The Effect of Phacoemulsification on the Intraocular Pressure of Patients with Open-angle Glaucoma: A Systematic Review and Meta-Analysis.

PRECIS: There is evidence that cataract surgery can reduce intraocular pressure in patients with primary open angle-, normal tension-, or exfoliative glaucoma. The complete effect of phacoemulsification is masked by topical intraocular pressure-lowering medications. PURPOSE: To assess the impact of phacoemulsification and intraocular lens implantation on intraocular pressure (IOP) level in individuals with primary open-angle glaucoma (POAG), exfoliative glaucoma (XFG), exfoliation syndrome (XFS), normal tension glaucoma (NTG), ocular hypertension (OH) or healthy controls 12 months after the surgery. METHODS: In July 2023, a comprehensive literature review was conducted across six databases. The analysis focused on the phacoemulsification arms of randomized controlled trials (RCTs). The primary outcome of interest was the mean IOP change observed 12 months after phacoemulsification. RESULTS: This meta-analysis included nine arms from nine RCTs, comprising a total of 502 participants. Overall, the average IOP was reduced by 3.77 mmHg (95%CI: -5.55 to -1.99, I2=67.9%) 12 months after surgery. The subgroup analysis, focused on whether a washout period was employed before measuring IOP, revealed that studies with a washout period exhibited a more pronounced IOP reduction of 5.25 mmHg (95%CI: -7.35 to -3.15, I2=0%), while studies without a washout period exhibited a reduction of 3.13 mmHg (95%CI: -5.46 to -0.81, I2=75.8%). The sensitivity analysis for the latter group, excluding an outlier study, showed a reduction of 1.81 mmHg (95%CI: -2.95 to -0.67, I2=0%). CONCLUSIONS: The findings of this systematic review and meta-analysis indicate that cataract surgery meaningfully lowers IOP in POAG, XFG/XFS, or OH 12 months after surgery. However, the use of topical medications masks the precise impact of phacoemulsification upon postoperative IOP. Further research using appropriate washout periods is warranted.

The large Hellenic Study of Uveitis: epidemiology, etiologic factors and classification.

PURPOSE: To analyse the demography, etiology, and classification of uveitis at a tertiary academic referral center. METHODS: An observational study was conducted on the archives of uveitic patients at the Ocular Inflammation Service of the Department of Ophthalmology at the University Hospital of Ioannina (Greece) from 1991 to 2020. This study aimed to investigate the epidemiological profile of patients, including their demographics and the main etiologic factors of uveitis. RESULTS: Out of 6191 cases with uveitis, 1925 were infectious, 4125 were non-infectious, and an overall of 141 masquerade syndromes were recorded. Among these cases, 5950 patients were adults, with a slight female predominance, while 241 were children (< 18 years old). Interestingly, 24.2% of cases (1500 patients) were associated with 4 specific microorganisms. Herpetic uveitis (HSV-1 and VZV/HZV) was the most common cause of infectious uveitis (14.87%), followed by toxoplasmosis (6.6%) and tuberculosis (2.74%). In 49.2% of non-infectious uveitis cases, no systematic correlation was found. The most frequent causes of non-infectious uveitis included sarcoidosis, white dot syndromes, ankylosing spondylitis, lens-induced uveitis, Adamantiades-Behçet disease, and idiopathic juvenile arthritis. Infectious uveitis was more common in the rural population, whereas non-infectious uveitis was more frequently recorded in the urban population CONCLUSIONS: Although our study was conducted on a predominantly white Caucasian population, it also reflects the effect of increasing immigration, improvements of diagnostic techniques, changes in referral patterns, and various actual changes in disease incidence.

Changing from preserved, to preservative-free cyclosporine 0.1% enhanced triple glaucoma therapy: impact on ocular surface disease-a randomized controlled trial.

