Trabeculectomy is not the best surgical option for glaucoma

Abstract

The goal of glaucoma surgery should be the preservation of visual function, the avoidance of sight-threatening complications, and the preservation of the quality of life of the patient. Curiously, the majority of glaucoma surgeons still consider trabeculectomy the best surgical option for their patients, despite evidence that trabeculectomy cannot meet these goals.The trabeculectomy operation has already been abandoned in favour of the augmented trabeculectomy with the antimetabolite mitomycin-C (MMC) 1 by the majority of UK and US glaucoma specialists. 2 MMC trabeculectomy, however, is not safe. The risk of bleb-related endophthalmitis (BRE) ranges from 1.5% per patient year 3 to 10% in one year, 4 with 11 recent studies giving an average incidence of 2.8% per year. [5][6][7][8][9][10][11][12][13] As the mean follow-up of these 11 studies was 19 months, the true incidence may be higher, as institutional reviews of BRE show that the mean time of presentation of BRE is 32 months postoperatively. [14][15][16][17][18] Of equal importance as a cause of central visual loss after MMC trabeculectomy is hypotony maculopathy, with a mean incidence of 3.2% per annum reported in 7 recent studies (mean follow-up of 28 months). 4,9,[19][20][21][22][23] The Collaborative Initial Glaucoma Treatment Study (CIGTS) showed that trabeculectomy increases the risk of cataract formation eightfold in the first postoperative year and by fourfold over 5 years. 24 Cataracts can be removed, but bleb failure occurs in 22% of eyes as a consequence of cataract surgery. 25 Numerous papers are published advising techniques for increasing the safety of MMC trabeculectomy, with posterior application of MMC and strategies to avoid early postoperative hypotony using tight sutures that can later be released, lasered, or adjusted. 26 However, these postoperative manipulations can cause serious complications, such as endophthalmitis, bleb leaks, suprachoroidal haemorrhage, flat anterior chambers, 15,27,28 and may reduce the success of the operation. 29 A 2006 study described a 'Safe trabeculectomy technique' that had a 1.5% rate of BRE in the first year. 13 A recent editorial 30 on the Tube vs Trabeculectomy (TVT) study 31 described as 'excellent' the first year's results of MMC trabeculectomy despite persistent hypotony causing 3% of failures, 1% of eyes suffering BRE, and an additional 2% of cases suffering blebitis, 32 a precursor of endophthalmitis. 14 Surely such a high incidence of serious bleb-related complications is at odds with the description of an 'excellent record'?As to efficacy, MMC trabeculectomy in the TVT study had a 13.5% failure rate and a 57% incidence of postoperative complications, including a 10% incidence of shallow or flat anterior chamber, 3% hypotony maculopathy, 3% suprachoroidal haemorrhage, and 19% choroidal effusions. 31,32 There were 85 surgically invasive postoperative interventions including 49% laser suture lysis and 22% needling. 31 Two recent studies of MMC trabeculectomy from Europe showed similar rates of postop...

Late results of phaco-canaloplasty in patients with concomitant advanced pseudoexfoliation glaucoma and cataract

“…Результаты многолетних исследований показывают, что TЭК не является лучшей хирургической альтернативой для глаз с ОУГ [6,13]. Одно из основных преимуществ непенетрирующей антиглаукоматозной операции перед TЭК -отсутствие осложнений, связанных с ФП и гипотонией [14].…”