Aim: To evaluate the efficacy and safety of XEN® 45 gel stent implantation with a new surgical approach by ab externo transconjunctival technique. Materials and methods: A total of 31 eyes of 31 patients affected with primary open-angle glaucoma (POAG) were treated with an ab externo transconjunctival approach. All the XEN gel stent implantations were performed at the Department of Ophthalmology of the Hospital of San Severino Marche, AV3- Asur Marche, Macerata, Italy between January 2021 and May 2021, and the follow-up duration was at least 6 months. Results: A total of 31 eyes of 31 patients (mean age 65.6 ± 12.3 years; 20 males and 11 females) were included in the study. All the patients were affected by POAG. The mean intraocular pressure (IOP) was 25.3 ± 3.8 mm Hg, and the mean number of IOP-lowering topical medications before surgery was 2.7 ± 0.9. No intraoperative complications were reported. During the follow-up, one patient received medical treatment for a choroidal detachment, one patient had a 2 mm hyphema, and one patient had a partial migration of the stent in the anterior chamber. At the 1-month follow-up, the mean IOP was 12.8 ± 2.5 mm Hg and no patient was on IOP-lowering treatment, while at the 3-month and 6-month follow-ups, four patients were on treatment with one IOP-lowering drug. During the follow-up period, seven patients required postsurgical bleb needling, and one patient underwent a revision with PreserFlo® Microshunt implantation. The final mean IOP was 15.9 ± 2.7 mm Hg, and 27 out of 31 patients had an IOP of <18 mm Hg. Conclusion: Ab externo transconjunctival XEN® 45 gel stent implantation represents a safe and effective surgical treatment approach. Clinical significance: The ab externo approach represents a safe and effective technique, allowing early surgical timing and widening the group of patients who could benefit from the filtrating surgical technique before many years of topical medical treatment, which causes marked conjunctival alteration.

Aim and background: The study aims to determine the accuracy of utilizing a temporal view in the detection of a shallow anterior chamber (AC), in comparison to the conventional anterior view, by evaluation of photographs of the anterior segment of the eye. Materials and methods: Two hundred fifty students who had completed basic undergraduate ophthalmology training as part of their medical education graded the AC depth in anterior segment photographs as “shallow” or “not shallow.” Each eye was photographed from the anterior and temporal views. A total of 40 photographs of 20 eyes were provided. Results: The ability to detect a shallow AC by temporal view had a sensitivity of 73.3%, compared to 63.2% in the anterior view. The specificity of the temporal view was better at 66.2% compared to the anterior view, which was 65.3%. The overall accuracy of the temporal view in detecting a shallow AC was higher than the anterior view (68.3 vs 64.7%, respectively). Combining both techniques increased the detection of a shallow AC to 88.3%. Conclusion: In our study, the temporal view was more accurate in detecting a shallow AC compared to the anterior view. Integrating the temporal view of AC depth assessment with the traditional anterior view further improves the chances of detecting a shallow AC.

Purpose: To analyze the outcomes of the iStent inject in a real-world clinical setting as a standalone procedure to lower intraocular pressure (IOP) in open-angle glaucoma. Materials and methods: Patients with open-angle glaucoma having undergone iStent inject insertion without concurrent cataract extraction were included in this multicenter observational real-world study in Australia. Patient data was entered into the Fight Glaucoma Blindness! Registry. Assessments through 12 months included glaucoma subtype, IOP, medications, best-corrected visual acuity (BCVA), secondary surgical procedures, and adverse events. Kaplan–Meier survival curves for outcomes were reported according to the World Glaucoma Association (WGA). Results: Sixty-one eyes from 44 patients with a mean age of 76 ± 11.4 underwent standalone iStent inject implantation. The mean ± SD preoperative IOP was 17.5 ± 7.5 mm Hg, and the mean preoperative number of topical medications was 2.5 ± 1.5. At 12 months postoperatively, there was no statistically significant IOP reduction, while the number of glaucoma medications used was reduced to 1.4 ± 1.5 (p < 0.001). Fourteen point one percent of eyes required a secondary pressure-lowering procedure within the 12-month follow-up window. Conclusion: This assessment of standalone iStent inject implantation did not show any significant reduction in IOP, but there was a significant decrease in medication use in the real-world clinical setting. The procedure is safe with minimal adverse outcomes; however, a subset of patients required secondary procedures within 12 months of follow-up.

Aim and background: Patients are increasingly turning to the internet to learn more about their ocular disease. In this study, we sought (1) to compare the accuracy and readability of Google and ChatGPT responses to patients’ glaucoma-related frequently asked questions (FAQs) and (2) to evaluate ChatGPT's capacity to improve glaucoma patient education materials by accurately reducing the grade level at which they are written. Materials and methods: We executed a Google search to identify the three most common FAQs related to 10 search terms associated with glaucoma diagnosis and treatment. Each of the 30 FAQs was inputted into both Google and ChatGPT and responses were recorded. The accuracy of responses was evaluated by three glaucoma specialists while readability was assessed using five validated readability indices. Subsequently, ChatGPT was instructed to generate patient education materials at specific reading levels to explain seven glaucoma procedures. The accuracy and readability of procedural explanations were measured. Results: ChatGPT responses to glaucoma FAQs were significantly more accurate than Google responses (97 vs 77% accuracy, respectively, p < 0.001). ChatGPT responses were also written at a significantly higher reading level (grade 14.3 vs 9.4, respectively, p < 0.001). When instructed to revise glaucoma procedural explanations to improve understandability, ChatGPT reduced the average reading level of educational materials from grade 16.6 (college level) to grade 9.4 (high school level) (p < 0.001) without reducing the accuracy of procedural explanations. Conclusion: ChatGPT is more accurate than Google search when responding to glaucoma patient FAQs. ChatGPT successfully reduced the reading level of glaucoma procedural explanations without sacrificing accuracy, with implications for the future of customized patient education for patients with varying health literacy. Clinical significance: Our study demonstrates the utility of ChatGPT for patients seeking information about glaucoma and for physicians when creating unique patient education materials at reading levels that optimize understanding by patients. An enhanced patient understanding of glaucoma may lead to informed decision-making and improve treatment compliance.

