EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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39 EW GLAUCOMA December 2014 Cucamonga, Calif.] or the Baerveldt glaucoma implant [Abbott Medical Optics, Santa Ana, Calif.]." This is a worthy undertaking, because "Trabectome rarely causes serious complications, and the rate of non-serious complications is 10 times less with Trabectome compared to trabeculectomy or aqueous shunts." Ms. Kola and colleagues re- viewed the charts of 125 patients undergoing Trabectome surgery and compared the outcomes to 162 pa- tients receiving a Baerveldt implant and 44 receiving an Ahmed valve. "The Trabectome group had mean IOP reductions from 22 mm Hg preoperatively to approximate- ly 15 mm Hg at 6 and 12 months postoperatively." In contrast, the Baerveldt group dropped from 26.5 mm Hg to about 14.5 mm Hg at the same two time points, and the Ahmed group from 31 mm Hg to approximately 17 mm Hg postop. The number of medications required to control IOP also dropped in all 3 groups by approximately 1 drop per patient on average. "All 3 groups had similar final IOP, and all had similar reductions in medications," said Ms. Kola. "In contrast to the patients undergoing aqueous shunts, the Trabectome group had no serious complications." Trabectome when tubes fail What is the next step when a tube shunt fails? Garrick Chak, MD, and colleagues at the University of California, Irvine addressed this question by reviewing the records of 24 patients with refractory glaucoma who had failed tube shunt surgery and then underwent trabecular ablation. "The mean preoperative IOP was 23 mm Hg, and the average number of medications was 3.2," he said. "At 12 months, the mean IOP was 16.1 mm Hg with patients using an average of 2.4 medications." The IOP reduction was statistically signif- icant but the medication reduction was not, he added. Defining success as IOP below 21 mm Hg and at least 20% re- duced from baseline with no further surgical interventions, 83% of the patients were deemed successes at 12 months. Complex glaucomas There are a handful of glaucomas that are notoriously difficult to treat. Among these are traumatic glaucoma, neovascular glaucoma, the inflammatory glaucomas, and glaucoma following posterior seg- ment surgery. Ralitsa Loewen, MD, and colleagues at the University of Pittsburgh reviewed their collective experience using the Trabectome in eyes such as these. "These were highly complex, mixed mechanism glaucomas in which minimally invasive glaucoma surgeries have traditionally been seen as ineffective or contraindicat- ed," said Dr. Loewen. The records of 17 subjects undergoing this procedure were reviewed. All had at least 1 full year of postoperative follow-up. From a mean preoperative IOP of approximately 40 mm Hg, Trabectome lowered IOP to around 25 mm Hg through 12 months of follow-up, Dr. Loewen said, adding, "The mean number of medications was also reduced from 3.8 to 1.2." Only one eye—with uveitic glauco- ma—required an additional IOP low- ering procedure (cyclophotocoagula- tion) during the follow-up period. "Good outcomes can be achieved as long as the angle can be visualized," said Dr. Loewen. Clinical applications Trabectome and other MIGS pro- cedures have traditionally been thought of as interventions for early-stage disease. These studies suggest that a broader view may be warranted. "Trabectome may be an appropriate treatment across the whole spectrum of glaucoma severity, from early to refractory disease," said Dr. Chak. Dr. Loewen agreed. "In challeng- ing cases, glaucoma surgeons should consider this low-risk and fast pro- cedure as an alternative approach to traditional glaucoma surgeries." EW Editors' note: Dr. Chak and Ms. Kola have no financial interests related to this article. Dr. Loewen has financial interests with NeoMedix. Contact information Kola: suk55@pitt.edu Chak: garrickchak@gmail.com Loewen: loewenna@upmc.edu Trabectome-mediated trabecular meshwork ablation, a microinvasive glaucoma surgery modality that relies on patency of the downstream conventional outflow system, can be surprisingly effective in complex and high risk mixed mechanism glaucomas. Source: Ralitsa Loewen, MD