OBJECTIVE: Halting and reversing glaucoma therapy-related ocular surface disease (GTR-OSD) will improve the success of long-term medical therapy, impacting millions of patients worldwide. METHODS: A single-centre, masked, prospective, placebo-controlled, crossover trial of 41 well-controlled open-angle glaucoma subjects with moderate to severe GTR-OSD on preserved latanoprost and dorzolamide/timolol fixed combination (DTFC) therapy was conducted. Subjects were randomized to preservative-free (PF) tafluprost and DTFC with either placebo or cyclosporine 0.1% drops for 6 months and were then crossed over to the opposite therapy. Oxford score of ocular staining was the primary outcome; osmolarity, matrix-metalloproteinase-9 (MMP-9) testing, tear film break-up time (TFBUT), meibomian gland dysfunction (MGD), punctum evaluation, adverse events and diurnal intraocular pressure (IOP) comprised secondary outcomes. RESULTS: GTR-OSD findings improved with PF therapy. At 6 months the triple PF with placebo group showed improvement compared to baseline in mean Oxford score (mean difference [MD]:-3.76; 95% confidence interval [CI]:-4.74 to -2.77; p < 0.001), osmolarity (MD:-21.93; 95%CI:-27.61 to -16.24 mOsm/l; p < 0.001), punctum stenosis (p = 0.008) and conjunctival hyperaemia (p < 0.001). Similar improvements occurred in the cyclosporine enhanced period, which also provided greater improvement in MMP-9 positivity (24 vs 66%; p < 0.001) and TFBUT (p = 0.022). The cyclosporine group was superior vs placebo in mean Oxford score (MD:-0.78; 95%CI:-1.40 to -0.15); p < 0.001), itchiness and objective adverse events (p = 0.034). Cyclosporine elicited more stinging vs placebo (63 vs 24%; p < 0.001). Both PF regimens reduced mean diurnal IOP more than preserved therapy (14.7 vs 15.9 mmHg; p < 0.001). CONCLUSIONS: Changing from preserved to PF glaucoma medications improves ocular surface health and IOP control. Topical cyclosporine 0.1% further reverses GTR-OSD.

Phacoemulsification versus Phacoemulsification/Trabeculectomy for the Treatment of Primary Open-Angle Glaucoma Coexistent with Cataract: A Comparative Study.

Background: The purpose of this study was to evaluate the clinical outcomes in patients with primary open-angle glaucoma (POAG) and coexistent cataract treated with phacoemulsification cataract surgery, either alone or in combination with trabeculectomy. Methods: Participants in this retrospective study were 52 patients diagnosed with previously controlled POAG and coexistent cataract, who underwent either uneventful phacoemulsification cataract surgery (Group I, n = 27) or combined uneventful phacoemulsification cataract surgery and trabeculectomy (Group II, n = 25), with at least a 24-month postoperative follow-up. We recorded the changes in intraocular pressure (IOP) and in the need of anti-glaucoma medications before and after surgical procedures. Results: There was a statistically significant decrease in IOP at postoperative day 7 in both groups (p < 0.001), which remained until the end of the 24-month follow-up. At month 24, the two groups did not differ significantly in terms of IOP (14.3 ± 1.4 vs. 13.1 ± 1.2 for Group I and Group II, respectively; p = 0.447). In addition, there was a statistically significant decrease in the number of anti-glaucoma medications needed at postoperative day 7 in both groups (p < 0.001 for both groups compared to baseline). At month 24, patients in both groups needed about one additional anti-glaucoma medication to control their IOP. Of note, during the first month after surgery, 20% of patients in Group II needed 0.1 mL 5-FU injections to the bleb, although antimetabolites were not used in the primary surgery. Conclusions: Both surgical interventions, namely phacoemulsification cataract surgery alone and phacoemulsification/trabeculectomy, were found to be effective in the management of POAG with coexistent cataract, presenting a significant decrease in IOP and in the need of anti-glaucoma medications postoperatively at a long-term follow-up period of 24 months.

The Large Hellenic Study of Uveitis: Diagnostic and Therapeutic Algorithms, Complications, and Final Outcome.

