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Editors Selection IGR 23-1

Surgical Treatment: PAUL Glaucoma Implant for uveitic glaucoma: 3-year outcomes

Comment by Ewald Lindner on:

126274 The PAUL Glaucoma Implant in the management of uveitic glaucoma-3-year follow-up, Richardson J; Tacea F; Yu J et al., Eye, 2025; 39: 931-937

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The surgical management of uveitic glaucoma remains difficult, with inflammation-driven fibrosis often undermining trabeculectomy and complicating tube shunt outcomes. Richardson and colleagues provide an analysis of the PAUL Glaucoma Implant (PGI) specifically in uveitic eyes, offering valuable data on efficacy and safety.

This single-centre, multi-surgeon, retrospective series included 50 eyes of 41 patients (mean age 45.8 years, range 6–81). Preoperatively, eyes had a mean IOP of 30.6 mmHg on 3.9 medications, with 62% requiring acetazolamide and 64% systemic immunosuppression. After a mean follow-up of 35.8 months (range 5–58), IOP was reduced to 12.2 mmHg on 1.1 medications (p < 0.0001). Complete success (IOP 5–21 mmHg with ≥20% reduction without medications) was achieved in 48% of cases, while qualified success (same IOP criteria with medications) reached 92%. Failure occurred in only 8% of eyes, mostly due to uncontrolled hypertension (6%), with just one case of prolonged hypotony (2%).

These results are impressive in the context of uveitic glaucoma, where high surgical failure rates are the rule rather than the exception. The PGI’s design—with a smaller internal tube lumen and large plate area—may balance safety and efficacy, helping explain the low hypotony rate.

However, several caveats remain. The retrospective design, lack of a control group, and heterogeneity of uveitic etiologies and systemic therapies limit generalizability. It is also unclear whether outcomes differed between eyes with quiescent versus active inflammation at surgery, an important determinant of long-term success.

In summary, this study provides encouraging evidence that the PGI is a promising option in complex uveitic glaucoma, achieving substantial IOP reduction and medication independence with relatively few complications. Prospective multicenter trials with standardized uveitis grading and comparative arms will be crucial to establish its role alongside established devices.

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