Eyeworld

EW GLAUCOMA 60 February 2019 by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer specialists, postoperative manipula- tions, follow-up frequency, reinter- ventions, and complications," she explained. Treatment cost also compris- es patient considerations, such as surgery length, the speed of visual recovery, frequency of bleb ma- nipulation, weekly postoperative visits for the first 4 weeks, lifestyle limitation in the early postoperative period, the potential risk of tran- sient or permanent vision loss, and potential loss of bleb dysesthesia, among others. "This issue is not black and white, and we can't say that trab- eculectomy is the ideal glaucoma surgery for all our patients. One size fits all is inappropriate in glauco- ma surgery, and we have to take into account various factors like efficacy and safety, but also patient experience, cost, and postoperative recovery when we decide which patient we want to treat with which surgery," Dr. Stalmans said. "Trabe- culectomy is effective to lower IOP, and the complication rates have come down with modern tech- niques but are still a reality. Bleb sur- gery provides low teen pressures but requires bleb management. Compar- ative data between trabeculectomy and MIGS are largely lacking, and evidence on cost effectiveness is needed. We have to weigh the op- tions to decide what is best." EW References 1. Edmunds B, et al. The national survey of trabeculectomy III. Early and late complica- tions. Eye (Lond). 2002;16:297–303. 2. Gedde SJ, et al. Postoperative complica- tions in the Tube Versus Trabeculectomy (TVT) study during five years of follow-up. Am J Ophthalmol. 2012;153:804–814. 3. Kirwan JF, et al. Trabeculectomy in the 21st century: a multicenter analysis. Ophthalmolo- gy. 2013;120:2532–2539. 4. King AJ, et al. Frequency of bleb manip- ulations after trabeculectomy surgery. Br J Ophthalmol. 2007;91:873–7 5. Musch DC, et al. Visual field progression in the Collaborative Initial Glaucoma Treatment Study the impact of treatment and other base- line factors. Ophthalmology. 2009;116:200– 7. Editors' note: Dr. Stalmans has no financial interests related to her comments. Contact information Stalmans: ingeborg.stalmans@uzleuven.be injections, one study showed, with IOP among patients with interven- tions always higher than in those that required no intervention. 4 "A more recent study showed that 63% of individuals still required postop management after trab," 3 Dr. Stalmans said. "Postoperative manipulations are necessary. We all want a surgery that is fast, easy, effective, with no complications, quick recovery, and no postop ma- nipulations. But can we get there?" Role of MIGS "Microinvasive glaucoma surgery (MIGS) uses different aqueous flow routes to achieve IOP reduction," Dr. Stalmans said. "Also, we now know more about the distal outflow channels, that there is resistance there, that they can collapse and cause outflow problems, even when we bypass the trabecular meshwork. Fibrosis is obviously a big enemy for several of these devices and for several MIGS flow routes, which can only be tackled in the subconjuncti- val space with the use of antimitot- ics or with needlings." MIGS are potentially less effec- tive than trabeculectomy, according to Dr. Stalmans, as studies compar- ing MIGS devices to trabeculectomy have demonstrated. "Despite its in- vasiveness and potential for postop- erative complications, trabeculecto- my is highly effective. It gives us the lowest pressures, followed in efficacy by external MIGS, internal MIGS, and phacoemulsification. Again, our objective is to best preserve visual function," she said. A study that investigated newly diagnosed patients undergoing primary medical or surgical treat- ment showed that the long-term outcomes were not that different in early glaucoma patients. In patients with more advanced visual defects, however, visual function was better in the long run following primary surgery. 5 "Cost effectiveness is part of the way we define the goal of glau- coma surgery," Dr. Stalmans said. "We need cost effectiveness studies comparing MIGS to trabeculectomy. The cost of treatment has financial implications for the individual and society, as do treatment inconve- nience and side effects. Factors affecting cost include device cost, surgery time, training for glaucoma tube shunts and trabeculectomy. Forty-five percent of the trabeculec- tomy patients in this study lost at least two lines of Snellen, whether they developed complications or not. 2 "I do want to stress, however, that trabeculectomy has evolved over time. Our techniques have greatly improved and trabeculecto- my has been refined. If you look at more recent reports about trabe- culectomy outcomes, complication rates have gone down," Dr. Stal- mans said. Good trabeculectomy outcomes with low rates of surgical compli- cations can be achieved, according to the results of another study that measured surgical success, IOP, visual acuity, complications, and interventions in 428 eyes of 395 patients with open angle glaucoma with no previous incisional glauco- ma surgery who underwent trabe- culectomy. Complication rates were improved compared to previous studies, with approximately two or more lines of Snellen lost in 5%, late-onset hypotony in 7%, and bleb leaks in roughly 14% of the patients. The study recommended intensive, proactive postoperative care to keep complications low. 3 Postoperative care Experienced glaucoma surgeons agree that labor intensive postoper- ative care goes a long way to ensure better outcomes after trabeculec- tomy. Seventy-eight percent of trabeculectomy patients need some measure of postoperative manipu- lation, whether massage, suture re- moval, needling, or subconjunctival T he goal of glaucoma treat- ment is to maintain the pa- tient's visual function and related quality of life at a sustainable cost. According to Ingeborg Stalmans, MD, Leuven, Belgium, who spoke at the 36th Congress of the European Society of Cataract and Refractive Surgeons about "good old trabeculectomy," visual function is best preserved by lowering IOP in a "robust, convinc- ing way." Trabeculectomy: the superstar Studies have consistently demon- strated IOPs of around 12 mm Hg following trabeculectomy. "If you look at various studies, trabeculec- tomy seems to be very effective in IOP lowering," Dr. Stalmans said. "It is still the most efficacious proce- dure, and that is why it is still our gold standard, reliably achieving low target pressures. Long-term data on trabeculectomy have resulted in mostly drop-free patients." So why look for alternatives if trabeculectomy is achieving its primary goal? According to Dr. Stalmans, the reason is safety, as some of the complications known to follow trabeculectomy are the night- mare of every glaucoma surgeon. An early study on trabeculecto- my showed that roughly one out of four patients developed hyphema, a shallow anterior chamber, or hypo- tony after trabeculectomy, and one out of five developed cataract or lost at least one line of Snellen. 1 Another investigation demonstrated early postoperative complications in 40% of trabeculectomy patients and late postoperative complications in an- other 40% in a comparison between Trabeculectomy holds its ground for providing reliable IOP reductions in glaucoma patients Trabeculectomy bleb Source: Ingeborg Stalmans, MD

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