PURPOSE: The purpose of this study is to present the diagnostic and therapeutic algorithms, complications, and final outcome in the management of uveitic patients at a tertiary academic referral center. DESIGN: Observational study. METHODS: Analysis of the archives of 6191 uveitic patients at the Ocular Inflammation Service of the Department of Ophthalmology of the University Hospital of Ioannina in Greece from 1991 to 2020. RESULTS: During the 30 years of the study, the diagnostic ability climbed from 45.43% (1991-1995) to 73.4% (2016-2020). This improvement was linked to several factors including the increase in the number of diagnostic paracenteses for the analysis of intraocular fluids, the range and quality of laboratory blood tests, the multimodal ophthalmic imaging, the proper use of nonophthalmic imaging, and the multidisciplinary approach. The degree of uveitis-related complications was related to the severity and cause of inflammation, the recurrence rate, inappropriate treatment, and the prolonged or initially inactive inflammation. The 3 most common complications included cataract, macular edema, and glaucoma. Apart from the modern treatments and surgical techniques, the 3-month preoperative control of inflammation played a critical role in the surgical outcomes. The percentage of patients with a successful outcome increased from 72% (2001-2005) to 90.50% (2016-2020). The center's experience, prompt referral, patient's compliance, and regular follow-ups are associated with a better outcome. The analysis of the results allowed the development of diagnostic and therapeutic algorithms. CONCLUSIONS: Developing diagnostic and therapeutic algorithms allows for the efficient management of uveitis, leading to better visual outcome and therefore a better quality of life.

Vitreous inflammatory and angiogenic factors on patients with proliferative diabetic retinopathy or diabetic macular edema: the role of Lipocalin2.

PURPOSE: Quantitative analysis of vitreous inflammatory and angiogenic factors from patients with proliferative diabetic retinopathy (PDR) or diabetic macular edema (DME). MATERIALS AND METHODS: Collection of undiluted vitreous samples from 20 diabetic patients: 13 with proliferative diabetic retinopathy (PDR) and 7 with diabetic macular edema (DME). DME patients had suboptimal response to anti-VEGF treatment. Samples from 11 control patients, with vitreomacular interface pathology such as idiopathic epiretinal membrane (iERM) (n = 4), vitreomacular traction syndrome (VMT) (n = 3) and full thickness macular hole (FTMH) (n = 3), were also collected. The levels of IL1b, IL6, IL8, IL27, TNFα, ICAM-1, VCAM, MCP-1, VEGFA and LCN2 were measured using cytometry flow analysis. Median values were compared with Mann-Whitney test since the distributions were skewed. Statistical analysis was performed with the Statistical Package for Social Sciences software (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.). RESULTS: The median concentration of LCN2, IL6, IL8, IL1b, IL27, ICAM, VCAM-1, MCP-1, TNFa and VEGFA was higher in PDR patients than in controls. Similarly, the median concentration of LCN2, IL6, IL8, IL27, ICAM, VCAM-1, TNFa and VEGFA was higher in DME patients than in controls. In particular, median LCN2 concentration in diabetic patients was 5,711 pg/ml (interquartile range [IR] = 2,534), while in controls was 2,586 pg/ml (IR = 2,345). Moreover, median LCN2 was 6,534 pg/ml in the DME group (IR = 6,850) and 4,785 pg/ml in the PDR group (IR = 2,608), (p = 0.025). CONCLUSION: Various inflammatory and angiogenic factors are involved in the pathophysiology of PDR and DME. Elevated vitreous levels of LCN2 in PDR and especially in DME patients reveal a potential pathogenic association. More extended studies could verify LCN2 as an alternative therapeutic target.

Myopic LASIK Outcomes: Comparison of Three Different Femtosecond Lasers and a Mechanical Microkeratome Using the Same Excimer Laser.

