm Hg; P P P =0.007). Final IOP between 6 and 18 mm Hg was reached by 97.1% of GI and 90.9% of GII ( P =0.708). Qualified success rates were high and comparable (GI: 97.4%; GII: 86.8%; P =0.08), while complications were infrequent (four in GI; one in GII; P =0.3). Quality of life improved after TRAB (EQ-5D: 0.71±0.19 to 0.78±0.14; P =0.031) but remained unchanged after CPC ( P =0.424). Conclusions: Both procedures reduced IOP at 12 months as primary glaucoma surgeries. TRAB achieved lower final IOP, required fewer medications, and was associated with improved quality of life, whereas CPC required more adjunctive medication and retreatment in some eyes.

Myopic glaucoma is a distinct subtype of glaucomatous optic neuropathy that is often underrecognized or misdiagnosed, particularly in younger patients whose intraocular pressures (IOP) fall within statistically normal ranges. High myopia presents complex structural, functional, and biomechanical challenges that hinder both early detection and effective disease management. This review summarizes current evidence on the pathophysiology, clinical presentation, diagnostic limitations, and tailored therapeutic strategies for myopic glaucoma, providing a practical clinical framework for improved management. This narrative review synthesizes current evidence from peer-reviewed clinical and basic science studies on myopic glaucoma. Drawing on a comprehensive literature search, it addresses the pathophysiology, clinical presentation, diagnostic limitations, and tailored therapeutic strategies for myopic glaucoma, with the aim of establishing a clinically relevant framework to inform optimized management. The global prevalence of myopia is increasing, with high myopia substantially elevating the risk of glaucoma, particularly among Asian populations. Structural alterations—including axial elongation, scleral thinning, lamina cribrosa deformation, and optic nerve head tilting—augment biomechanical vulnerability to glaucomatous damage, even when IOP remains within normal limits. Myopic glaucoma is often characterized by tilted optic discs, peripapillary atrophy, and early paracentral visual field defects, which may not be detected by standard perimetric methods. Diagnosis is complicated by the limitations of optical coherence tomography (OCT), including segmentation errors and the lack of normative databases specific to myopic eyes. Moreover, disease progression may occur even with low IOP, and distinguishing glaucomatous damage from myopia-induced structural changes remains a significant challenge. Recent advances, such as the identification of the crescent moon sign, implementation of 10-2 visual field testing, and use of biomechanically compensated tonometry, have improved diagnostic accuracy. Management requires lower IOP targets due to increased structural fragility, often necessitating combined medical therapy or early surgical intervention. However, surgery in young highly myopic patients carries a heightened risk of hypotony maculopathy. Emerging technologies, including artificial intelligence (AI)-based algorithms and widefield optical coherence tomography angiography (WF-OCTA), enhance diagnostic precision by addressing anatomical distortions and facilitating the early detection of glaucomatous changes. Early identification and tailored management of myopic glaucoma are crucial to mitigate vision loss in this high-risk population. Awareness of the unique challenges posed by high myopia, combined with emerging diagnostic and therapeutic approaches, can improve patient outcome and reduce the burden of undiagnosed disease. Diniz CK, Meira MA, Gondim LAVAS, et al. Managing Myopic Glaucoma—Beyond Structural Fragility and Diagnostic Challenges: Review Article. J Curr Glaucoma Pract 2026;20(1):20–25.

Purpose: To evaluate the agreement between optic nerve head structural parameters obtained using swept-source optical coherence tomography and the Laguna ONhE software. Methods: This retrospective cross-sectional study included 353 eyes from healthy individuals, glaucoma suspects, ocular hypertensive patients, and patients with glaucoma. Optic nerve head parameters—including disc area, vertical and area cup-to-disc ratios, and rim volume—were measured using swept-source optical coherence tomography and Laguna ONhE. Agreement between methods was assessed using Bland–Altman analysis. A regression-based calibration model was developed for disc area measurements. Results: Laguna ONhE systematically underestimated disc area (p < 0.001) and cup-to-disc ratios (p<0.001) and overestimated rim volume (p=0.0002) compared with swept-source optical coherence tomography. After applying the calibration equation for disc area, agreement improved substantially, with no statistically significant bias (p=0.3). Conclusion: Laguna ONhE provides structural estimates comparable with those obtained with swept-source optical coherence tomography after calibration, suggesting it may serve as a practical and cost-effective alternative for glaucoma evaluation.

Repeat selective laser trabeculoplasty has emerged as a valuable option for managing intraocular pressure in pa-tients with primary open-angle glaucoma or ocular hypertension. This review synthesizes current evidence of the efficacy, safety, and clinical applicability of repeat selective laser trabeculoplasty. Evidence from randomized controlled trials, systematic reviews, and observational studies indicate that repeat selective laser trabeculoplasty effectively sustains significant intraocular pressure reduction with minimal complications. This procedure demonstrates comparable efficacy to that of initial selective laser trabeculoplasty, supporting its role as a sustainable, drop-free management strategy. However, further research is warranted to optimize treatment intervals, assess long-term outcomes, and evaluate cost-effectiveness across different healthcare settings.

