Four articles. Four minutes. | Issue #10
Medication: Perioperative prostaglandin analog use was not associated with higher risk of CME after routine cataract surgery
Surgery: Trabeculectomy and tube shunts showed higher endophthalmitis rates than MIGS
Health Systems: Trabeculectomy remains more cost-effective than XEN45 in Medicare cost modeling
Diagnostics: Gamified virtual reality perimetry aligned with Humphrey visual field testing while shortening tests and improving patient engagement
A Large-Scale Cohort Analysis of Topical Prostaglandin Analog Use and Pseudophakic Cystoid Macular Edema Following Cataract Surgery.
Methods
This TriNetX retrospective cohort study used electronic health record data from 69 US health care organizations to compare lower-risk cataract surgery patients with perioperative topical prostaglandin analog (PGA) prescriptions versus matched no-PGA controls. Patients with pre-existing high-risk factors for pseudophakic cystoid macular edema (PCME) were excluded, and the primary endpoint was diagnostically coded PCME within 3 months.
Results
After propensity matching, the primary preoperative-PGA comparison included 9,457 patients per group, with PCME in 2.32% of PGA-exposed patients versus 2.08% of controls (HR 1.08, 95% CI 0.89-1.31). Secondary analyses also found no higher PCME risk with postoperative PGA prescriptions (1.96% vs 1.76%; HR 1.08, 95% CI 0.68-1.70) or prescriptions both before and after surgery (2.45% vs 2.70%; HR 0.86, 95% CI 0.61-1.23).
Conclusion
In this large coding-based cohort, perioperative PGA prescriptions were not associated with higher 3-month PCME risk after routine cataract surgery in lower-risk eyes. Interpretation remains limited by EHR coding, prescription rather than confirmed drop use, residual confounding, and deliberate exclusion of higher-risk macular and inflammatory disease.
Our Angle
This study addresses one of the most persistent perioperative glaucoma debates: whether prostaglandin analogs should be stopped around cataract surgery because of concern for CME. For routine cataract cases, these data suggest that the historical concern may have been overstated and that withholding an effective IOP-lowering medication could potentially expose some glaucoma patients to unnecessary pressure elevation without providing meaningful retinal benefit.
The question is probably not whether prostaglandins increase CME risk in all patients, but whether there are specific high-risk subgroups in whom prostaglandin-mediated inflammation meaningfully contributes to disease. Future studies should therefore move beyond broad population analyses and focus on patients frequently encountered in glaucoma practice but excluded here, including eyes with uveitis, retinal vascular diseases, prior CME, and complex anterior segment surgery. Until then, perioperative prostaglandin management is probably best individualized according to retinal risk factors and glaucoma severity rather than applied universally.
One additional area of future interest will be whether sustained prostaglandin delivery at the time of cataract surgery demonstrates similar safety profiles with respect to postoperative macular edema. While this study did not specifically evaluate intracameral prostaglandin implants, the absence of an increased CME signal with topical PGAs in routine cataract surgery provides some reassurance regarding the broader concept of continuous prostaglandin exposure during the perioperative period.
Surgery
Comparative Endophthalmitis Rates in Adult and Pediatric Patients across Various Ophthalmic Procedures: An IRIS Registry Analysis.
Design: IRIS Registry analysis
Journal: Ophthalmology, April 2026
Authors: Chaaya et al.
Among 17,457,881 ophthalmic procedures performed between 2016 and 2024, postoperative endophthalmitis remained rare but varied substantially by procedure type. The highest rates were observed after open-globe repair (0.94%) and penetrating keratoplasty (0.40%). The risk of endophthalmitis following standalone MIGS (0.039%) was nearly identical to cataract surgery (0.038%) and substantially lower than traditional filtering surgeries such as trabeculectomy (0.10%) and tube shunts (0.075%), while combining cataract and glaucoma surgery did not significantly increase infection risk compared with glaucoma surgery alone. Pediatric cataract surgery carried approximately 2.5-fold higher odds of endophthalmitis than adult cataract surgery. Interpretation is limited by billing and EHR coding, lack of granular operative or antibiotic data, and a 30-day window that does not capture late bleb- or implant-related infections.
Health Systems
Comparative cost-effectiveness of Xen45 Gel Stent versus trabeculectomy in the United States Medicare system.
Design: Markov cost-utility modeling study
Journal: Ophthalmology. Glaucoma, May 2026
Authors: Bigirimana et al.
Using a US Medicare Markov cost-utility model based primarily on the randomized Gold-Standard Pathway Study (GPS) trial, investigators found that Xen45 provided slightly higher short-term quality-of-life benefits but at a substantially higher cost of $10,512 at 1 year versus $8,649 for trabeculectomy and produced an incremental cost-effectiveness ratio (ICER) of $236,628 per quality-adjusted life-year (QALY), well above accepted cost-effectiveness thresholds of $50,000/QALY. Over longer time horizons, trabeculectomy became both less expensive and more effective due to greater IOP reduction, fewer medications, higher success rates, and slower projected glaucoma progression. Xen became cost-effective only under highly favorable assumptions regarding device cost (below $683), markedly reduced facility fees, follow-up burden, and postoperative quality of life. Major limitations include reliance on a single randomized trial for efficacy inputs and the assumptions inherent to long-term Markov modeling of glaucoma progression.
Diagnostics
Visual field testing on the Envision head-mounted perimeter with and without gaming elements.
Design: Prospective clinical device study
Journal: Ophthalmology. Glaucoma, April 2026
Authors: Tsamis et al.
A prospective clinical device study of 30 healthy controls and 30 glaucoma patients found that a virtual reality head-mounted perimetry (Envision) produced visual field measurements such as total deviation and mean deviation, test-retest variability, and structure-function concordance comparable to the Humphrey Field Analyzer (HFA), while maintaining more consistent test durations across glaucoma severity levels. A gamified version of the test incorporating immersive visual and audio feedback was strongly preferred by patients, who rated it as more engaging, easier for fixation, and subjectively shorter than both conventional VR testing and HFA. Broader validation is still needed as the study cohort was small, single-site, supervised, and included patients already experienced with standard perimetry, limiting conclusions regarding performance in unsupervised settings or broader populations.
Direct selective laser trabeculoplasty lowers intraocular pressure in a real-world series of 218 eyes, with the greatest benefit in treatment-naive open-angle glaucoma and ocular hypertension.
Thyroid eye disease gains a second FDA-approved targeted therapy as Lumvoa, an intravenous IGF-1R antibody, joins teprotumumab (Tepezza) as an approved drug option for both active and chronic disease.
REGENXBIO doses the first patient in NAAVIGATE, a phase 2b/3 trial of a one-time suprachoroidal gene therapy designed to sustain anti-VEGF activity in diabetic retinopathy without repeated injections.
ARPA-H commits up to $75.8 million to develop a closed-loop tear-duct biosensor that could continuously track ocular surface biomarkers and microdose therapy for dry eye and systemic disease.
Which procedure did Jules Gonin pioneer in 1922 as the first successful surgery for retinal detachment?
A. Pneumatic retinopexy
B. Pars plana vitrectomy
C. Ignipuncture
D. Scleral buckling
See answer at bottom of newsletter
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The Open Angle is a weekly glaucoma research digest for busy eye care professionals.
Four papers worth knowing, in under four minutes.
Edited by Jella An, MD, MBA and Jason Dossantos, MD.
The Open Angle is an educational editorial product. It is not medical advice. Readers should review original sources before changing practice.
Trivia Answer: C