STRETCH study explained

Published on: January 19, 2026 with help of ChatGPT to organise my thoughts by Dr Muhammad Azeem

Intravitreous HPMC for Hypotony: Promise, Caution, and the Pakistani Context

A recent innovation being discussed widely in ophthalmology circles across the world is the use of intravitreal HPMC in selected cases of hypotony. Interest in this approach grew after the initial results from the STRETCH study, conducted at Moorfields Eye Hospital, London, UK, where eight patients were included. The early outcomes have generated excitement and hope, particularly for a condition that has limited treatment options. However, when we look at this innovation in the context of Pakistan, the situation may become complicated if caution is not exercised.

We have already seen a similar story

unfold with Anti-VEGF therapy. For nearly ten years, Anti-VEGF was cheaply available and widely used by eye doctors in Pakistan. The drug came from a single source and was prepared in a controlled environment. Over time, however, uncontrolled sales began. The medication was sold without proper storage or sterile conditions. As a result, some patients suffered severe complications, including blindness. This led the government to introduce strict legislation. Today, the affordable option is no longer available, and only FDA-approved, expensive medications can be offered. The financial burden now lies entirely on the patient. This experience should serve as a clear warning. Before intravitreal HPMC is adopted for the management of hypotony, its careful and restricted use must be clearly understood. It should only be used in selected cases and within a strictly controlled environment. The sourcing, storage, and handling of HPMC must be secure before planning any intraocular injection. Another important point highlighted by the STRETCH study is that HPMC injections are not a single-step treatment. Patients require repeated injections, typically between 10 and 13, which further emphasizes the need for safety, sterility, and proper patient selection. There is no doubt that this represents a significant scientific achievement, but innovation without safeguards can be harmful. The risks and benefits must be explained clearly to the patient before proceeding.

Based on the current evidence, suitable patients are those who:

Have had low intraocular pressure for more than three months Have an IOP of less than 6.5 mmHg Show at least one structural change Have visual potential It is also important to recognize the limitations of the STRETCH study. The sample size is small, and long-term outcomes are not yet available. The published data covers only 11 months of follow-up, and further research results are still awaited.

In conclusion,

intravitreal HPMC offers promise in the treatment of chronic hypotony, but its use must be responsible, regulated, and evidence-based, especially in Pakistan, where past experience has shown how misuse of a good therapy can lead to serious consequences. #hypotony #intravitreal #HPMC #stretch #innovation

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