Delayed presentation remains a major contributor to visual impairment and blindness across diverse ophthalmic diseases, particularly in resource-limited settings where barriers to timely eye care remain substantial. Although advanced disease at presentation is widely recognized clinically, the broader biologic, neurodegenerative, developmental, surgical, and health systems consequences of delayed ophthalmic care have received comparatively less integrated attention. We examine delayed ophthalmic presentation as a multidimensional process that may influence inflammatory activity, ischemic injury, fibrosis, neurodegeneration, tissue remodeling, therapeutic responsiveness, and long-term visual outcomes across ophthalmic subspecialties. We further evaluate the clinical implications of delayed presentation in glaucoma, cataract, retinal disease, microbial keratitis, ocular trauma, pediatric ophthalmology, and ocular oncology, while examining the socioeconomic, geographic, behavioral, and health system determinants that contribute to delayed care. Emerging context responsive strategies involving decentralized ophthalmic services, teleophthalmology, integrated referral systems, and earlier disease detection are also discussed. Delayed ophthalmic presentation should therefore be considered not merely as a temporal delay in healthcare seeking behavior, but as a complex biologic and systems level determinant of ophthalmic disease progression and visual prognosis.

Diabetic retinopathy is a leading cause of vision loss in adults with diabetes, and the role of systemic fibrate therapy in its prevention and progression remains debated. We performed a systematic review and meta-analysis to evaluate the effect of fibrates on diabetic retinopathy development and progression, distinguishing randomized from non-randomized evidence. We searched PubMed, Scopus, and Web of Science from inception to August, 2025, and included 31 studies (17 development, 15 progression). Trials enrolling mixed populations were extracted by baseline retinopathy status. Random-effects pooling of 2 randomized trials showed no evidence of a benefit of fenofibrate for incident diabetic retinopathy (odds ratio 1.00, 95% confidence interval 0.70-1.43; low certainty). This estimate is imprecise and cannot exclude a modest protective or harmful effect. Five randomized trials in patients with established disease showed reduced overall progression (odds ratio 0.56, 95% confidence interval 0.42-0.74; moderate certainty) and reduced progression to diabetic macular edema (odds ratio 0.52, 95% confidence interval 0.36-0.74; moderate certainty). Adjusted estimates from non-randomized studies were directionally consistent. These findings support a stage-specific role for fenofibrate in patients with established diabetic retinopathy, particularly to reduce progression to diabetic macular edema, while the evidence for primary prevention remains inconclusive.

Teprotumumab, the first approved therapy for thyroid eye disease, is highly effective, but has been increasingly associated with otologic adverse events, prompting a United States Food and Drug Administration warning regarding hearing impairment in 2023. Reported incidence varies widely across studies, and the true burden of toxicity remains uncertain. We conducted a systematic review and meta-analysis of PubMed/MEDLINE, Embase, and Cochrane CENTRAL from inception through May, 2026 (PROSPERO CRD420261337579), identifying 22 eligible studies (5 randomized controlled trials and 17 observational studies) comprising 856 teprotumumab-treated patients. The pooled incidence of any otologic adverse event was 27.3% (95% CI, 20.8-34.3%), including subjective hearing loss, tinnitus, aural fullness, and autophony. Clinically significant ototoxicity occurred in 7.7% (95% CI, 3.1-13.8%), while objective audiometric ototoxicity was detected in 20.0% (95% CI, 10.0-32.0%) of patients undergoing serial audiometric monitoring. Compared with placebo, teprotumumab increased the risk of otologic adverse events nearly four-fold (risk ratio, 3.6; 95% CI, 1.3-10.1). Among affected patients, 39.0% (95% CI, 18.0-62.0%) had persistent impairment at last follow-up. Ascertainment method was the major source of between-study heterogeneity, with active surveillance identifying substantially higher event rates than passive reporting (42.0% vs. 20.0%). Preexisting hearing loss, older age, and diabetes were associated with increased risk. Although overlap-adjusted findings were consistent, heterogeneity in design, ascertainment, definitions, and follow-up means these estimates should be regarded as approximate rather than definitive. These results support baseline audiometric assessment, active symptom surveillance during treatment, and informed counseling regarding the potential for persistent hearing impairment. REGISTRATION: PROSPERO CRD420261337579.

Expanded polytetrafluoroethylene (ePTFE) has evolved from its origins as an industrial polymer into a biomedical material with a range of demonstrated uses across cardiovascular, hernia repair, and ophthalmology. Its application in ophthalmology has expanded significantly over the past few years owing to its unique physical and chemical properties, including its biocompatibility, inertness, bio-integration, mechanical and chemical stability, high tensile strength, and softness. The earliest ophthalmic applications of ePTFE focused on corneal perforation repair and keratoprosthesis scaffolds, followed by its use in ocular surface reconstruction, scleral buckling, and eyelid procedures. In current products under development, ePTFE has demonstrated unique capabilities in a novel keratoprosthesis and a novel glaucoma shunt. Modifications tailored for ophthalmic applications were made to the ePTFE to optimize pore size for biointegration, reduce thickness and profile, and incorporate hydrophilic coating to enhance tissue integration and cosmesis. The modifications promise to combine the best attributes of ePTFE engineered to address unmet needs in ophthalmology. Continued clinical trials and translational research are essential to expand its safety and efficacy profile. We provide an up-to-date overview of the physicochemical properties and surgical uses of ePTFE in ophthalmology.

