This Week in Ophthalmology — Aug 15, 2026

Welcome to This Week in Ophthalmology. This week we're covering 10 notable papers spanning glaucoma risk stratification, retinal imaging and pharmacotherapy, and pediatric and anterior segment practice — including two randomized trials that may change what you offer in clinic tomorrow. Let's dive in.

Let's start with glaucoma, where two papers from the American Journal of Ophthalmology tackle the same uncomfortable question: how do we know a pressure that looks fine in the office actually is fine? In a prospective cohort of 67 glaucomatous eyes, Malek and Medeiros used a standardized water-drinking test as an intraocular pressure stress test, then tracked visual field mean deviation and optical coherence tomography retinal nerve fiber layer thinning over about two years [7]. Among the 59 eyes whose office pressure sat within their severity-specific target, 37 percent of those eyes still spiked above 21 millimetres of mercury on stress testing — and those eyes lost field at roughly two-thirds of a decibel per year while the rest were, on average, stable. Even more striking, of the 13 eyes classified as fast progressors, only about a quarter would have looked out of target on office tonometry, whereas more than three quarters spiked on the water-drinking test. That association held after adjusting for office pressure, which is the key point: this is complementary prognostic information, not a restatement of what your Goldmann already told you. It is a small single-cohort study and not a trial of treatment intensification, but for the patient who keeps progressing on paper-perfect pressures, a stress test is cheap and may explain the discrepancy. Alongside that, Lee, Morales and Caprioli report long-term outcomes of selective laser trabeculoplasty in 500 eyes followed for nearly a decade [6]. Median time to failure was 4.6 years after initial treatment but only 2.7 years after repeat treatment, and failure came sooner in eyes with prior glaucoma surgery, moderate-to-advanced disease, asthma, or lower laser energy. Interestingly, higher energy intensity predicted better pressure survival yet was also associated with greater visual field progression at five years, alongside higher pre-laser medication burden and thinner corneas — a tension the authors flag rather than resolve. Practically, counsel patients that a repeat laser buys roughly half the durability of the first, and monitor advanced eyes more closely rather than assuming the laser has bought you time.

Moving to the retina, three papers address how we predict, and how we treat, macular disease. In Ophthalmology, Matar and colleagues analysed 502 eyes with intermediate age-related macular degeneration using machine-learning-enhanced layer segmentation with certified reader correction, asking which baseline optical coherence tomography features predicted two-year progression to atrophy [8]. Eyes that converted had greater ellipsoid zone attenuation, thinner ellipsoid zone to retinal pigment epithelium and outer nuclear layer measurements, higher drusen volume, and more hyperreflective foci. A random forest model using all baseline features reached an area under the curve of 0.85, with ellipsoid zone integrity and hyperreflective foci count the most influential predictors. This is not yet a clinic tool, but it tells you where to look on the scans you already have — photoreceptor layer thinning without frank retinal pigment epithelium loss is a warning sign, and these metrics are likely to define enrolment in prevention trials. In JAMA Ophthalmology, Chong and colleagues followed 205 eyes across the pachychoroid spectrum prospectively for two years [10]. The reassuring headline is that progression to a worse phenotype occurred in only about 7 percent of eyes, with no meaningful change in visual acuity or choroidal thickness overall. Neovascularization developed in just seven eyes — and every one of those had shallow, irregular retinal pigment epithelium elevation at baseline. That single imaging feature, if confirmed, is the one worth documenting when you decide follow-up intervals for pachychoroid pigment epitheliopathy or central serous chorioretinopathy. And on treatment, Ophthalmology Retina reports 48-week results from the phase 3b/4 SALWEEN trial of faricimab in 135 treatment-naïve Asian patients with polypoidal choroidal vasculopathy [4]. On a treat-and-extend regimen after loading, mean visual acuity gained about nine letters, central subfield thickness fell by roughly 127 microns, and the proportion of patients free of subretinal or intraretinal fluid rose from about 14 percent at baseline to 76 percent. Among eyes with reading-centre-confirmed lesions, about 61 percent achieved complete polypoidal lesion regression, and more than 80 percent of patients were on intervals of 12 weeks or longer, with over half assigned to 20-week dosing. Remember this is single-arm and open-label, so there is no comparator — but for a phenotype long treated with combination photodynamic therapy, durable extension on dual angiopoietin-2 and vascular endothelial growth factor-A inhibition is clinically meaningful.