INTRODUCTION: To compare the influence of one microkeratome and three femtosecond lasers on myopic laser in situ keratomileusis (LASIK) outcomes. METHODS: Retrospective, observational cohort study. We compared 134 eyes treated with the IntraLase 60 kHz, 112 eyes treated with the Femto LDV Z6, 206 eyes treated with the FS200, and 98 eyes treated with the Hansatome zero compression microkeratome. All eyes were operated on using the same surgical protocol with the same excimer laser (Wavelight Allegretto) and were allocated to refraction-matched groups. RESULTS: One day and one week postoperatively, uncorrected distance visual acuity was significantly lower in the FS200 group compared to others (P = 0.0001). This difference disappeared at the 1- and 3-month postoperative visits. Significant differences were found among groups in terms of safety index (P = 0.0001), residual sphere (P = 0.0001), and residual cylinder (P = 0.02) at the 3-month postoperative visit. No significant differences were found in corrected distance visual acuity or efficacy index. CONCLUSION: According to our results, a slight delay in visual restoration after FS200 LASIK surgery might be expected. This delay was statistically significant at 1 day and 1 week postoperatively, but there were no differences from the 1-month visit onwards. Additionally, significant differences were found among devices in terms of safety index and the refractive results, which were found not to be clinically relevant.

Evaluation of the choriocapillaris after photodynamic therapy for chronic central serous chorioretinopathy. A review of optical coherence tomography angiography (OCT-A) studies.

PURPOSE: Emerging evidence suggests that choroidal microcirculation and microstructural changes after verteporfin photodynamic therapy (vPDT) for chronic central serous chorioretinopathy (CSC) can be shown in detail using OCT-Angiography (OCT-A). The use of OCT-A for the examination of choriocapillaris (CC) has attracted significant attention as the technique offers potential explanations for the effects of vPDT on choroidal tissue. METHODS: A meticulous literature search was performed in the PubMed database without restriction on year of publication until June 2021. The reference list of all electronically retrieved articles was carefully reviewed for potentially relevant articles that had not been identified. RESULTS: We identified and reviewed 11 studies reporting a comprehensive update on microvasculature and morphologic changes of the CC layer as seen on OCT-A in chronic CSC. The reviewed articles extensively analyze both the qualitative and quantitative characteristics of the CC flow pattern after applying vPDT safety-enhanced protocols. The changes in the CC plexus indicate the potential of beneficial or deleterious treatment effect on choroidal tissue remodeling. The reviewed series have revealed variability of flow pattern, vessel density, and perfusion of the CC over time. CONCLUSION: The CC plexus alterations during the post-vPDT period in chronic CSC may imply the treatment effect on choroidal tissue, indicating the potential of anatomical or functional recovery over time. The reviewed literature may confirm the diagnostic value of OCT-A in the assessment of the pathophysiology of eyes with CSC.

The Choroid after Half-Dose Photodynamic Therapy in Chronic Central Serous Chorioretinopathy.

PURPOSE: To characterize choroidal structure and vasculature after half-dose verteporfin photodynamic therapy (hd-vPDT) in eyes with chronic central serous chorioretinopathy using Enhanced Depth Imaging Optical Coherence Tomography (EDI OCT) and Optical Coherence Tomography Angiography (OCT-A). METHODS: This prospective case-control study included 10 eyes. Choroid was examined before and at 1 month following hd-vPDT. We measured choroidal thickness (CT) at subfoveal area and at 750 µm nasal and temporal of fovea and thickness of Haller and choriocapillaris/Sattler layers. Whole (WA), luminal (LA) and interstitial area (IA) at EDI-OCT, and perfusion density at OCT-A were analyzed. The unaffected fellow eyes were used for comparisons. RESULTS: Mean CT at subfoveal area and at 750 µm nasal and temporal of fovea, values of Haller and choriocapillaris/Sattler layers and those of WA, LA and IA were reduced, while PD increased at 1 month after hd-vPDT (all p < 0.001). There was a significant (p < 0.05) negative correlation (ρ = -0.658) between PD and post-treatment logMARVA. None of analyzed parameters reached values of unaffected fellow eye. CONCLUSION: Following hd-vPDT, choroidal thickness with both luminal and interstitial components markedly decreased, while perfusion of choriocapillaris improved.