Orbital diseases-including thyroid eye disease, tumors, inflammation, fractures, vascular lesions, infections, and congenital abnormalities-are uncommon but clinically consequential. Because orbital diseases are heterogeneous and generate multimodal data, artificial intelligence (AI) is well-positioned to support their evaluation and management. We explore the current relationship between AI and orbital diseases and propose future directions. Four questions are addressed. First, why do orbital diseases need AI? Current orbital care remains limited by manual, observer-dependent measurements, multimodal imaging that complicates decision-making, and disparities in access to orbital expertise. Second, why is the orbit technically ready for AI? Orbital diseases generate rich visual and multimodal data; most core tasks are also image-based, anatomically defined, and measurable. Third, what has AI already achieved? Applications are summarized in diagnostic assistance, segmentation, and measurement, ocular sign detection, activity and severity assessment, treatment response prediction, surgical assistance, and medical education. Finally, what are the gaps in orbital AI, and where should the field go next? Barriers related to data scarcity, privacy, and multimodal integration are discussed. For future development, we propose a 3-tiered roadmap comprising OrbitBank, OrbitFM, and OrbitAgent. These represent short-, medium-, and long-term directions, progressing from multicenter data infrastructure and privacy-preserving collaboration to multimodal foundation models and, ultimately, clinician-supervised agentic systems for more standardized and precise orbital care.

Glaucoma is the leading global cause of irreversible blindness, with primary open-angle glaucoma (POAG) its most prevalent subtype. While elevated intraocular pressure is a major risk factor, glaucoma progression is multifactorial, influenced by genetic, environmental, vascular and mechanical factors. Genetic polymorphisms have been linked to both POAG susceptibility and progression, yet most studies focus on risk factors for disease onset rather than progression. We provide an overview of the current literature on gene polymorphisms associated with POAG progression. We conducted a systematic search following PRISMA guidelines in MEDLINE, EMBASE, Web of Science, Cochrane Library, Scopus and Public Health Genomics and Precision Health Knowledge Base. Eligible studies investigated associations between genetic variants and structural or functional markers of glaucoma progression in adult-onset POAG patients. Eighteen articles were included. HLA class I haplotypes (A1-B8 and A2-B40) and MYOC.mt1+ carriers showed faster progression of optic nerve head damage. The APOE ε4 allele was linked to faster macular thinning in normal tension glaucoma patients. BDNF rs6265 Val/Val homozygotes exhibited accelerated retinal nerve fiber layer loss, particularly in females. TGFBR3-CDC7 (rs1192415: G) and MYOC.mt1+ carriers experienced accelerated visual field deterioration. Carriers of GAS7 (rs9913911: AA), IL1B (rs1143627: CT and rs16944: CT) and OPTN (rs2234968) had a higher likelihood of requiring surgery. Variants in ABCA1, CDKN2B-AS, eNOS and Piezo1 showed inconclusive results. These findings support a role for genetic polymorphisms in POAG progression and highlight the potential of genetic screening to identify patients at increased risk for rapid disease progression.

Patients with hemorrhagic posterior vitreous detachment (hPVD), defined as concomitant PVD and vitreous hemorrhage, are at heightened risk of retinal breaks (RBs) and detachment (RD). Despite this, patients are routinely given the option between conservative management and early intervention with vitrectomy, as no consensus has been reached regarding the superiority of either strategy. Herein, we provide a scoping review of the current evidence regarding the risk of RBs and RD and management of patients with hPVD. Findings suggest that 30-60% of patients with hPVD may suffer from retinal breaks and are therefore at risk of retinal detachment. Several studies, however, report no appreciable differences in visual outcomes between patients with hPVD that are treated with early surgery and those managed conservatively. Ultimately, various factors may impact management strategy in this clinical context, and we provide a nuanced summary of pertinent factors.

Across Europe, children living with low vision often face inconsistent approaches to the assessment of their visual function, leading to delays in diagnosis and unequal access to care. To address this gap, a multidisciplinary group of experts from 8 European countries developed a clinical consensus statement (CCS), using a modified Delphi process. This CCS provides guidance on evaluation of primary visual functions in children with low vision, regardless of etiologies. Assessing visual function can be challenging and cannot be limited to testing visual acuity. It requires a comprehensive approach that takes into account the child's developmental age and necessary adjustments for vision loss. This consensus statement presents different validated tools to evaluate visual acuity, contrast sensitivity, visual field, and color vision. It provides practical guidance for their use across developmental stages, including infancy and in children with syndromic or neurodevelopmental conditions, and highlights the critical role of caregivers in ensuring reliable assessments. The recommendations emphasize the need for age-appropriate testing strategies, tailored adaptations for low vision and additional impairment, and the importance of early assessment to support timely habilitation and optimize developmental outcomes.

