This Week in Ophthalmology — Jul 11, 2026

Welcome to This Week in Ophthalmology. This week we are covering ten notable papers spanning three major areas: optimizing glaucoma monitoring and preventative therapies, refining safety and outcomes in retinal disease management, and understanding patient-centered trajectories in ocular surface and systemic inflammatory conditions. Let's dive in.

We begin with new clinical insights into glaucoma management, starting with a large-scale cohort study published in JAMA Ophthalmology that investigates the role of systemic nicotinamide supplementation in patients with ocular hypertension [1]. Ocular hypertension is a primary risk factor for primary open-angle glaucoma, and while nicotinamide has shown neuroprotective potential in laboratory models, real-world data have been limited. This study evaluated deidentified electronic medical records from a federated research network of sixty-seven United States healthcare organizations between March 2006 and March 2026, matching over fourteen hundred patients taking nicotinamide with an equal number of controls. The propensity score-matched sample had a mean age of approximately fifty-four years, and about fifty-nine percent were female. Over a mean follow-up of nearly four years, the researchers found that primary open-angle glaucoma was diagnosed in only three and a half percent of the nicotinamide group compared with nine percent of the control group, representing an absolute risk reduction of five and a half percent. Furthermore, patients taking nicotinamide were less likely to initiate topical intraocular pressure-lowering therapies, with a rate of roughly fourteen percent compared to twenty-one percent in the control group. They were also less likely to undergo laser trabeculoplasty, which was performed in point eight percent of the nicotinamide group compared to nearly two percent of the control group. These findings suggest that nicotinamide could serve as a valuable, low-risk adjunctive strategy to delay disease progression in ocular hypertension, though prospective randomized trials are needed to confirm these benefits.

Next, we turn to the practical utility of visual field testing. Writing in the journal Ophthalmology, researchers evaluated whether the ten-dash-two visual field test provides additional value over the standard twenty-four-dash-two test for detecting central visual field progression in early glaucoma [2]. In a prospective longitudinal study of ninety-six early glaucoma patients and fifty-six healthy controls followed for a median of over four and a half years with up to thirteen pairs of tests, the investigators compared the central twelve points of the twenty-four-dash-two test directly against the ten-dash-two test. When looking at global or quadrant mean deviation slopes, there was no significant difference between the two tests in their ability to distinguish glaucoma progression from healthy controls. At a ninety percent specificity for the global mean deviation slope, the overlap in patients classified as progressing with both tests was only fifty-three percent. However, pointwise analysis revealed that the ten-dash-two test was superior at detecting progression when using steeper slope cut-offs of negative one point two five decibels per year or worse. Patients who showed progression exclusively on the ten-dash-two test tended to have worse central visual field loss at baseline. For the practicing clinician, this suggests that while routine ten-dash-two testing may not be necessary for all early glaucoma patients, it remains highly valuable for monitoring individuals who present with pre-existing, localized central defects.

This need for targeted monitoring is further emphasized by a long-term cohort study published in The British Journal of Ophthalmology, which followed two hundred and seventy-four Asian patients with normal-tension glaucoma for an average of thirteen years [8]. The patients were treated with topical medications and followed for more than five years. The researchers sought to characterize fast progressors, defined as those losing more than one decibel of mean deviation per year. Approximately eleven percent of the cohort fell into this fast-progressing category, experiencing an average loss of over one point six decibels per year, while sixteen percent showed moderate progression, and seventy-three percent exhibited slow progression. The study identified two primary modifiable risk factors associated with this rapid decline: the presence of disc hemorrhage and an insufficient percentage reduction in intraocular pressure. Notably, progressors with disc hemorrhage exhibited significantly faster functional progression compared with those without disc hemorrhage. Clinically, this reminds us that normal-tension glaucoma is not always a slow-moving disease, and the detection of a disc hemorrhage should prompt clinicians to aggressively lower intraocular pressure, even when baseline pressures appear normal.

