Four articles. Four minutes. | Issue #20
Surgery: In a single-arm pivotal trial, implant-free excimer laser trabeculostomy with phaco met prespecified 24-month IOP performance goals
Diagnostics: OCT angiography detected progression a mean 2.3 years before visual fields in eyes progressing on both tests
Medication: Five-year ocular-surface outcomes were broadly similar after initial mono- versus multitherapy
Laser: One-third of phakic PACS eyes had persistent gonioscopic angle closure 5 years after iridotomy
ELIOS Excimer Laser Trabeculostomy with Phacoemulsification in Primary Open-Angle Glaucoma: 24-Month Outcomes of Pivotal Trial
Methods
This prospective, multicenter FDA pivotal trial enrolled 318 patients with mild-to-moderate POAG and operable cataract at 20 US sites who underwent phacoemulsification combined with ELIOS excimer laser trabeculostomy, a non-thermal, implant-free procedure that photoablates microchannels in the trabecular meshwork. Coprimary endpoints at 12 and 24 months were compared against performance goals derived from phacoemulsification-only arms of prior MIGS pivotal trials.
Results
At 24 months, 76.1% of patients achieved at least 20% reduction in unmedicated mean diurnal IOP, exceeding the 68.5% performance goal (P = 0.0018), and mean unmedicated diurnal IOP decreased 7.35 mmHg from a washed-out baseline of 24.5 mmHg, exceeding the 6.15 mmHg performance goal (P < 0.0001). More than 80% of patients remained medication-free from month 3 through month 23. Endothelial cell loss stabilized after month 3 with no progressive decline through 24 months.
Conclusion
ELIOS excimer laser trabeculostomy combined with phacoemulsification produced sustained IOP and medication reductions through 24 months in mild-to-moderate POAG, with no unexpected safety findings through 24 months. The single-arm design used historical performance goals from phaco-only controls rather than a concurrent comparator, so the incremental benefit of ELIOS and its relative advantage over other angle procedures cannot be determined.
Our Angle
These 24-month results are reassuring and add another prospective data set showing that angle-based surgery at the time of cataract surgery can achieve meaningful medication-free IOP control in mild to moderate POAG with a reassuring safety profile. The implant-free, non-thermal approach is conceptually attractive, and the absence of progressive endothelial loss or unexpected ELIOS-related complications is reassuring. To me, however, the more important question is what it adds to an already crowded field of effective angle-based procedures.
Without a concurrent phaco control or head-to-head comparison with trabecular stents, goniotomy/trabeculotomy, or canaloplasty, this study cannot tell us whether ELIOS provides better IOP lowering, medication reduction, durability, safety, efficiency, or cost. Its outcomes appear broadly consistent with prior angle-based MIGS studies, which I view as a positive confirmation of the overall strategy rather than evidence of superiority of this specific technology. Comparative data, and practical factors such as operative time, learning curve, access, cost, and longer-term durability, will ultimately determine where ELIOS fits in our surgical algorithm.
Diagnostics
Event-Based Progression Detection Among OCT, OCT Angiography, and Visual Field in Glaucoma
Design: Retrospective cohort study
Journal: JAMA Ophthalmology, September 2026
Authors: Hashemi et al.
In 180 eyes followed for 5.1 years, OCT angiography and OCT often detected progression before visual fields. Peripapillary vessel-density loss was the sole earliest change in 40 of 107 progressing eyes, versus retinal nerve fiber layer thinning in 32 and visual field deterioration in 26. Among eyes progressing on both tests compared, changes preceded visual field progression by 2.3 years with OCT angiography and 1.5 years with OCT, without a clear timing difference between imaging tests. Specificity in 45 clinically stable eyes was 68.9% for OCT angiography and 75.6% for OCT. Measurement variability and false positives limit this retrospective comparison, and improved visual outcomes from adding OCT angiography remain unproven.
Medication
Impact of mono- or multitherapy on ocular surface health and quality of life after 5 years of follow-up in the Glaucoma Intensive Treatment Study (GITS)
Design: Secondary analysis of a randomized controlled trial
Journal: Acta Ophthalmologica, August 2026
Authors: Jóhannesson et al.
Five-year ocular-surface findings were similar after initial monotherapy or intensive treatment in 219 patients with newly diagnosed open-angle glaucoma. The Glaucoma Intensive Treatment Study randomized patients to 1 medication with stepwise escalation or 3 drug classes plus 360-degree laser trabeculoplasty. Normal tear breakup time was present in 46% overall and normal Schirmer results in 60%, without group differences. A separate quality-of-life item found more ocular pain with intensive treatment at months 1 and 60, although the change between visits did not differ. Pretreatment ocular-surface measurements were unavailable, so the findings cannot establish that either regimen preserved baseline ocular-surface health.
Laser
Long-term Persistent Angle Closure and Anatomic Changes after Laser Iridotomy in Suspected Primary Angle-Closure
Design: Subanalysis of a randomized fellow-eye trial
Journal: Ophthalmology, April 2026
Authors: Servillo et al.
Laser peripheral iridotomy produced sustained angle widening in primary angle-closure suspects, although one-third still had residual angle closure at 5 years. Among 375 phakic participants with complete follow-up in the randomized Singapore trial, 124 treated eyes (33.1%) had gonioscopic closure in at least 2 quadrants, with less persistent closure than untreated fellow eyes. Angles widened during the first 2 years and remained stable thereafter. In the 130-participant imaging subset, younger age and thicker peripheral iris were associated with persistent closure; the thickness association was confined to narrower baseline angles. Exclusion of incomplete follow-up and cataract surgery limits generalizability, and these anatomic findings do not establish which eyes will develop glaucoma.
FDA authorizes a three-site US feasibility study of an investigational ab externo uveal spacer in approximately 30 patients with primary open-angle glaucoma.
iCare launches a camera-guided handheld rebound tonometer for markets outside the United States, while device-specific agreement data remain unavailable.
The UK government plans NHS Online access for home-based elements of glaucoma care and more ophthalmic surgical hubs across England.
The AMA backs classifying myopia as a disease and urges insurance coverage for treatments that can slow progression in children and adolescents.
The oldest known ocular prosthesis, discovered in a burial site in present-day Iran, dates to approximately:
A. 800 BC
B. 2800 BC
C. 400 AD
D. 1200 AD
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 EXPLANATION
The oldest known ocular prosthesis, discovered in a burial site in present-day Iran, dates to approximately:
B. 2800 BC
The artificial eye from Shahr-i Sokhta in present-day Iran dates to roughly 2900 to 2800 BC, making 2800 BC the closest answer. It was found in a woman's burial and is described in the site's UNESCO documentation.
Fine gold lines on its surface were arranged to resemble tiny vessels, and holes at the sides allowed it to be secured. The workmanship makes the object more than a simple placeholder: its makers were trying to reproduce recognizable features of an eye.