Iridocorneal endothelial (ICE) syndrome is a rare acquired anterior segment disorder characterized by abnormal proliferation and migration of corneal endothelial cells, leading to progressive angle closure, iris abnormalities, secondary glaucoma, and corneal decompensation. Historically divided into Chandler syndrome, progressive iris atrophy, and Cogan-Reese syndrome, ICE is now recognized as a disease spectrum with a shared pathophysiologic basis. Diagnosis and management remain challenging because of variable clinical manifestations and progressive vision-threatening complications. We provide a comprehensive review of ICE syndrome, presenting an updated overview relevant to ophthalmologists on epidemiology, pathogenesis, multimodal diagnosis, differential diagnosis, and current management strategies while highlighting emerging molecular insights and future therapeutic directions.

No light perception (NLP) vision is the most severe measurable level of visual loss. Recovery is widely understood to be possible in some settings, but its probability has never been quantified across etiologies. Following PRISMA 2020 and MOOSE guidelines (PROSPERO: CRD420261337887), we searched 4 databases from inception to March 11, 2026. The search captured a broad, prespecified range of ocular etiologies, but only open globe injury (OGI), traumatic optic neuropathy (TON), and autoimmune optic neuritis yielded NLP-specific subgroups large enough to pool. Of 37 included studies, 24 (1339 eyes) entered quantitative synthesis. Pooled recovery to light perception or better was 43.3% (95% CI: 33.8-53.1%), with considerable heterogeneity (I[2] = 89.8%); recovery was strongly etiology-dependent: autoimmune optic neuritis 92.1%, TON 44.6%, OGI 37.4%. Recovery to ≥ 20/200 occurred in 12.1% of eyes and to ≥ 20/40 in 1.5%. Certainty of evidence was very low. NLP is therefore not a single prognostic entity: the probability of recovery differs roughly 2- to 3-fold by etiology, while recovery of functional acuity remains uncommon irrespective of cause. Prognosis should be framed by mechanism rather than by acuity alone.

Subretinal surgery has evolved from a niche indication for choroidal neovascular membrane excision to a versatile microsurgical platform enabling gene and cell therapy delivery, submacular hemorrhage displacement, and removal of subretinal fibrosis or proliferative vitreoretinopathy membranes. Across these indications, the creation of a controlled subretinal bleb and atraumatic manipulation of the neurosensory retina are the technical cornerstones. Recent advances - including intraoperative optical coherence tomography, high-gauge instruments, and robotic assistance - have markedly improved surgical precision and safety. We summarize current subretinal surgical applications, describing the principles, techniques, and clinical evidence underlying each, as well as common complications and future directions toward standardized, image-guided, and robotic subretinal intervention.

Outflow facility is one of 4 parameters of aqueous humor dynamics that together determine the intraocular pressure (IOP). Specific abnormalities in tissues in the drainage pathways that reduce outflow facility are the main causes of pathologic IOP elevation. As most new treatments for elevated IOP target these tissues, accurate assessment of outflow facility is of crucial importance in understanding glaucoma and efficacy of treatments. Outflow facility is measured noninvasively in humans primarily by a tonographic method and less often by a fluorophotometric method. These clinical research methods are used to study and understand the physiology and pathology of the eye and could be applied to personalize management and therapy for patients with glaucoma. We discusse these 2 methods, summarize important clinical findings from this outflow facility data, discusse the need for standardizing the methods, and provide our thoughts on future approaches for clinical adoption.

Optic disc melanocytoma (ODM) is a benign pigmented tumor historically regarded as stationary. ODM can produce visual dysfunction and rarely undergoes malignant transformation. We synthesize evidence on predicting visual field defects and recognizing malignant transformation. Optical coherence tomography angiography (OCTA) studies demonstrate that visual field defects correlate more strongly with absent intratumoral blood vessel networks than with tumor size. A validated threshold of capillary density loss > 0.75% per year identifies patients at increased risk of visual field progression. OCTA measurements demonstrate high intra-device reproducibility (intraclass correlation coefficients >0.8) but poor inter-device reliability, requiring strict standardization. Regarding malignant transformation, a synthesis of case series indicates a rate of approximately 1.7%, with transformation potentially occurring decades after diagnosis. OCTA detects malignant transformation through identification of intrinsic tumor vasculature. In choroidal studies, intralesional vessel diameter ≥ 76.3μm has demonstrated 100% sensitivity and specificity for distinguishing melanoma from nevus; however, ODM-specific validation is needed. Key warning signs include progressive tumor growth, unexplained vision loss, vitreous seeding, and intrinsic tumor vasculature. Evidence-based surveillance protocols recommend imaging every 3-6 months for the first 2 years after detection of high-risk features, then annually if stable. These findings support long-term surveillance with multimodal imaging and standardized quantification protocols.