Comparison of Surgical Methods for the Correction of Low Amounts of Corneal Astigmatism During Cataract Surgery

Schallhorn SC, Schallhorn JM. Ophthalmology. 2025;132(11):1202-1211. doi:10.1016/j.ophtha.2025.06.011

Question

What is the effect of various astigmatic correction methods on postoperative outcomes in a large population of eyes with preexisting corneal astigmatism of between 0.75 and 1.50 D?

Background/Summary of Findings

Residual postoperative astigmatism has negative visual effects and patient-reported outcomes. A residual manifest cylinder between 0.75 to 1.00 D increases the odds of not achieving postoperative 20/20 vision by 6 times, and a manifest cylinder between 1.25 and 1.50 D increases the odds of not achieving postoperative 20/20 vision by 20 to 30 times. Multiple strategies exist to surgically address preexisting corneal astigmatism, but no clear, evidence-based guidelines address which intervention is the most beneficial, or whether intervention is beneficial at all.

Using a retrospective design, patients undergoing cataract or refractive lens exchange with preoperative corneal astigmatism between 0.75 and 1.50 D were divided into 3 groups: eyes with implantation of a toric intraocular lens, eyes with nontoric intraocular lenses that underwent limbal relaxing incisions or astigmatic keratotomy, and the uncorrected group, which comprised eyes with nontoric intraocular lenses that did not receive any intentional corneal astigmatism correction. Data were stratified further according to the magnitude of preoperative corneal astigmatism into 3 categories: 0.75 D or more to less than 1.00 D, 1.00 D or more to less than 1.25 D, and 1.25 D or more to 1.50 D or less. A multivariable model was used to assess the effect of the procedure type on outcomes. The main outcome measures were the percentage of eyes achieving 0.50 D or less residual astigmatism and odds ratios for the likelihood of not achieving 0.50 D or less manifest astigmatism.

The study included 40 289 eyes (10 100 eyes in the toric group; 5811 eyes in the limbal relaxation or astigmatic keratotomy group; and 24 378 eyes in the uncorrected group). In the group of eyes with preoperative astigmatism of 0.75 D or more to less than 1.00 D, compared with toric intraocular lenses, the odds of not achieving 0.50 D or less manifest astigmatism increased 2.83-fold in the limbal relaxation incision or astigmatic keratotomy group and 5.72-fold in the uncorrected group. For corneal astigmatism of 1.00 D or more to less than 1.25 D, the odds increased 3.9-fold with limbal relaxation incisions or astigmatic keratotomy and 7.64-fold in eyes with uncorrected astigmatism. In the eyes with 1.25 D or more to 1.50 D or less of corneal astigmatism, the odds increased 4.70-fold and 10.27-fold for the limbal relaxation incision or astigmatic keratotomy group and uncorrected group, respectively. The presence of against-the-rule astigmatism considerably increased the odds of not achieving 0.50 D or less manifest astigmatism, mainly in the eyes with uncorrected astigmatism.

The authors concluded that the toric intraocular lens group showed the most accurate and consistent astigmatism correction, regardless of the magnitude of preoperative corneal astigmatism or axis orientation

Clinical Value/Implications

This study showed that toric intraocular lenses provided the most accurate and reliable correction of preexisting low corneal astigmatism. These results warrant consideration in preoperative patient counseling when discussing the cost-benefit analysis of intraoperative astigmatic correction.

Spontaneous Soft Drusen Regression Without Atrophy and the Drusen Ooze

Monés J, Pagani F, Santmaría JF, Garcia M, Romero C, Garcia D, Serrano A, Carrasco A. Ophthalmol Retina. 2025;9(9):828-837. doi:10.1016/j.oret.2025.02.023

Question

What is the incidence of spontaneous soft drusen regression without atrophy in patients with intermediate or atrophic age-related macular degeneration, are there associated events, and if so, how are those events explained?