Purpose: To evaluate whether regionally customized high-density MP-3 microperimetry guided by regions of interest (ROIs) derived from standard automated perimetry (SAP) provides stronger structure–function correlations with ganglion cell layer thickness (GCLT) than conventional SAP in glaucoma. Methods: This cross-sectional study included 85 eyes of 55 glaucoma patients. All participants underwent SAP (Octopus 900) and MP-3 microperimetry (Nidek Co. Ltd). Individual high-density grids were customized to target the quadrant of lowest mean sensitivity on SAP. Optical coherence tomography (DRI-OCT Triton) was used to measure mean GCLT in the corresponding quadrant (GCLTq). Structure–function relationships between GCLTq and visual field (VF) sensitivity indices were analyzed with linear mixed-effects models accounting for inter-eye correlation. VF sensitivities were expressed on logarithmic and linear scales. Comparative model performance was assessed using Akaike’s Information Criterion (AIC), ΔAIC, and Akaike weights (w_i). Results: All VF indices correlated significantly with GCLTq (p < 0.05). MP-3 mean sensitivity on the linear scale (MS-MP3) showed the strongest association (R² = 0.139; p = 0.003), followed by MS-MP3 in dB (R² = 0.134; p = 0.003), SAP in dB (R² = 0.111; p = 0.008), and SAP on the linear scale (R² = 0.062; p = 0.021). Model comparison indicated a better fit for MP-3 on the linear scale (ΔAIC = 8; w_i = 0.982) than SAP, while differences on the dB scale were minor (ΔAIC = 2). The ROI-guided approach provided a wider sensitivity range and stronger spatial correspondence between functional and structural damage. Conclusion: ROI-guided MP-3 microperimetry yielded a statistically supported yet modest improvement in structure–function correlation compared with SAP. The AIC-based analysis confirms that ROI targeting enhances the reliability and topographic accuracy of structure–function mapping in glaucoma.

We sought to investigate the influence of selective laser trabeculoplasty (SLT), as a primary treatment option, on long-term (between visits) intraocular pressure (IOP) variation parameters in eyes with ocular hypertension (OH) or open-angle glaucoma (OAG). This multicenter, real-world data based, retrospective study consecutively enrolled untreated patients that had undergone a single SLT treatment and had a minimum follow-up of 24 months post-SLT. All included patients had to have at least 3 IOP measurements before (within 90 days) the SLT procedure. Patients requiring any glaucoma medication or procedure during the follow-up were excluded. Main outcome measurements were the comparison between pre and post-SLT IOP variation parameters (mean, peak and IOP fluctuation), based on data collected from each follow-up visit. Among 835 patients that had undergone SLT between January 2011 and December 2020, 67 eyes from 67 patients (mean age, 60.5 ± 16.8 years) fulfilled all study inclusion/exclusion criteria and were included in the final analysis. After 24 months of follow-up, mean baseline IOP was significantly reduced from 19.1 ± 2.9 mmHg to 13.6 ± 2.1 following SLT (IOP change, 29%; p < 0.001). Regarding IOP variation parameters, mean baseline IOP peak was significantly reduced from 20.7 ± 3.5 mmHg to 15.1 ± 2.5 mmHg (IOP change, 27%; p < 0.001). In addition, mean baseline IOP fluctuation (based on within subject standard deviation values) was significantly reduced from 1.8 ± 0.1 mmHg to 1.2 ± 0.1 mmHg (IOP change, 33%; p < 0.001). Our results, derived from real world data, suggest that SLT not only effectively reduces mean IOP values, but also positively impacts (by approximately 30%) both IOP fluctuation and peak. Even though our findings provide additional support for the use of SLT on clinical practice, they certainly warrant confirmation by a prospective study.

Précis: Patients with clinically uncontrolled open angle glaucoma submitted to isolated gonioscopy-assisted transluminal trabeculotomy or combined with phacoemulsification not only achieved low mean IOPs, but also demonstrated stable IOP patterns during a 24-month follow-up. Purpose: To assess the impact of gonioscopy-assisted transluminal trabeculotomy (GATT) on long-term intraocular pressure (IOP) variation. Patients and Methods: An unicentric retrospective study including 169 consecutive patients who had undergone standalone GATT or combined with phacoemulsification (PHACOGATT) due to clinically uncontrolled open angle glaucoma, with at least 12 months of follow-up was conducted. Long-term mean IOP, long-term IOP peak, long-term IOP fluctuation, coefficient of variation, mean-positive IOP variation, sustained clinically significant positive IOP variation, and number of follow-up visits with IOP ≥15 mm Hg were investigated. Results: One hundred sixty-nine eyes from 169 patients were included (GATT group=101 patients; PHACOGATT group=68 patients). Mean long term IOP (12.0±1.8 vs. 11.2±2.0 mm Hg), mean long-term IOP peak (12.9±2.6 vs. 11.8±3.5 mm Hg), and mean coefficient of variation (0.07±0.08 vs. 0.05±0.09) were lower in the PHACOGATT group, while mean IOP fluctuation (1.0±3.7 vs. 1.2±1.8 mm Hg) was lower in the GATT group. In addition, the overall mean-positive IOP variation was 0.79±1.64 mm Hg. Finally, only 6.5% of the patients presented sustained clinically significant positive IOP variation and IOP was ≥15 mm Hg in 5.9% of the follow-up visits. Conclusions: Patients with clinically uncontrolled open angle glaucoma submitted to GATT or PHACOGATT achieved low mean IOPs and demonstrated stable IOP patterns. Our results provide additional evidence supporting GATT and PHACOGATT as viable options for the treatment of medically uncontrolled glaucoma patients requiring low and stable IOPs.

