Current practice of trabeculectomy in a cohort of experienced glaucoma surgeons in Australia and New Zealand

Abstract

Background/Objectives To evaluate current routine trabeculectomy technique preferences among Australian and New Zealand Glaucoma Society surgeons regularly performing trabeculectomy surgery. Subjects/Methods Survey of experienced surgeons who perform trabeculectomy. Results Forty-nine surgeons (33 male:16 female) participated in the survey. Trabeculectomy was performed as day surgery (39/47, 83.0%) under local anesthesia (44/47, 93.6%). The surgical techniques most commonly used were a corneal traction suture (44/47, 93.6%), fornix-based conjunctival flap (43/47, 91.5%) and half-thickness scleral flap (38/47, 81.0%). Mitomycin C antifibrotic agent was used in routine cases by 45/46 (97.8%) surgeons. Surgeons applied the antifibrotic agent under the Tenon layer with a pledget (36/46, 78.2%) with a concentration of 0.02% (37/46, 80.4%) for 2 (11/46, 23.9%) or 3 min (30/46, 65.2%). The Kelly (26/46, 56.5%) and the Khaw Descemet (19/46, 41.3%) punches were used to perform the sclerostomy. Most surgeons performed a peripheral iridectomy in all phakic patients (46/47, 97.9%), but less commonly in pseudophakic patients (34/47, 72.3%). Techniques for closure of the limbal conjunctival edge were quite varied with a combination of suturing including purse string (21/47, 57.4%), wing (20/47, 42.6%) and horizontal mattress sutures (33/47, 70.2%). Surgeons reviewed their routine patients four times in the first month (29/47, 61.7%) and continued the postoperative topical steroids for 3–4 months (28/47, 59.6%). Conclusions Although a wide range of techniques for trabeculectomy exists among surgeons, there are consistent procedures currently in use to optimize patient outcomes. This report will assist surgeons in choosing which surgical techniques fit their best practice.

Changing trends in anaesthesia for trabeculectomy: a clinical effectiveness and safety analysis

“…A recent study conducted in Australia and New Zealand correlate these findings and reflect the shift towards day case surgery within the NHS [5]. Although PLA is the traditional anaesthetic of choice for trabeculectomy, SLA has gained popularity in recent years, possibly due to the risks of sharp-needle LA.…”

A Brief Review of Historical and Current Trends in Trabeculectomy

“…[54][55][56][57][58] Current surveys of surgical practice patterns in the United States, the UK, Australia, and New Zealand show that over 99%, 97%, and 98%, respectively, of surgeons now routinely incorporate adjunctive antimetabolite in primary trabeculectomy, with MMC favored as the predominant antifibrotic agent therapy since 2008. [59][60][61][62] 5-Fluorouracil (5-FU) The 5-FU compound was initially discovered as a chemotherapy agent that selectively accumulated in rapidly dividing tumor cells. 63 5-FU is a pyrimidine analog that disrupts RNA synthesis and inhibits the production of thymidine nucleotides essential in DNA replication.…”

“…60,83 The dosing of MMC reported in the literature is widely variable with a range of 0.2 to 0.5 mg/mL (0.02% to 0.05%) applied for 1 to 5 minutes to the sub-Tenon space. 60,62 Clinical outcomes have not supported a doseresponse in surgical success with greater concentration or exposure time to MMC. [84][85][86] Instead, there is a strong correlation between higher concentration, prolonged exposure, and the incidence of serious adverse advents, including hypotony maculopathy and choroidal detachments.…”

“…Results of many RCTs confirm that the adjunctive use of antimetabolite delays wound healing and conjunctival fibrosis, leading to greater success in filtration surgery 54–58 . Current surveys of surgical practice patterns in the United States, the UK, Australia, and New Zealand show that over 99%, 97%, and 98%, respectively, of surgeons now routinely incorporate adjunctive antimetabolite in primary trabeculectomy, with MMC favored as the predominant antifibrotic agent therapy since 2008 59–62 …”

“…The dosing of MMC reported in the literature is widely variable with a range of 0.2 to 0.5 mg/mL (0.02% to 0.05%) applied for 1 to 5 minutes to the sub-Tenon space 60,62 . Clinical outcomes have not supported a dose-response in surgical success with greater concentration or exposure time to MMC 84–86 .…”