Background/Summary of Findings

Age-related macular degeneration is the most common cause of blindness in the developed world in patients aged 55 years and older. Complex biological processes precede atrophy of retinal pigment epithelium and photoreceptors. Advances in the understanding of how those processes variously manifest in the intermediate stage of disease may give us insight into how to manage different patients with these various phenotypes. It is well known that a subset of atrophy cases occurs when soft drusen collapse. However, in cases where soft drusen collapse without atrophy, there exists a lack of knowledge as to why this phenomenon occurs.

Using a retrospective design, imaging of a consecutive series of 640 eyes from 320 patients with intermediate or atrophic age-related macular degeneration that were followed for greater than 2 years was reviewed. Retinal imaging included infrared reflectance imaging, fundus autofluorescence, spectral-domain optical coherence tomography, and color fundus photography. The main outcome measures included drusen regression without atrophy with integrity of the retinal pigment epithelium and repositioning over Bruch’s membrane. In addition, drusen that would collapse with atrophy in the same area simultaneously were named “sentinel.” Outcomes also included the reversibility of features of incomplete retinal pigment epithelium and outer retinal atrophy, and the areas (“halos”) of drusen without atrophy around the “sentinel” drusen.

Among 427 eyes, 53 events of drusen without atrophy were found (24.17% of the eyes with soft drusen). In 50 of those 53 eyes, a “sentinel” drusen with atrophy was found in the vicinity. In 58% of the cases there was a “halo” of drusen disappearance around the “sentinel” drusen with atrophy present.

The authors found that drusen regression without atrophy frequently occurs with soft drusen and is invariably within close proximity of a “sentinel” drusen that does undergo atrophy. The disappearance of drusen material due to retinal pigment epithelial death has been previously proposed to explain drusen with atrophy. The coalescence of drusen and the spatial and temporal association of drusen without atrophy and drusen with atrophy, the authors propose, suggests that the material from the drusen that does not atrophy escapes to the sentinel drusen, which does atrophy. This is consistent with the authors’ hypothesis of “drusen ooze” in which drusen content moves to the subretinal space through retinal pigment epithelium defects, coalescing in sentinel drusen that atrophy, and sparing the retinal pigment epithelium from where the other drusen oozed to the sentinel drusen. Given that not all soft drusen in this study were associated with atrophy, the authors suggest that therapies that target drusen material removal prior to retinal pigment epithelium disruption may potentially prevent atrophy secondary to soft drusen collapse.

Clinical Value/Implications

This study reinforces that soft drusen formation and resorption is dynamic and that atrophy may not be inevitable in all cases. If soft drusen content can be removed prior to irreversible retinal pigment epithelium damage, atrophy might be preventable. Determining which soft drusen are likely to be associated with atrophy and which are not would be an important treatment consideration in the future.

Randomized Noninferiority Trial of Direct Selective Laser Trabeculoplasty in Open-Angle Glaucoma and Ocular Hypertension: GLAUrious Study

Gazzard G, Congdon N, Azuara-Blanco A, Blumenthal EZ, Gomelauri K, Zaliniyan M, Traverso CE, Bracha Z, Dvalishvili A, Solberg Y, Belkin M, Samuelson TW; GLAUrious Study Group. Ophthalmology. 2025;132(10):1091-1104. doi:10.1016/j.ophtha.2025.05.004

Question

Is automated, gonioscopy-free, noncontact, image-guided direct selective laser trabeculoplasty noninferior to conventional selective laser trabeculoplasty in open-angle glaucoma and ocular hypertension to reduce intraocular pressure?