Moving to the posterior segment, we examine the real-world performance and safety of advanced retinal therapies. A systematic review and meta-analysis in Survey of Ophthalmology evaluated post-approval outcomes of voretigene neparvovec, also known as Luxturna, which is the first approved gene therapy for patients with biallelic RPE65-mediated inherited retinal disease [5]. The pooled analysis confirmed that real-world patients experience statistically significant improvements in full-field stimulus testing of two point two log decibels and a small but significant improvement in visual acuity of point zero eight logMAR, which actually exceeds the visual acuity changes observed in the pivotal phase three clinical trial. However, the meta-analysis also highlighted a safety concern not formally documented in the clinical trials: chorioretinal atrophy occurred in thirty percent of patients overall, and in half of the patients, it occurred outside the retinotomy site. While the long-term clinical significance of this atrophy remains uncertain, it underscores the necessity of close, ongoing fundus surveillance in all patients receiving gene therapy.

In intermediate age-related macular degeneration, identifying reliable imaging biomarkers for progression to geographic atrophy is a major clinical focus. A study in the American Journal of Ophthalmology used swept-source optical coherence tomography to investigate whether hyporeflective core drusen are associated with the onset of large choroidal hypertransmission defects, which serve as a surrogate for atrophy [10]. Evaluating one hundred and seventy-one eyes from one hundred and twenty-one patients over a median of nearly five years, the researchers found that eighty-two eyes developed at least one large hypertransmission defect during follow-up. However, the total area of hyporeflective core drusen was not a significant independent predictor of progression to atrophy in univariable or multivariable Cox regression models. Instead, the risk of developing large hypertransmission defects was driven primarily by the presence of calcified drusen, regardless of whether they contained hyporeflective cores. This suggests that while advanced imaging algorithms can segment subtle drusen characteristics, clinicians should maintain their primary focus on broader calcification patterns when risk-stratifying intermediate macular degeneration.

Patient safety in the operating room remains paramount, particularly regarding the use of intraocular gases. A study in The British Journal of Ophthalmology analyzed national patient safety incident databases in England alongside a surgeon survey to address errors in the preparation and dilution of fluorinated gases during vitreoretinal surgery [3]. Out of forty-seven reported incidents, twenty-nine involved incorrect gas concentrations, with fourteen resulting in moderate to severe harm, including eight cases of blindness or severe visual impairment. These devastating outcomes, often caused by the inadvertent administration of pure, undiluted gas leading to central retinal artery occlusion, are entirely preventable. Among one hundred and eight surgeon respondents, nearly thirty-nine percent recalled at least one significant complication related to incorrect gas concentration. The expert panel recommends standardizing dilution protocols, implementing mandatory two-person verification steps, utilizing color-coded labeling, and employing postoperative patient safety wristbands or cards to prevent these catastrophic surgical errors.

The risk of acute vascular occlusion is also the subject of a large-scale retrospective cohort study in Ophthalmology Retina, which analyzed the five-year probability and predictors of fellow-eye involvement after a unilateral retinal artery occlusion [6]. Utilizing the TriNetX database of over nineteen thousand patients in the United States, the study found that fellow-eye occlusion occurred in approximately four percent of central retinal artery occlusion patients and over three percent of branch retinal artery occlusion patients within five years, with central retinal artery occlusion carrying a significantly higher risk. Notably, these events were highly front-loaded, with the risk rising most rapidly within the first three months. The study also revealed a strong concordance in subtype, meaning patients with an initial central occlusion almost always developed a central occlusion in the fellow eye. In patients with central retinal artery occlusion, key baseline predictors of bilateral disease included carotid stenosis, cerebral infarction, hypertension, diabetes, and sleep apnea. These findings emphasize the critical importance of immediate, comprehensive cardiovascular workups and close bilateral surveillance in the acute post-occlusion period.

