Four articles. Four minutes. | Issue #13
Epidemiology: Visual field progression more sensitive to IOP in African-descent than European-descent glaucoma patients
Surgery: Adding ECP to phaco lowered IOP and medication use more at two years in PACG
Medication: Preservative-free latanoprost showed comparable IOP lowering with less hyperemia than preserved latanoprost
Diagnostics: Poorer sleep was linked to thinner peripapillary RNFL in older Chinese adults with POAG
Differential Impact of Intraocular Pressure Lowering on Glaucoma Progression in African and European Descent Individuals
Methods
Longitudinal data from 794 participants (1,382 eyes) who self-identified as African or European descent in the multicenter African Descent and Glaucoma Evaluation Study (ADAGES) were analyzed retrospectively. In eyes with at least 5 usable visual fields, mixed-effects models tested whether IOP was associated differently with sliding-window field-loss rates across ancestry groups, with exploratory stratification by age, disease severity, and trabeculectomy status.
Results
Among glaucomatous eyes, higher IOP was associated with faster visual field progression, but the strength of this association differed by ancestry. Each 1 mmHg higher IOP was associated with -0.014 dB/year of additional visual field loss in African-descent eyes (P<.001) versus -0.003 dB/year in European-descent eyes (P>.05). Importantly, overall average progression rates were not significantly worse in the African-descent group. The difference in IOP sensitivity was most apparent in older patients and those with more advanced glaucoma. The ancestry-dependent IOP interaction was detected before trabeculectomy (P=.014) but not afterward (P=.792). Visual field change among glaucoma suspects showed little relationship to IOP.
Conclusion
The effect of IOP on glaucoma progression may not be uniform across patients. African-descent patients, especially older participants and those with advanced glaucoma, were particularly sensitive to higher IOP, supporting further study of treatment targets individualized by disease severity, age, and ancestry rather than a uniform target IOP.
Our Angle
The key message is not that patients of African descent necessarily progress faster overall, but that their visual fields may be more sensitive to each millimeter of IOP, particularly with older age and severe disease. Although this observational study cannot define ancestry-specific target pressures, it supports considering earlier escalation or more stringent target setting when IOP is not adequately controlled in higher-risk eyes. Importantly, greater IOP sensitivity may also mean that these eyes derive more benefit from each millimeter of pressure reduction.
The authors hypothesize that this difference may reflect greater biomechanical susceptibility of the optic nerve head, including larger discs and potentially more deformable connective tissues that experience greater lamina cribrosa strain at a given IOP.
The loss of the ancestry–IOP interaction after trabeculectomy is therefore intriguing and may suggest that sufficiently low, durable, adherence-independent pressure control can reduce this vulnerability. However, surgery was not randomized, the postoperative cohort was smaller, and medication adherence was not measured, so residual confounding remains substantial.
Future studies should incorporate standardized treatment, objective adherence measures, home or continuous IOP monitoring, optic nerve biomechanics, and socioeconomic factors to determine whether more intensive IOP lowering can reduce disparities in long-term visual field preservation.
Surgery
Phacoemulsification Combined With Endoscopic Cyclophotocoagulation Versus Phacoemulsification Alone in Primary Angle Closure Glaucoma - A Randomized Controlled Trial
Design: Single-center prospective randomized controlled trial
Journal: Journal of Glaucoma, April 2026
Authors: Angmo et al.
In a randomized trial of 66 Indian patients with cataract and predominantly moderate-to-advanced primary angle-closure glaucoma (both arms also received nasal viscodilation), adding 180° nasal endoscopic cyclophotocoagulation to phacoemulsification yielded a lower mean IOP at 24 months than phaco alone (14.0 vs 15.7 mmHg) and a greater reduction in medication use (1.8 vs 1.0 medications), although final counts were similar (2.2 vs 2.4). More ECP-treated eyes achieved IOP of 12 mmHg or less with no more than 2 medications (46.6% vs 13.7%), while visual field, endothelial cell counts, and overall complications did not differ. The modest sample size, single-center Indian cohort, medication adjustment based on postop IOP, and limited follow-up prevent firm conclusions about long-term disease control or comparative safety.
Medication
Efficacy and Safety of Preservative-Free Versus Preserved Latanoprost in Glaucoma and Ocular Hypertension: A Systematic Review and Meta-Analysis
Design: Systematic review and meta-analysis of 10 randomized controlled trials
Journal: Journal of Glaucoma, July 2026
Authors: Alfatih et al.
Across 10 randomized trials involving 1,880 participants with glaucoma or ocular hypertension, preservative-free and preserved latanoprost showed no clear difference in IOP reduction at 4, 6, and 12 weeks. Preservative-free therapy was associated with a 34% lower risk of hyperemia, while overall and other individual ocular adverse events did not differ. Preservative-free latanoprost may be considered when hyperemia complicates treatment or preservative sensitivity is suspected, although the evidence was low to moderate certainty, formulations varied across trials, and follow-up of no more than 12 weeks did not establish improved adherence or long-term glaucoma outcomes.
Diagnostics
Sleep Pattern and Structural Damage in Older Adults with Glaucoma: A United States and China Study
Design: Cross-sectional observational analysis of US and Chinese cohorts
Journal: Ophthalmology Science, July 2026
Authors: Luo et al.
Among 392 older adults classified as having glaucoma and 2,925 controls in the National Health and Nutrition Examination Survey (NHANES), glaucoma was associated with more self-reported sleep disorders and difficulty initiating sleep. In a separate 200-person Chinese cohort, patients with POAG but not PACG reported poorer sleep and had longer wearable-estimated light sleep and lower urinary melatonin levels than controls. Within the 90-person POAG subgroup, worse sleep was independently associated with thinner peripapillary retinal nerve fiber layer and greater depressive symptoms. The cross-sectional design cannot determine whether sleep disturbance contributes to glaucoma damage or results from glaucoma, mood symptoms, or other confounders, and interpretation is limited by photo-based glaucoma classification in NHANES, baseline differences between POAG and PACG, small Chinese subgroups, and lack of polysomnography.
FDA approves bevacizumab-vikg as the first ophthalmic bevacizumab formulation for wet AMD in the United States, with availability expected before year-end.
Australia adds class-wide NAION warnings to GLP-1 drug information and advises urgent ophthalmic assessment for sudden vision loss.
European glaucoma patient groups call for mandatory DICOM adoption so OCT and visual-field data can move across devices and care settings.
ASCRS supports CPT 66740 plus 67255 for cyclodialysis with scleral reinforcement until a dedicated Category III code takes effect January 1, 2027.
The Ebers Papyrus, one of the earliest written records of eye disease treatment, dates to approximately:
A. 2250 BC
B. 1800 BC
C. 1550 BC
D. 900 BC
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