Background/Summary of Findings

Treatment of open-angle glaucoma is often initiated with topical hypotensives. However, adherence is a rate-limiting step to successful treatment, with an estimated 20% to 60% of patients in the United States failing to take medications as prescribed. Nonadherence is associated with progressive visual field and functional loss. Intervention with selective laser trabeculoplasty has shown to be an effective alternative to medications in open-angle glaucoma treatment and is now a recommended first-line intervention by the American Academy of Ophthalmology, the European Glaucoma Society, and the United Kingdom National Institute for Health and Care Excellence. Direct selective laser trabeculoplasty is a novel method that allows 360-degree treatment of the trabecular meshwork by delivering up to 120 laser pulses to the overlying limbal tissue. Given that direct selective laser trabeculoplasty is both automated and noncontact, its applicability by a broader range of eyecare professionals should be greater than with conventional selective laser trabeculoplasty. Hence, the GLAUrious trial was conducted to evaluate the safety and effectiveness of direct selective laser trabeculoplasty compared with conventional selective laser trabeculoplasty, based on the hypothesis that direct selective laser trabeculoplasty may provide a novel, automated treatment option for open-angle glaucoma with comparable intraocular pressure–lowering effectiveness to that of selective laser trabeculoplasty and an acceptable safety profile

This was a prospective, multicenter, randomized, controlled, evaluator-masked noninferiority trial including patients aged 40 years or older with open-angle glaucoma or ocular hypertension, on 0 to 3 hypotensive medications at screening and a washout intraocular pressure of 22 to 35 mm Hg. After washout, 192 participants were randomized 1:1 to direct selective laser trabeculoplasty (99) or selective laser trabeculoplasty (93). Intraocular pressure was assessed before treatment and through 12 months after the procedure, with washout intraocular pressure at baseline and 6 months and with the main outcome measure being the difference between direct selective laser trabeculoplasty and selective laser trabeculoplasty in mean intraocular pressure change from baseline to 6 months.

The mean standard error washout intraocular pressure reduction from baseline at 6 months was 5.5±0.5 mm Hg after direct selective laser trabeculoplasty and 6.2±0.5 mm Hg after selective laser trabeculoplasty. At 12 months, the mean standard error nonwashout intraocular pressure reduction from screening was 3.2±0.4 mm Hg after direct selective laser trabeculoplasty and 3.2±0.4 mm Hg after selective laser trabeculoplasty. Safety profiles were similar between groups, although clinically nonsignificant punctate subconjunctival hemorrhage was more frequent in the direct selective laser trabeculoplasty group. Ocular adverse events generally were mild and resolved without intervention.

The 6-month primary end point did not achieve statistical noninferiority compared with conventional selective laser trabeculoplasty, although direct selective laser trabeculoplasty was well tolerated and provided effective intraocular pressure lowering, which was sustained at 12 months. The authors concluded that direct selective laser trabeculoplasty is an effective option and can be considered first-line treatment when selective laser trabeculoplasty is not readily accessible.

Clinical Value/Implications

Although not statistically noninferior to conventional selective laser trabeculoplasty in this study, direct selective laser trabeculoplasty is clinically effective and a viable treatment option in patients with primary open-angle glaucoma and ocular hypertension. Its manner of delivery extends the accessibility of laser trabeculoplasty to patients that otherwise would not have had the option due to limited provider access and should be considered alongside conventional selective laser trabeculoplasty as a first-line treatment option.

Associations Between Clustered Visual Field Progression and Locations of Disc Hemorrhages in Glaucoma

Akagi T, Fukuchi T, Higashide T, Udagawa S, Ohkubo S, Sugiyama K, Tanihara H, Araie M, Tomita G, Matsumoto C, Tomidokoro A, Hangai M, Kawata H, Inai M, Tanaka Y; SVF Prospector Study Group. Ophthalmol Glaucoma. 2025;8(5):528-537. doi:10.1016/j.ogla.2025.04.009

Question

Over 3 years of observation, what is the influence of disc heme location on clustered visual field progression in primary open-angle glaucoma?

Background/Summary of Findings

Disc hemorrhages are a well-established risk factor for the development and progression of glaucoma. Although numerous studies have shown local structural optic nerve deterioration associated with disc hemes, fewer have investigated the association between disc heme location and functional glaucomatous visual field progression.