To report the surgical outcomes of patients with primary congenital glaucoma who underwent gonioscopy-assisted transluminal trabeculotomy. This retrospective, noncomparative, interventional study included consecutive patients with primary congenital glaucoma with uncontrolled intraocular pressure undergoing gonioscopy-assisted transluminal trabeculotomy between January 2017 and January 2020. The included participants were followed up for at least 24 months, and only one surgeon performed all the procedures. The number of glaucoma medications, pre- and postoperative intraocular pressure, treatment extension (in quadrants), surgical complications, and any associated events or interventions were documented. This study included 13 eyes from 10 patients (mean age, 4.5 ± 3.2 years; range, 3 months to 10 years). After a 24-month follow-up, the mean intraocular pressure significantly decreased from 26.1 ± 3.7 to 11.8 ± 2.5 mmHg (p<0.001). The mean number of glaucoma medications was reduced from 3.3 ± 0.5 to 0.85 ± 1.0 (p<0.001). At the end of the follow-up interval, all eyes (13 out of 13) had an intraocular pressure between 7 and 15 mmHg. In 11 of 13 eyes (84.6%), gonioscopy-assisted transluminal trabeculotomy was performed in all quadrants (360º). The most frequent postoperative complication was transitory (self-limited) hyphema (7 out of 13 eyes [53.8%]). No sight-threatening adverse events occurred during the entire follow-up period. The 2-year follow-up results indicated gonioscopy-assisted transluminal trabeculotomy as an efficient and safe option for primary congenital glaucoma treatment with minimal postoperative complications.

This study aimed to report the surgical outcomes and success predictors of micropulse transscleral cyclophotocoagulation in eyes with refractory glaucoma. This was a noncomparative, interventional case series. Patients with refractory glaucomas, defined as eyes with prior incisional glaucoma surgery failure and uncontrolled intraocular pressure, who underwent micropulse transscleral cyclophotocoagulation between March 2017 and June 2021 were enrolled. A minimum follow-up period of 6 months was required. Preoperative and postoperative intraocular pressure, number of hypotensive medications, surgical complications, and any subsequent related events were recorded. Success criteria were as follows: 1) intraocular pressure reduction ≥20% and intraocular pressure ≤18 mmHg; 2) intraocular pressure reduction ≥30% and intraocular pressure ≤15 mmHg. The need for topical hypotensive medications was not considered a failure. Seventy-nine (79) eyes (79 patients; mean age, 57.5 ± 20.6 years) were included. Overall, the median follow-up duration was 12.0 (interquartile interval, 6-24) months, and the mean intraocular pressure was reduced from 22.8 ± 6.8 mmHg to 15.5 ± 5.6 mmHg at the last follow-up visit (p<0.001). The mean number of medications was reduced from 2.8 ± 0.7 to 2.0 ± 1.0 (p<0.01). At 12 months postoperatively, the success rates for criteria 1 and 2 were 54.9% and 49.7%, respectively. Aside from one case of corneal ulcer, which fully resolved with clinical treatment, and two cases of persistent hypotony (with no visual acuity loss during follow-up), no other vision-threatening complications were observed during the postoperative period. The magnitude of intraocular pressure reduction at 1 month (adjusted to preoperative intraocular pressure; HR=1.01; p=0.002). Our findings suggest that micropulse transscleral cyclophotocoagulation is a relatively effective alternative for managing refractory glaucomas, with minor postoperative complications. In addition, the initial intraocular pressure reduction was a statistically significant predictor of 1-year success in patients undergoing micropulse transscleral cyclophotocoagulation.

Angle-closure glaucoma is a major cause of visual impairment worldwide, with Plateau iris syndrome presenting management challenges. We present a case report of a 58-year-old woman with advanced, uncontrolled angle--closure glaucoma and Plateau iris. Her history included laser peripheral iridotomy and three glaucoma medications in both eyes. Different treatments were implemented. For the eye with lower intraocular pressure, fewer peripheral anterior synechiae, and milder disease: phacoemulsification with intraocular lens implantation. For the eye with more advanced disease, a two-step approach was used: slow-coagulation transscleral cyclophotocoagulation using the double-arc protocol, followed by phacoemulsification with intraocular lens implantation 2 months later. Both eyes achieved improved visual acuity and intraocular pressure control with fewer medications, without significant complications. This case highlights transscleral cyclophotocoagulation followed by phacoemulsification as an alternative to combined surgeries in uncontrolled angle-closure glaucoma with Plateau iris, offering a simpler technique, more predictable refractive and pressure-control outcomes, and more straightforward postoperative management.