Next, we look at patient-reported outcomes and surgical techniques in the anterior segment. A prospective, multicenter cohort study published in JAMA Ophthalmology characterized longitudinal pain trajectories in over three hundred patients undergoing bilateral LASIK or photorefractive keratectomy [7]. While nearly twenty-nine percent of patients reported no clinically relevant pain and forty-four percent experienced pain only on the first postoperative day, roughly eighteen percent suffered from prolonged pain lasting three to six months. This prolonged pain trajectory was independently associated with receiving photorefractive keratectomy, preoperative lubricating drop use, chronic low back pain, and a higher baseline dry eye symptom score. Interestingly, the presence of corneal staining at six months was actually associated with lower odds of prolonged pain, suggesting that the underlying mechanism of persistent discomfort may be neuropathic rather than purely related to ocular surface dryness. This highlights the value of preoperative screening for chronic pain conditions and dry eye symptoms to better counsel and manage patients at risk for prolonged postoperative pain.

For patients suffering from severe corneal anesthesia or neurotrophic keratopathy, restoring sensation is vital to prevent corneal perforation. A systematic review in the American Journal of Ophthalmology compared the clinical outcomes of using autologous nerve grafts versus processed nerve allografts for indirect corneal neurotization [9]. Analyzing eleven studies representing one hundred and fifty eyes, the authors found that both graft types led to substantial improvements in corneal sensation, with mean Cochet-Bonnet esthesiometry scores increasing from baseline in both cohorts. Visual acuity improved in over sixty percent of patients in both groups, and persistent epithelial defects resolved in the majority of cases. While autografts carried a small risk of mild donor-site morbidity, no graft rejections were reported in the allograft group. Given the lack of clear superiority of one technique over the other, the choice of graft can be tailored to surgeon preference and graft availability, though higher-quality comparative trials are still needed.

Finally, we address systemic management strategies for non-infectious uveitis. A multicenter cohort study in Ophthalmology compared the five-year risk of systemic complications in patients treated with biologic therapies versus conventional immunomodulatory therapies [4]. Using propensity score matching on data from the TriNetX network, the researchers found that compared to no systemic therapy, biologic treatment was associated with higher five-year risks of serious infections, such as pneumonia and sepsis, as well as hematologic cytopenias. When compared directly to conventional immunomodulatory therapy, biologics demonstrated a broadly comparable five-year safety profile, with the primary exceptions of higher rates of cytopenias, psychiatric illness, and all-cause hospitalization. These findings support a cautious, stepwise approach to immunosuppression in uveitis, emphasizing the need for regular hematologic monitoring and vigilant infection surveillance when escalating patients to biologic agents.

If you only have time for one paper this week, make it the cohort study on nicotinamide supplementation in ocular hypertension published in JAMA Ophthalmology [1]. This study provides the first large-scale, real-world evidence that a simple, low-cost oral metabolic supplement is associated with a substantial reduction in the risk of primary open-angle glaucoma conversion and a delayed need for subsequent medical or surgical interventions, offering a highly practical adjunctive option for our ocular hypertension patients.

Here are the key takeaways from this week in Ophthalmology. First, systemic nicotinamide supplementation is associated with a significant reduction in the risk of primary open-angle glaucoma conversion and delayed treatment escalation in patients with ocular hypertension, suggesting a potential role as a low-risk, oral adjunctive therapy. Second, routine ten-dash-two visual field testing does not offer additional benefit over twenty-four-dash-two testing for detecting global progression in early glaucoma, but it remains highly valuable for pointwise monitoring in patients with pre-existing central defects. Third, the real-world use of voretigene neparvovec gene therapy is associated with high rates of chorioretinal atrophy, occurring in up to half of patients outside the retinotomy site, which necessitates vigilant, long-term funduscopic monitoring. Fourth, the risk of fellow-eye involvement after a unilateral retinal artery occlusion is significant, highly front-loaded within the first few months, and strongly predicted by systemic vascular risk factors, emphasizing the need for immediate systemic workup and close bilateral follow-up. Fifth, roughly eighteen percent of patients undergoing laser refractive surgery experience prolonged postoperative pain lasting three to six months, with risk factors including photorefractive keratectomy, pre-existing dry eye symptoms, and chronic systemic pain conditions.

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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