This prospective multicenter cohort study followed primary open-angle glaucoma patients over 3 years. Visual field testing, intraocular pressure measurements, fundus photographs, and optical coherence tomography scans were conducted on a quarterly basis. Disc hemorrhage location was categorized as superior, inferior, temporal, and nasal. Visual field was divided into superior, inferior, and central regions with the central visual field further divided into superior central and inferior central zones. There were a total of 186 eyes from 109 patients divided into high-tension glaucoma (intraocular pressure > 21 mm Hg) and low-tension glaucoma (intraocular pressure consistently below 21 mm Hg). All patients in the study were undergoing prostaglandin analog monotherapy.

Overall, disc hemorrhage was observed in 61 of the 186 eyes (32.8%), 12 of 39 high-tension glaucoma eyes (30.8%), and 49 of 147 low-tension glaucoma eyes (33.3%). Of the 61 eyes with disc hemorrhage, inferior, temporal, superior, and nasal disc hemes were observed in 31, 21, 18, and 2 eyes. Location of disc hemorrhage was strongly associated with corresponding clustered visual field progression. Both temporal and inferior disc hemes were risk factors for faster central visual field progression. Although disc heme recurrence was observed in 37 eyes (60.7%), these patients did not exhibit faster progression on visual field over 3 years.

Clinical Value/Implications

Disc heme has a location-dependent impact on visual field progression in patients with primary open-angle glaucoma. In this study, inferior and temporal disc hemes carried a higher risk for more rapid central visual field progression. This is a significant finding and warrants further investigation as it may suggest the need for more aggressive treatment and closer follow-up in individuals with disc hemes in these areas. Furthermore, recurrent disc hemes did not show an additive effect on the rate of corresponding visual field progression, suggesting recurrence should not be the sole determinant for more aggressive intraocular pressure–lowering therapy.

Seddon JM, De D, Rosner B. Ophthalmology. 2025:S0161-6420(25)00619-0. doi:10.1016/j.ophtha.2025.09.030. Epub ahead of print.

Question

Over 5 years, does adopting a healthy lifestyle offset high genetic risk for progression to advanced age-related macular degeneration?

Background/Summary of Findings

Genetic factors contribute significantly to the risk for development and progression of age-related macular degeneration to advanced stages. Modifiable risk factors such as smoking and diet also can contribute to disease outcomes. Family members of individuals with advanced age-related macular degeneration may have questions and concerns regarding their risk for the same disease diagnosis and outcome. Previous studies on macular degeneration have established modifiable lifestyle factors associated with higher risk for disease progression. These include smoking, body mass index, daily caloric intake, and a diet rich in green leafy vegetables and fish.

In this study, an ideal health-promoting lifestyle profile was defined as adhering to each of the following healthy behaviors:

  1. Body mass index less than 25 kg/m2

  2. Caloric intake less than sex-specific median

  3. Greater than or equal to 2.7 servings/week of green leafy vegetables

  4. Greater than or equal to two 4-oz. servings of fish/week

Smoking status was defined as either never smoked or ever smoked (those who have quit and those who currently smoked). Ever smoked status was further defined into current smoking as a risk-inducing behavior and past smoking as health-promoting behavior.

Of the 898 high genetic risk eyes, 207 eyes (23%) progressed to advanced age-related macular degeneration over 5 years. Among individuals who never smoked, a high risk–inducing lifestyle was associated with a 3-fold increased risk of advanced disease, compared with an ideal health-promoting lifestyle. Among ever smokers, a high risk–inducing lifestyle was associated with a 5-fold increased incidence of advanced age-related macular degeneration. Risk-inducing lifestyle analyses showed an 8- to 12-fold higher risk for progression to geographic atrophy and a 2- to 3-fold increased risk for progression to neovascularization. High risk–inducing profile included all unhealthy behaviors evaluated (body mass index > 25 kg/m2, caloric intake > sex-specific median, fewer than 2.7 servings of green leafy vegetables per week and less than two 4-oz. servings of fish per week).