A new look at the safety and tolerability of prostaglandin analogue eyedrops in glaucoma and ocular hypertension.

INTRODUCTION: In the last 25 years, topical prostaglandin analogues (PGAs) have emerged to become first line and first choice therapeutic options in the management of glaucoma and ocular hypertension (OHT). Although the short-term efficacy and safety of PGAs has been extensively investigated, less is known about their long term safety and tolerability. This gap in current knowledge is clinically relevant, because treatment-related adverse events and long-term tolerability issues are key determinants of the overall success of long-term therapy and the final outcome of a lifelong, symptomless disease like glaucoma. AREAS COVERED: We include selected evidence pertaining to the safety and tolerability of available and emerging PGA formulations. We also outline PGA formulations with different concentrations of the active ingredient, different preservatives, and preservative-free (PF) options. EXPERT OPINION: Undoubtedly PGAs will continue to play a major role in the medical therapy of glaucoma and OHT. Despite extensive literature and prolonged clinical experience with these agents worldwide, a number of areas that warrant further research have been identified in the present review. Recently launched novel PGAs, or those still in development offer new opportunities and future challenges.

Femtosecond LASIK for the correction of low and high myopic astigmatism.

INTRODUCTION: Higher preoperative myopic astigmatism is associated with a higher probability of retreatment due to patient dissatisfaction as a result of residual cylindrical error. Nonetheless, retreatment is safe and the final clinical results are comparable to those of patients with lower preoperative astigmatism who were satisfied with the primary treatment. Our purpose is to compare the efficacy and safety of femtosecond LASIK (FS-LASIK) for the refractive correction of patients with low (< 1.5 Diopters (D) versus high (≥ 1.5 D) myopic astigmatism. METHODS: Retrospective observational study of 841 eyes of 825 eligible patients treated with FSLASIK for the correction of simple or compound myopic astigmatism. Outcome measures included residual error, best corrected and uncorrected distance visual acuity (BCVA and UCVA), efficacy and safety 3 months after the primary procedure or the retreatment. RESULTS: Of 841 eyes in total, 432 (51.37%) had < 1.5 D (Group 1) and 409 (48.63%) had ≥ 1.5 D (Group 2) preoperative myopic astigmatism. The efficacy index of primary treatment was 0.94 ± 0.18 in Group 1 and 0.89 ± 0.22 in Group 2 (P = 0.001). Of 138 eyes (16.41%) that were retreated due to dis-satisfaction related to residual refractive error, 28 belonged to Group 1 (6.5%) and 110 (26.9%) to Group 2 (P < 0.001). Following retreatment, small but statistically significant differences in the residual mean postoperative cylinder (-0.08 ± 0.24 vs -0.27 ± 0.46 D, P = 0.001) and UCVA (1.11 vs 0.96, P = 0.0001) were detected for Groups 1 and 2, respectively. However, there were no statistically significant differences in the safety and efficacy indices. CONCLUSION: Following FS-LASIK, eyes with myopic astigmatism ≥ 1.5 D have approximately four times more chances of undergoing retreatment due to dis-satisfaction caused by residual refractive error compared to eyes with myopic astigmatism < 1.5 D. However, the clinical results after retreatment are highly satisfactory and comparable in both groups.

Does the ISNT rule apply to the radial peripapillary capillary vessel density in OCT angiography?

