Four articles. Four minutes. | Issue #9
Surgery: Hydrus slows visual field progression by nearly 45% in HORIZON, with the benefit driven primarily by superior medication-free IOP control
Diagnostics: Low minimum 24-hour BP linked to faster RNFL loss in POAG
Epidemiology: Denosumab (RANKL Inhibitor) associated with lower risk of OHT and POAG than bisphosphonates in osteoporosis patients
Health Systems: Medicare payment cuts coincided with a MIGS shift from stents to goniotomy
Effect of intraocular pressure control on visual field progression in the HORIZON trial.
Methods
This post hoc analysis of the 5-year HORIZON trial included 517 eyes with mild to moderate primary open-angle glaucoma undergoing cataract surgery alone or combined with Hydrus microstent. Using a novel Bayesian model designed to minimize the effects of perimetric noise and learning effects, investigators examined the relationship between multiple measures of IOP control, including postoperative IOP, day-1 IOP, washed-out IOP, and peak washed-out IOP at year 1 and 2, and rates of visual field (VF) mean deviation (MD) progression over 5 years to determine which aspects of IOP control best explained the visual field preservation observed with Hydrus implantation.
Results
VF progression was substantially slower in the Hydrus group (-0.30 vs -0.55 dB/year, 44.6% reduction, p=0.004). The difference persisted after adjustment for mean postoperative IOP (p=0.002) and after removing eyes with day-1 IOP spikes (p=0.001). In contrast, adjustment for washed-out mean and peak IOP almost completely abolished the treatment effect, indicating that superior medication-independent IOP control largely explained the VF advantage.
Conclusion
The HORIZON VF benefit appears to arise not from lower measured clinic IOP, but from better continuous and medication-independent IOP control achieved with the Hydrus Microstent.
Our Angle
The most important clinical message from this study is that two patients with identical clinic IOPs may have very different risks of progression depending on how that pressure is achieved and how well it is controlled outside the clinic setting. Hydrus appears to reduce the burden of unmeasured IOP elevation by providing continuous outflow enhancement that is independent of medication adherence, dosing schedules, treatment escalation, and diurnal fluctuations. This may explain why the VF benefit persisted despite nearly identical medicated clinic IOPs between groups. For clinicians who have historically viewed trabecular MIGS primarily as a medication or IOP-reduction strategy, these findings support a broader paradigm: appropriately selected Schlemm canal MIGS may function as an early interventional glaucoma strategy capable of preserving visual function over time.
More broadly, this study adds to a growing body of evidence from HORIZON and LiGHT suggesting that the quality, consistency, and treatment independence of IOP control may matter as much as the absolute clinic IOP itself. Future MIGS studies should therefore move beyond traditional endpoints such as mean IOP reduction and medication burden and incorporate VF progression, treatment escalation, and long-term disease preservation as primary measures of success.
Diagnostics
Association between 24-Hour Blood Pressure and Rates of Retinal Nerve Fiber Layer Progression in Glaucoma: The Vascular Imaging in Glaucoma Study.
Design: Prospective cohort study
Journal: American Journal of Ophthalmology, June 2026
Authors: Zhou et al.
Among 79 eyes from 42 patients with primary open-angle glaucoma followed for about 43 months, lower baseline 24-hour ambulatory blood pressure was associated with faster OCT retinal nerve fiber layer thinning. The association was most evident for minimum mean arterial, systolic, and diastolic values. For patients progressing despite acceptable IOP, the findings support asking about systemic hypotension and coordinating with the primary clinician, although the small, single-center, observational design with baseline-only ambulatory monitoring cannot establish that changing systemic therapy will slow glaucoma.
Epidemiology
RANKL Inhibition and the Risk of Ocular Hypertension and Primary Open-Angle Glaucoma.
Design: Retrospective cohort study
Journal: Investigative Ophthalmology & Visual Science, June 2026
Authors: Tsai et al.
In a multinational TriNetX cohort of 94,624 propensity-matched adults with osteoporosis, RANKL inhibitor denosumab use was associated with 28% lower risk of ocular hypertension (HR 0.72, 95% CI 0.59-0.88) and 37% lower risk of primary open-angle glaucoma (HR 0.63, 95% CI 0.53-0.75) than bisphosphonate therapy. The association was consistent across most demographic and clinical subgroups including steroid users and patients without diabetes. The authors propose that inhibition of the RANKL/RANK/NF-kB inflammatory pathway may reduce trabecular meshwork fibrosis and retinal ganglion cell neuroinflammation. However, the study was retrospective and based on administrative coding without clinical ophthalmic data such as IOP, VF, optic nerve imaging, or medication adherence information, causality cannot be established and residual confounding remains possible.
Health Systems
Comparing national microinvasive glaucoma surgery procedure rates in response to Medicare and industry payment changes.
Design: Retrospective claims-based policy study
Journal: Ophthalmology Glaucoma, June 2026
Authors: Gulani et al.
In a 20% Medicare Part B sample, investigators examined 260,242 glaucoma procedures performed between 2018 and 2023 to assess how the 2022 payment cut for trabecular bypass stents from roughly $500 to $34 was followed by a 33% decline in stent use. Goniotomy rose 61% and canaloplasty rose 19% over the same period, while total MIGS volume stayed relatively stable. Stent manufacturers increased physician transfer-of-value payments more than eightfold, yet stent utilization still declined across all payment tiers. The analysis suggests that reimbursement policy exerts a stronger influence on procedural selection than industry incentives when clinically substitutable procedures exist, although the observational design, reliance on administrative coding, lack of patient-level clinical data, exclusion of research-related industry payments, and inability to establish causality remain important limitations.
Thea launches Zolymbus, a preservative-free bimatoprost gel for open-angle glaucoma and ocular hypertension, offering a benzalkonium-free prostaglandin option for patients with ocular surface sensitivity.
Zeiss partners with Envision Health Technologies to develop gamified, VR-based visual field testing for glaucoma, aiming to make perimetry more patient-friendly than standard automated testing.
Nicox reports positive Chinese regulatory feedback for NCX 470, a nitric oxide-donating bimatoprost drop that lowers intraocular pressure through two pathways, as a United States new drug application is also planned.
Belite Bio completes a rolling FDA submission for tinlarebant, an oral once-daily therapy for Stargardt disease type 1, after its phase 3 DRAGON trial reportedly slowed retinal lesion growth versus placebo.
In the original 1991 Science paper introducing OCT, the authors compared OCT's imaging concept most closely to which older modality?
A. Ultrasound pulse-echo imaging
B. Scanning laser ophthalmoscopy
C. Magnetic resonance imaging
D. Scheimpflug photography
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: A