Estimated population attributable risks suggested that an ideal health-promoting profile could prevent 56% of incidence advanced age-related macular degeneration in never smokers and 60% in ever smokers. In other words, more than half of advanced age-related macular degeneration cases could be prevented among individuals with a strong family history solely by modifying lifestyle behaviors.

Clinical Value/Implications

This study found that unhealthy behaviors increased the incidence of advanced disease by 3- to 5-fold in highly genetically susceptible individuals. Smoking, high body mass index, high caloric intake, and low intake of foods rich in lutein-zeaxanthin and omega-3 fatty acids contributed to significantly higher incidence of advanced age-related macular degeneration. These findings emphasize the important role that optometrists can play in lifestyle counseling, including smoking cessation, healthy weight, avoiding high caloric intake, and incorporating foods rich in lutein-zeaxanthin (spinach, kale, collards, turnip greens, brussel sprouts, broccoli) and fishes rich in omega-3 fatty acids (salmon, sardines, mackerel, tuna, trout) into the diet of patients with a strong family history of macular degeneration. These individuals should not assume that they are predestined for a poor disease outcome as there was a 56% to 60% decreased risk for advanced age-related macular degeneration by modifying the lifestyle behaviors emphasized in the study.

Loss to Follow-up and Risk of Incident Blindness Among Patients With Glaucoma in the Intelligent Research in Sight Registry

Williams AM, Liang HW, Lin HS. Ophthalmol Glaucoma. 2025;8(6):544-552. doi:10.1016/j.ogla.2025.05.001

Question

Is there an association between loss to follow-up and risk of incident blindness among patients with primary open-angle glaucoma?

Background/Summary of Findings

Patient education regarding risk for blindness from glaucoma may include established risk factors such as severe-stage disease, older age, Black race, and higher intraocular pressure. Providers typically educate patients on the need for strict medication compliance to lower pressure and slow down disease progression; however, the issue of loss to follow-up in glaucoma is also widespread and needs to be emphasized in patient education.

The Intelligent Research in Sight Registry is the largest ophthalmic clinical registry in the United States. It identified that half of patients with primary open-angle glaucoma lapsed at least 1 calendar year without an encounter between 2014 and 2019. Only one-third of these patients returned to care after being lost to follow-up.

This retrospective longitudinal cohort study evaluated rates for incident blindness (visual acuity worse than or equal to 20/200) in 1 or both eyes in 2019 among patients who were not blind in 2014. Based on the American Academy of Ophthalmology Preferred Practice Guidelines, loss to follow-up was defined as the absence of an encounter during any calendar year within the study period.

Fortunately, most patients in the cohort were not lost to follow-up (90.0%). This was followed by 8.8% being lost to follow-up for 1 to 2 years, and 1.1% were lost to follow-up for 3 to 4 years.

Of the 149 172 patients, monocular blindness occurred in 4.2% and binocular blindness occurred in 0.5% over the 6-year period. Patients who were lost to follow-up had greater risk for blindness compared with those with no lapse in care. The risk of blindness after a lapse of 3 to 4 years was higher in Black patients than white patients. Furthermore, Black race was the only race associated with an increased risk for blindness after a lapse of only 1 to 2 years.

Of concern, patients with severe-stage disease or visual impairment at baseline evaluation were at greatest risk of loss to follow-up.

Clinical Value/Implications

Loss to follow-up was identified as an independent risk factor for blindness in this primary open-angle glaucoma population. Black patients faced a higher risk for blindness from loss to follow-up compared with any other race and were the only race who had higher risk for blindness after 1 to 2 years lapse in care. This study highlights the need to address barriers to consistent follow-up adherence and eyecare. Engaging at-risk patients with primary open-angle glaucoma is crucial for reducing these health disparities and mitigating potentially preventable blindness from loss to follow-up.