Eyeworld

suggested that in prostaglandin re- sponders, the additional IOP reduc- tions offered by SLT are not as impressive as in those non-respon- ders. "Jorge Alvarado, M.D., [profes- sor of ophthalmology, University of California, San Francisco] first sug- gested that people who do not re- spond well to prostaglandins likewise are not going to respond well to laser," Dr. Mundorf said. "We can always add a laser for a little ad- ditional IOP drop, but the bigger drops we tend to expect won't mate- rialize in that group of patients." Dr. Cantor suggested clinicians initiate discussion about potential surgery as early on in the process as possible. For the vast majority, be- ginning management strategies usu- ally involve medications, but for some—those with dementia or Parkinson's, for instance—beginning treatment with a surgical strategy might be advised. "Those who initially present with advanced glaucoma usually by- pass meds and head straight into surgery," he said. "For the most part, though, one or two bottles of med- ications are manageable. One could be on a fixed combo, so those two drops might actually be three med- ications. Once you add in a third bottle, though, it becomes increas- ingly difficult for the patient and that's when we'll typically talk more about lasers and surgery." Surgical management strategies should differ between phakic and pseudophakic eyes, Dr. Samuelson said. "In a phakic eye, I tend to use minimally invasive measures, whether it's medication or laser, until the patient develops a visually significant cataract," he said. "I tend to reserve phaco-trab for far-ad- vanced disease, not for early-to- moderate disease. Once you remove the cataract, the glaucoma is often easier to manage. For pseudophakic eyes, I'm much more willing to per- form transscleral procedures. In such cases, if the lens has been removed February 2011 February 2011 GLAUCOMA and medications aren't controlling the IOP, I am more willing to per- form a trabeculectomy than in a phakic eye. Yet, even in pseudopha- kic eyes, I reserve trabeculectomy for more advanced disease and favor less invasive procedures such as canaloplasty for early to moderate disease." Dr. Singh—who is on the data and safety monitoring committee for the Tube vs. Trabeculectomy (TVT) Study—said he still generally performs trabeculectomy first in eyes that have had prior temporal pha- coemulsification and will often con- sider a second trabeculectomy in eyes where the first procedure worked for several years and then gradually failed. The results with tube implantation were better than those with trabeculectomy in the TVT Study but "the investigators have at no time published that tube implantation is always the best choice in patients who are pseudophakic or have had prior failed trabeculectomy," he said. "There are many factors that go into the decision regarding which proce- dure should be performed in a par- ticular patient, and it is unfortunate that so many have misinterpreted the study results and conclusions. One such misperception is that while the tube study group had a higher success rate, this group re- quired, on average, more medica- tions than the trab group. While this was true at the 1-year post-op time point, there was no difference in the mean number of medications in the two groups at the 3-year post-op time point, and the trend is toward the trab group requiring compara- tively greater medications over time. Similarly, the misperception that the trabeculectomy complication rates were higher in the TVT Study rela- tive to those seen in other studies is not supported by the data that shows, for example, that the results with trabeculectomy in TVT com- pared favorably with those reported in the prior Collaborative Initial continued on page 70 EW FEATURE 69 58-81 Feature_EW February 2011-DL2_Layout 1 2/4/11 2:30 PM Page 69

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