PURPOSE: To investigate the applicability of ISNT (inferior ≥ superior ≥ nasal ≥ temporal), IST (inferior ≥ superior ≥ temporal), and T min (temporal quadrant with the minimum value) rules to the peripapillary nerve fiber layer (NFL) thickness and radial peripapillary capillary (RPC) vessel density (VD) using Optical Coherence Tomography (OCT) and OCT angiography (OCT-A). MATERIALS AND METHODS: This cross-sectional study included 134 eyes of 74 healthy individuals. NFL thickness and RPC VD were measured in all four quadrants using OCT and OCT-A in order to determine the number of eyes that obey the ISNT, IST, and T min rules. RESULTS: Mean age was 48.8 ± 15.5 (range 25-82) years. The ISNT rule was valid in 52 eyes (38.81%) on OCT and only 12 eyes (8.95%) on OCT-A scans. The IST rule was followed by 83 (61.94%) and 37 (27.61%) eyes on OCT and OCT-A scans respectively. The T min rule was valid in 86 eyes (64.18%) in OCT scans and in 26 eyes (19.4%) in OCT-A scans. CONCLUSION: The topography of the RPC network does not obey the ISNT rule in healthy eyes. The ISNT rule and its variants were found to be more relevant in OCT NFL thickness measurements compared to OCT-A RPC VD measurements.

A Comparison of Hyper-Reflective Retinal Spot Counts in Optical Coherence Tomography Images from Glaucomatous and Healthy Eyes.

PURPOSE: To compare the number of hyper-reflective retinal spots (HRS) in optical coherence tomography (OCT) images of healthy controls and patients affected with primary open angle glaucoma (POAG). METHODS: Thirty patients affected with POAG and 34 healthy controls were recruited and underwent raster OCT examination of the macular region. Among the acquired B-scans, the one with the lowest foveal thickness was selected, and a central area of 3000 µm was defined (region of interest, ROI), in order to identify HRS. HRS were defined as small point-like hyper-reflective elements, detectable at the visual inspection of the OCT image. HRS were independently counted by two investigators in the ROI of each OCT scan. RESULTS: Inter-rater agreement for HRS counting was good to excellent (ICC = 0.96, 95% CI: 0.83-0.99). More HRS were found in the OCT images from glaucoma patients, in comparison with healthy controls (average value: 90.5 ± 13.02 and 74.72 ± 11.35, for glaucoma and healthy subjects, respectively; p < 0.01). Significant correlations between the average number of HRS and visual field mean deviation (MD, p = 0.01) and pattern standard deviation (PSD, p < 0.01) were found. CONCLUSIONS: OCT images from glaucoma patients showed a higher number of HRS when compared with healthy controls. As HRS have been hypothesized to be a sign of neuroinflammation, these results may support the role of neuroinflammation in glaucoma etiopathogenesis.

Efficacy and Safety of PreserFlo® MicroShunt After a Failed Trabeculectomy in Eyes with Primary Open-Angle Glaucoma: A Retrospective Study.

INTRODUCTION: To evaluate the efficacy and safety of PreserFlo® MicroShunt in primary open angle glaucoma (POAG) eyes after a single failed trabeculectomy. METHODS: Retrospective review of POAG eyes with a failed trabeculectomy that underwent PreserFlo® MicroShunt implantation from March 2019 to November 2019, in two Italian glaucoma centers. Pre- and postoperative data were collected and compared. RESULTS: A total of 31 surgeries in 31 patients were reviewed. Mean preoperative IOP and mean preoperative number of medications were 24.12 ± 3.14 mmHg and 3.29 ± 0.64, respectively, and decreased to 12.56 ± 2.64 mmHg and 0.46 ± 0.77 at the 12-month postoperative follow-up visit (p < 0.01). The most frequent adverse events were transient hypotony (6 eyes, 19.3%) and choroidal effusion (3 eyes, 9.6%). In all cases spontaneous resolution was observed, with no intervention. CONCLUSION: In POAG eyes with a single failed trabeculectomy, the PreserFlo® MicroShunt was safe and effective in reducing the IOP after a 12-month follow-up. The PreserFlo® MicroShunt may represent a viable choice as a second surgery.

What Do We Really Know about the Effectiveness of Glaucoma Interventions?: An Overview of Systematic Reviews.