Aim and background: The OMNI surgical system allows for 360° canaloplasty and trabeculotomy for patients with glaucoma, either as a standalone procedure or in combination with cataract surgery. There is currently limited evidence on its use in forms of angle-closure glaucoma, though other microinvasive glaucoma surgeries have been used. We present three patients with angle closure who underwent the procedure. Methods: Retrospective review of three patients who underwent canaloplasty and trabeculotomy with the OMNI surgical system with forms of angle closure. Data on demographics, intraocular pressure (IOP), glaucoma medication use, best corrected visual acuity (BCVA), visual fields (VFs), and complications were collected for a 6-month period. Results: Three eyes of three patients underwent the procedure: one with primary angle closure glaucoma (PACG), one acute angle closure, and one primary angle closure (PAC). All had surgery combined with phacoemulsification and intraocular lens (IOL) implantation. The mean age was 56 years. Preoperative IOP was 25.33 ± 2.49 mm Hg, improving to 11.67 ± 2.87 mm Hg at 6 months. Mean glaucoma medication use was reduced by 3.00, from 3.67 ± 1.21 to 0.67 ± 0.94. Preoperative mean BCVA was 0.10 ± 0.08 and 0.20 ± 0.08 LogMAR at 6 months. Mean deviation (MD) on VFs was –9.67 preoperatively and –6.72 at 6 months. Two patients had mild, self-limiting hyphema postoperatively which resolved without further intervention; no other complications were reported. Conclusion: We have found the OMNI surgical system to be a safe, effective tool in the management of angle-closure glaucomas in a small cohort of patients. Clinical significance: The OMNI surgical system has the potential to add a less invasive surgical solution in the management of angle closure glaucoma, prior to the use of filtering surgery such as trabeculectomy or glaucoma drainage device. Larger trials assessing the use of microinvasive glaucoma surgery (MIGS) in these patients will be eagerly received.

Aim: To evaluate the efficacy and safety of MicroPulse transscleral laser therapy (MPTLT) for cyclophotocoagulation in the treatment of glaucoma with different doses of energy. Materials and methods: A retrospective review was done of 136 eyes in 90 patients treated with MPTLT between 2018 and 2022. Intraocular pressures (IOP) at follow-ups were compared with a paired student t-test and treatment outcomes with a Chi-squared test. The cohort was stratified into subgroups to analyze the effect of total applied energy on outcomes. The variance between energy groups was analyzed with the Kruskal–Wallis test adjusted for multiple comparisons. Results: A total of 136 eyes of 90 patients underwent MPTLT for mostly open angle (36.0%) and childhood glaucoma (30.1%). Applied energy range was between 37.5 and 195.6 J with a mean [standard deviation (SD)] of 100.7 (34.3) J. Applied energy of 125–200 J reduced IOP the most at 2 years with 90% of eyes within 6–21 mm Hg and 66% of eyes having IOP reduced at least 20% (p < 0.001) from baseline. However, at 2 years, energy 50–75 J achieved fewer eyes with two or more Snellen lines lost than energy 125–200 J and a lower proportion of eyes with at least one symptom (p < 0.05). No severe complications of hypotony, phthisis bulbi, or chronic inflammation were reported. Conclusion: IOP reduction and safety outcome of MPTLT varied with applied energy. Doses should be adjusted to target the treatment goals for individual patients. Clinical significance: MPTLT was found to be effective in lowering IOP in glaucoma. Using high levels of energy is associated with higher rates of complications.

Aim and background: To describe a novel and uncomplicated technique of elongating the tubing of a glaucoma drainage device (GDD) sourced from a segment of the tube from a Paul® Glaucoma Implant (PGI). Surgical technique: Conjunctival and Tenon's peritomy are performed with relaxing incisions to expose the original tube. The original tube is then removed from the anterior chamber, and the original entry site is closed. The tip of the original Baerveldt/Ahmed tubing is shortened to near the plate, and the lumen is stretched open using Burke's forceps (nontoothed to avoid damage to the tubing) while the appropriate length of the Paul tube was being pushed inside and is secure without the need for any suturing. The new smaller Paul tube is then inserted back into the anterior chamber using a 26-gauge tract. An 8-0 Ethilon® was then used to secure the tube to the sclera, and TISSEL® was used to secure it (Baxter, United States). Depending on the positioning, either the original Tutoplast® pericardium or new double-layered Tutoplast® can be placed over the tube to prevent erosion. The Tenon's and conjunctiva were then closed to secure the conjunctival and Tenon's back in their original position at the limbus, and the radial conjunctival incisions can be closed using TISSEL® fibrin glue or further sutures if required. Conclusion: This method offers several benefits over previously documented techniques; it avoids significant bulkiness, and the elongated tube conforms to the curvature of the globe owing to the suitable rigidity of the extended section. The additional tubing segment fits securely without the need for sutures. Introducing a smaller diameter tube into the anterior chamber in comparison to other GDDs minimizes the surface area between the tube and corneal endothelium, therefore decreasing the rate of potential endothelium cell loss. Clinical significance: This novel “tube-in-tube” technique is efficient, safe, and straightforward to perform. It eliminates the need for alterations in glaucoma medication since the PGI is not thought to offer any flow resistance.