Now to pediatric and anterior segment care, where the most immediately practice-relevant trial of the week appears. In JAMA Ophthalmology, Zheng and colleagues randomized 160 infants under one year with congenital nasolacrimal duct obstruction to either in-office lacrimal duct probing or standardized lacrimal sac massage taught to parents [1]. Resolution at three months was 86 percent with massage versus 84 percent with probing — a difference of 2.5 percentage points, comfortably within the prespecified noninferiority margin of minus 10 points — with no serious complications in either arm. The trade-off is speed: symptoms resolved in about one week with probing versus nearly four weeks with massage. So for the anxious parent of a six-month-old with epiphora, structured massage is a legitimate first-line alternative to instrumentation, provided you set expectations that it takes weeks rather than days. Bear in mind this was a single centre in Guangzhou over six months, and the massage was standardized and supervised. Also in Ophthalmology, a one-year double-masked three-arm trial of 225 children aged 6 to 14 compared a novel dual-sided composite defocus spectacle lens against a single-surface defocus lens and single-vision spectacles [3]. Refractive progression was 0.22 dioptres in the dual-sided group versus 0.83 with single vision and 0.45 with the single-surface lens, and axial elongation was 0.19 versus 0.42 millimetres against single vision. That works out to a 74 percent reduction in refractive progression and a 55 percent reduction in axial elongation relative to single-vision lenses. Importantly, the axial length difference between the two defocus designs was not statistically significant, so the claim of superiority over existing defocus optics rests on refraction alone at one year.

Rounding out the anterior segment, the American Journal of Ophthalmology published the largest contemporary series of uveitis-glaucoma-hyphema syndrome — 232 eyes over a decade [5]. Posterior chamber lenses accounted for 92 percent of cases, three quarters of those in the sulcus, and two thirds of the sulcus lenses were single-piece designs that should never have been placed there. Median time from surgery to diagnosis was 4.8 years, recurrence occurred in 46 percent of eyes, and although pressure and acuity improved modestly after intervention, persistent ocular hypertension remained in 59 percent of eyes — so this syndrome leaves a lasting glaucoma problem even when the mechanical cause is fixed. On the surgical side, a comparative study of 87 eyes undergoing Yamane intrascleral fixation found every formula tested — Hoffer Q, Holladay 1, SRK/T, T2, Barrett Universal II, and EVO 2.0 — produced a systematic hyperopic shift of roughly half to three quarters of a dioptre, and after constant optimization no formula outperformed another [9]. The implication is that variability in actual lens position, not formula choice, drives your refractive misses here, so consider targeting slight myopia. And briefly, a post hoc analysis of the Zoster Eye Disease Study in JAMA Ophthalmology examined whether valacyclovir's effect varies over time [2]. Recall the primary outcome was negative; this exploratory analysis found lower hazards during the treatment period and the first six months in particular, but none of these reached statistical significance. Read it as consistent with the existing one-year recommendation, not as new evidence of benefit.

If you only have time for one paper this week, make it the congenital nasolacrimal duct obstruction trial in JAMA Ophthalmology [1]. It is a properly powered randomized noninferiority comparison that lets you offer a non-invasive first-line option to a very common referral, and it will change conversations in general and pediatric clinics immediately.

Here are the key takeaways from this week in Ophthalmology. First, standardized parent-performed lacrimal sac massage matched probing for resolution at three months in infants under one year, but takes about three weeks longer to work. Second, an office pressure inside target does not exclude ongoing damage — a water-drinking stress test flagged most of the fast progressors that tonometry missed. Third, repeat selective laser trabeculoplasty lasts roughly half as long as the first treatment, and advanced eyes with high medication burden warrant closer field monitoring. Fourth, in intermediate macular degeneration, ellipsoid zone integrity and hyperreflective foci are the strongest optical coherence tomography predictors of progression to atrophy, and in pachychoroid disease, shallow irregular retinal pigment epithelium elevation was the sole feature preceding neovascularization. Fifth, faricimab maintained vision and produced complete polypoidal regression in about 60 percent of confirmed lesions with most patients extended to 12 weeks or beyond — though in an uncontrolled single-arm trial. And finally, expect a hyperopic surprise after Yamane fixation regardless of which formula you use.

That's your roundup for This Week in Ophthalmology. The full transcript and references are available on the episode page in your AudioScholar library. This is an AI-curated summary — for clinical decisions, always consult primary sources and current guidelines. See you next week.

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