Four articles. Four minutes. | Issue #19
Surgery: Adding iStent or KDB to cataract surgery reduced medication burden, but not IOP
Epidemiology: Retinal arteriosclerosis on fundus photography was associated with long-term structural glaucoma conversion
Diagnostics: Reaction-time analysis may offer a more stable false-positive index for visual field testing
Medication: Low-dose preservative-free bimatoprost/timolol gel matched standard-dose drops for 12-week IOP lowering
Randomized Controlled Trial Comparing Cataract Surgery Alone vs. Combined with iStent Inject W or Kahook Dual Blade Glide: The Swedish Microinvasive Glaucoma Surgery Study
Methods
This single-center Swedish RCT randomized 120 patients with cataract and medically treated ocular hypertension or mild to advanced open-angle glaucoma, including pseudoexfoliation glaucoma, 1:1:1 to phacoemulsification alone, phacoemulsification with iStent Inject W, or phacoemulsification with Kahook Dual Blade (KDB) Glide. The primary endpoint was 12-month surgical success, defined as IOP reduction of at least 20% or reduction of at least 1 medication.
Results
Surgical success was significantly higher in both MIGS arms (87.5% each) than in the cataract-alone arm (52.5%, P < 0.001), driven by greater medication reduction (-0.8 and -0.9 vs -0.4 medications, P = 0.01). Mean IOP reduction was similar across all three arms (approximately -3 mmHg, P = 0.755). Day-1 IOP spikes were less frequent after MIGS (10% and 15% vs 37.5%, P = 0.005), while transient layered hyphema occurred only after KDB (15%). Corneal edema occurred more often after iStent and KDB (35% and 37.5% vs 5%, P = 0.001), generally on day 1 only; one iStent eye with guttata had edema that resolved by month 6.
Conclusion
Adding either iStent Inject W or KDB Glide to cataract surgery reduced medication burden more than phacoemulsification alone in this unmasked single-center trial. No statistically significant difference in IOP lowering was detected across the three arms at 12 months.
Our Angle
Medication burden is often as important to patients as another few millimeters of pressure lowering, especially when glaucoma is already reasonably controlled at the time of cataract surgery. This trial supports that practical role for trabecular MIGS: phacoemulsification produced much of the IOP reduction, while adding iStent or KDB made it easier to reduce drops. For a patient with mild-to-moderate disease whose main goal is fewer medications while preserving conjunctiva for future surgery, that is a meaningful benefit.
The medication endpoint is softer than a washed-out IOP endpoint, however. Drops were tapered after surgery by an unmasked treating physician using individualized target pressures, and the cataract-alone group started on more medications. I therefore would not use the 87.5% “success” rate as a pure measure of MIGS efficacy or infer that iStent and KDB are equivalent from this small trial. If the eye needs a large pressure reduction or a very low target IOP, these data do not answer that question; if the goal is reducing medication burden at the time of cataract surgery, they are reassuring.
Epidemiology
Incidence and Risk Factors of Glaucoma in a Health Screening Cohort: Findings Over 10 Years from the Gangnam Eye Cohort Study
Design: Retrospective cohort study
Journal: American Journal of Ophthalmology, August 2026
Authors: Bak E et al.
In a Korean cohort of 17,212 participants followed for a mean of 13 years, 399 (2.3%) developed definite structural glaucoma. Retinal arteriosclerosis was independently associated with conversion (HR 1.46, 95% CI 1.25 to 1.71), with a 15-year cumulative incidence of 6.76% in affected participants versus 2.58% in those without; each 1 mmHg higher baseline IOP was associated with a 16% higher conversion hazard. Total cholesterol and triglycerides also reached significance after adjustment, although the triglyceride association weakened and was no longer significant when metabolic syndrome and abdominal obesity were omitted as covariates from the Cox model. The cohort relied on serial fundus photography without routine OCT or visual fields and detected only definite structural change in a self-selected screening population.
Diagnostics
Validation of the Reaction Time-Based False-Positive Rate as a Reliability Index for Standard Automated Perimetry
Design: Retrospective cross-sectional study
Journal: Ophthalmology Science, October 2026
Authors: Nomoto H et al.
A retrospective study of 1,201 eyes from 607 glaucoma patients tested with the imo perimeter's AIZE algorithm evaluated reaction time-based false-positive (RT-FP) rates derived from threshold-test responses. Using a 300-ms window and excluding locations at estimated thresholds of 10 dB or below, optimized RT-FP discriminated conventional catch-trial false-positive rates of at least 15% with an AUC of 0.776. Both indices had weak correlations with mean deviation (r = -0.081), while RT-FP had lower relative variability (coefficient of variation 1.27 vs 1.52). Among 140 eyes meeting the conventional threshold, 53 (37.9%) had RT-FP below the exploratory 2.40% cutoff and mild field loss; this disagreement did not establish which index was correct. The study covered five Japanese sites on one platform and lacked test-retest data.
Medication
Low-concentration bimatoprost 0.01% and timolol 0.1% eye gel versus bimatoprost 0.03% and timolol 0.5% eye drops in open-angle glaucoma or ocular hypertension: a phase III randomised study
Design: Phase III randomized controlled trial
Journal: British Journal of Ophthalmology, April 2026
Authors: Cordeiro MF et al.
In a phase III trial at 83 international centres, 554 patients with open-angle glaucoma or ocular hypertension inadequately controlled on first-line monotherapy were randomized to preservative-free bimatoprost 0.01%/timolol 0.1% fixed-combination eye gel or preservative-free bimatoprost 0.03%/timolol 0.5% eye drops for 12 weeks. At 08:00 at week 12, mean IOP reductions from baseline after at least 28 days of monotherapy washout were 10.96 mmHg with gel and 11.14 mmHg with drops (adjusted difference -0.04 mmHg, 95% CI -0.51 to 0.43), meeting the prespecified noninferiority margin. No gel recipients discontinued for a treatment-related adverse event compared with 8 (2.9%) drop recipients; conjunctival hyperemia was reported in 9.4% versus 13.1%. The sponsor-funded trial lasted 12 weeks, leaving longer-term tolerability, systemic safety, and efficacy unanswered.
Alcon launches UNITY M, a premium surgical microscope with a red reflex zone up to six times larger than focused-beam competitors, with U.S. and Japan shipments starting this month.
Oculis begins PIONEER-1, a registrational trial of Privosegtor for optic neuritis, testing a neuroprotective small molecule that crosses the blood-brain barrier and demonstrated activity in glaucoma animal models.
Harrow acquires global rights to TYRVAYA, the only FDA-approved nasal spray for dry eye, from Viatris for $30 million upfront plus up to $70 million in milestone payments.
FDA updates TearCare labeling to include the first indication for improving meibomian gland function, giving the thermal gland expression system a regulatory-backed claim in evaporative dry eye.
Who performed the first full cataract extraction in the Western world in 1707?
A. Jacques Daviel
B. George Bartisch
C. Charles Saint Yves
D. Harold Ridley
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