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EW FEATURE 71 Trabeculectomy remains the most common surgical procedure for glaucoma treatment in Europe A s diverse as the European continent is in history and tradition, there are many similarities in attitudes to- ward glaucoma treatment. For one, most European ophthal- mologists would first consider med- ical therapy, according to Norbert Pfeiffer, M.D., director, Mainz Uni- versity Hospital, Mainz, Germany, and past executive committee mem- ber of the European Glaucoma Soci- ety. Of course, this practice has been supported by the availability of prostaglandins and other medica- tions now in routine use for almost 10 years, he said. Surgery is not seen as a last re- sort but as a step taken when med- ical therapy fails or when maximally tolerated medical therapy is not ade- quate or efficacious, Dr. Pfeiffer said. In addition, because surgeons recog- nize that patient compliance and ad- herence to medication is not as good as it should be, there is a tendency to do surgery earlier than it was done 5 or 10 years ago, he ex- plained. Surgery is also performed earlier when patients have unacceptable side effects of glaucoma medications and in children where glaucoma sur- gery can be attempted early on in the course of the disease as opposed to using medication, according to Tarek M. Shaarawy, M.D., director, glaucoma sector, Geneva University Hospital, Geneva, Switzerland. In complicated cases such as neovascular glaucoma or uveitic glaucoma, surgical intervention is also proposed to the patient earlier in the course of the disease than it is to regular primary open-angle pa- tients, he said. Primary surgery is only done very rarely, despite support from studies showing how successful it is, Dr. Pfeiffer said. When medications fail Trabeculectomy remains the opera- tion for glaucoma practiced most in Europe, followed by non-penetrating glaucoma surgery and implants, al- though it is difficult to say which of the latter two is more popular, Dr. Shaarawy said. Dr. Pfeiffer agreed. "By and large, the most charismatic and in- fluential surgeons still use tra- beculectomy knowing that it is not an ideal method by far." Trabeculectomy is a procedure that has been around since the late 60s, he said, and while it's more ef- fective than other surgeries avail- able, it may have more side effects. With regard to laser surgery, otherwise known as non-penetrating glaucoma surgery, some European surgeons do it in between medica- tion and penetrating surgery, but there are a lot of surgeons, including Dr. Pfeiffer, who are reluctant to use laser trabeculoplasty because of its poor results overall. "Laser surgery helps to the same extent as one medication, and usu- ally there is a loss in efficacy of about 10% per year," Dr. Pfeiffer said. "Therefore, most surgeons see laser trabeculoplasty or selected laser trabeculoplasty as adequate only for those patients who don't have very severe glaucoma but can't take or tolerate medications and might do well with just a laser procedure." A few other methods have come up, many of which are being used more in Germany than other coun- tries; they include non-penetrating deep sclerectomy, canaloplasty, and trabeculotomy, he said. These three compete with each other as well as with trabeculectomy. Some of them may have fewer side effects than tra- beculectomy but unfortunately are not as efficacious when it comes to lowering IOP, Dr. Pfeiffer explained. In very difficult cases, when other methods have failed, cy- clophotocoagulation is seen as a last resort, he said. Implants There are several new stents that have the CE mark in Europe, Dr. February 2011 February 2011 GLAUCOMA by Enette Ngoei EyeWorld Contributing Editor European perspectives in treating glaucoma iStent device Source: Glaukos A Baerveldt 350-mm 2 drainage device and Ahmed drainage device implanted inferiorly Source: Steven J. Gedde, M.D. AT A GLANCE • Surgery is not seen as a last resort but as a step taken when medical therapy fails or when maximally tolerated medical therapy is not adequate or efficacious • Trabeculectomy remains the operation for glaucoma practiced most in Europe, followed by non-penetrating glaucoma surgery and implants • It is difficult to say how the new stents fit into the European glau- coma treatment paradigm without any long-term results. However, they do come with a new set of advantages—they are not depend- ent on the health of the conjunctiva and they are fast procedures. Specific challenges include the mastering of anchor surgery and gonioscopy before approaching these kinds of procedures • It appears that the development of glaucoma surgery is hampered by reimbursement systems • Glaucoma specialists are starting to realize that the quality of IOP reduction could be just as impor- tant as the quantity of reduction continued on page 72 58-81 Feature_EW February 2011-DL2_Layout 1 2/4/11 2:30 PM Page 71

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