PURPOSE: To identify systematic reviews of interventions for glaucoma conditions and to assess their reliability, thereby generating a list of potentially reliable reviews for updating glaucoma practice guidelines. DESIGN: Cross-sectional study. PARTICIPANTS: Systematic reviews of interventions for glaucoma conditions. METHODS: We used a database of systematic reviews and meta-analyses in vision research and eye care maintained by the Cochrane Eyes and Vision United States Satellite. We examined all Cochrane systematic reviews of interventions for glaucoma conditions published before August 7, 2019, and all non-Cochrane systematic reviews of interventions for glaucoma conditions published between January 1, 2014, and August 7, 2019. MAIN OUTCOME MEASURES: We assessed eligible reviews for reliability, extracted characteristics, and summarized key findings from reviews classified as reliable. RESULTS: Of the 4451 systematic reviews in eyes and vision identified, 129 met our eligibility criteria and were assessed for reliability. Of these, we classified 49 (38%) as reliable. We found open-angle glaucoma (22/49) to be the condition with the most reviews and medical management (17/49) and intraocular pressure (IOP; 43/49) to be the most common interventions and outcomes studied. Most reviews found a high degree of uncertainty in the evidence, which hinders the possibility of making strong recommendations in guidelines. These reviews found high-certainty evidence about a few topics: reducing IOP helps to prevent glaucoma and its progression, prostaglandin analogs are the most effective medical treatment for lowering IOP, laser trabeculoplasty is as effective as medical treatment as a first-line therapy in controlling IOP, the use of IOP-lowering medications in the perioperative or postoperative periods to accompany laser (e.g., trabeculoplasty) reduces the risk of postoperative IOP spikes, conventional surgery (i.e., trabeculectomy) is more effective than medications in reducing IOP, and antimetabolites and ß-radiation improve IOP control after trabeculectomy. The evidence is weak regarding the effectiveness of minimally invasive glaucoma surgeries. CONCLUSIONS: Most systematic reviews evaluating interventions for glaucoma are of poor reliability. Even among those that may be considered reliable, important limitations exist in the value of information because of the uncertainty of the evidence as well as small and sometimes unimportant clinical differences between interventions.

Glaucoma and neuroinflammation: An overview.

Glaucoma is an optic neuropathy characterized by well-defined optic disc morphological changes (i.e., cup enlargement, neuroretinal border thinning, and notching, papillary vessel modifications) consequent to retinal ganglion cell loss, axonal degeneration, and lamina cribrosa remodeling. These modifications tend to be progressive and are the main cause of functional damage in glaucoma. Despite the latest findings about the pathophysiology of the disease, the exact trigger mechanisms and the mechanism of degeneration of retinal ganglion cells and their axons have not been completely elucidated. Neuroinflammation may play a role in both the development and the progression of the disease as a result of its effects on retinal environment and retinal ganglion cells. We summarize the latest findings about neuroinflammation in glaucoma and examine the connection between risk factors, neuroinflammation, and retinal ganglion cell degeneration.

The treatment of glaucoma using topical preservative-free agents: an evaluation of safety and tolerability.

Introduction: Preservative-free (PF) medications represent a valuable treatment strategy in the lifelong management of glaucoma. By removing preservative toxicity, PF formulations provide tangible clinical benefits to glaucoma patients worldwide. They improve tolerability and adherence, leading to a positive impact in long-term intraocular pressure (IOP) control.Areas covered: A critical review of the subject is provided, including selected evidence on the safety and tolerability of currently available topical PF formulations. Cumulative evidence confirms that topical PF medications are at least equally efficacious to their preserved equivalents. There is convincing short-term evidence for superior tolerability and safety of PF formulations compared to preserved medications. The long-term benefits and success of PF therapy requires further elucidation.Expert opinion: Successful stepwise administration of medical therapy for glaucoma remains elusive. There is a greater risk for ocular toxicity and therapy failure with preserved topical glaucoma therapy. Currently available and emerging PF therapy options potentially optimize lifelong stepwise glaucoma therapy and may enhance outcome. To avert complications from preservatives leading to poor adherence, ideally, future antiglaucoma therapy should become 100% PF. There are still key aspects of PF therapy that warrant further investigation.