Four articles. Four minutes. | Issue #12
Epidemiology: Routine dilation carries minimal risk of acute angle closure, but medication-associated risk continues to evolve
Diagnostics: TSNIT curve disruptions on OCT distinguished established glaucoma from nonpathologic myopia across international cohorts
Nutrition: Nicotinamide exposure linked to fewer POAG diagnoses in matched ocular hypertension patients
Surgery: Five-year vision-related quality-of-life declined similarly after primary trabeculectomy and Baerveldt implant
Epidemiology, Safety of Dilation, and Medication-Associated Risk of Acute Angle-Closure Crisis in the United States
Methods
This nationwide U.S. electronic health record study identified adult acute angle-closure crisis (AACC) cases from 2010 to 2025. Investigators assessed the incidence of AACC after 3,400,372 dilation-associated examinations and assessed associations between 209 commonly prescribed medications and AACC using propensity-matched cohorts.
Results
Among 2,444,570 patients, only 105 AACC cases followed 3,400,372 dilation-associated examinations, or 3.1 per 100,000 examinations. Patients with documented narrow angles had a substantially higher risk (0.5 per 1,000 examinations). The incidence of AACC increased over the study period, while the prevalence of primary angle-closure glaucoma among patients presenting with AACC more than doubled. In addition to confirming established associations with medications such as topiramate, sulfonamides, anticholinergics, and adrenergic agents, the study identified new pharmacovigilance findings involving CGRP monoclonal antibodies, PCSK9 inhibitors, calcium channel blockers, and α1-blockers. Important limitations include the retrospective design, reliance on administrative coding, inability to analyze eye-level anatomy or medication adherence, and the inability to establish causality for medication-associated findings.
Conclusion
Routine pharmacologic dilation appears to be safe for most patients, with AACC remaining exceedingly rare. However, patients with predisposing anatomic risk factors continue to account for most events, and medication evaluation remains an important component of risk assessment as new systemic therapies emerge.
Our Angle
For most ophthalmologists, the most reassuring finding is that routine pharmacologic dilation carries an extraordinarily low risk of precipitating acute angle closure. These data support continuing to dilate patients when clinically indicated rather than avoiding dilation because of theoretical concerns, provided clinicians remain attentive to patients with known anatomic risk factors.
The more important clinical message is not about dilation, but it is about identifying anatomically susceptible eyes before they present with an acute attack. Despite decades of emphasizing gonioscopy as the gold standard, relatively few patients underwent documented gonioscopy before developing AACC. While anterior segment OCT continues to improve and may expand screening capacity, it should complement rather than replace careful gonioscopy in patients with suspected narrow angles.
Perhaps the most intriguing finding is the emergence of several new medication findings. As novel systemic medications - including CGRP inhibitors for migraine and PCSK9 inhibitors for hyperlipidemia - become increasingly common, ophthalmologists will need to recognize potential ocular adverse effects and collaborate with other specialties. Although these associations do not establish causality or warrant changing systemic therapy, they underscore the importance of careful medication reconciliation, patient education about angle-closure symptoms, and prospective studies to determine which pharmacologic associations represent true causal risks.
Diagnostics
Diagnostic Performance of Prespecified OCT Rules for Glaucomatous Optic Neuropathy in Nonpathologic Myopia.
Design: Multicenter cross-sectional diagnostic validation study
Journal: JAMA Ophthalmology, July 2026
Authors: Li et al.
In a multicenter diagnostic study of 1,525 eyes from 943 adults with nonpathologic moderate or high myopia, prespecified OCT rules differentiated glaucomatous optic neuropathy from myopic structural variation with high accuracy across international cohorts using multiple OCT platforms. In the 684-eye multiethnic external validation cohort, a focal dip or depression in the temporal-superior-inferior-nasal-temporal (TSNIT) curve achieved 93% sensitivity and 93% specificity, while inferior peripapillary retinal nerve fiber layer or inferotemporal macular ganglion cell-inner plexiform layer thinning achieved 90% sensitivity and 93% specificity. Performance remained stable across moderate and high myopia subgroups and across mild and moderate-to-advanced glaucoma. For equivocal OCT scans in moderate or high myopia, the study supports examining the shape of the TSNIT curve for a focal dip or broad flattening rather than relying only on red or green normative classifications. The study excluded pathologic myopia and preperimetric glaucoma, and the rules' performance in routine practice without standardized reader training remains uncertain.
Nutrition
Nicotinamide Supplementation and Primary Open-Angle Glaucoma in Patients With Ocular Hypertension.
Design: Retrospective propensity-matched electronic health record cohort study
Journal: JAMA Ophthalmology, July 2026
Authors: Muayad et al.
Among 2,920 propensity-matched patients with ocular hypertension, documented systemic nicotinamide exposure was associated with lower rates of primary open-angle glaucoma diagnosis (3.5% vs 9.0%, HR 0.34) and reduced initiation of topical IOP-lowering therapy (HR 0.57) and laser trabeculoplasty (HR 0.38) over a mean follow-up of 3.7 years. The association persisted among patients whose nicotinamide use began after the ocular hypertension diagnosis and among those with at least three documented prescriptions. Results support a neuroprotective prevention hypothesis and may inform prospective trial design. However, the retrospective electronic health record study lacked dose, duration, adherence, and ocular biometric data, and healthy-user bias prevents a causal interpretation or recommendation for routine supplementation.
Surgery
Vision-related quality of life following trabeculectomy versus Baerveldt glaucoma implant: Five-year results from a randomized clinical trial.
Design: Secondary analysis of a randomized clinical trial
Journal: Acta Ophthalmologica, June 2026
Authors: Popescu-Giovanitsas et al.
In a secondary analysis of a randomized trial involving 119 surgery-naïve patients, vision-related quality of life declined by clinically meaningful amounts over 5 years after both primary trabeculectomy and Baerveldt glaucoma implantation, with no statistically or clinically significant difference detected between procedures. Among Baerveldt recipients, diplopia remained common (28.6% at year 1 and 26.5% at year 5) but was not associated with lower questionnaire scores. The findings suggest that neither operation clearly outperforms the other in overall patient-reported visual functioning or socioemotional well-being. However, the study was not powered for quality-of-life differences, included a small single-center white European cohort, and used an instrument insensitive to procedure-specific burdens such as diplopia, bleb symptoms, and continued medication use. Surgical choice should remain individualized around anatomy, comorbidities, medication burden, adverse effects, and patient preferences.
A nationwide Class II recall covers 2.53 million bottles of prednisolone acetate 1% after a complaint involving foreign particulate matter.
Bausch + Lomb ends topical alpha-2B adrenergic agonist development as it misses phase 2 primary visual-field and key secondary visual-function endpoints.
CMS proposes 1.19% to 1.68% cuts to 2027 base Medicare physician payment rates. CMS's proposal would also pay only the highest-cost same-day office visit or procedure with bundled follow-up care in full, with all other services from the same practice paid at 50%.
An artificial intelligence chart-screening tool increased retina trial enrollment by 37.5% and reduced screening failures by about 13% in a single-practice study.
Who first used the word "gonioscopy" in the early 1900s?
A. Maximilian Salzmann
B. Hans Goldmann
C. Alexios Trantas
D. Theodore Scheie
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 articles 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