At one of the premiere residency training programs in the US, a member of the full-time glaucoma faculty announced that he no longer recommends or performs trabeculectomy. His rationale is based on the results of the landmark multicenter randomized Tube Versus Trabeculectomy (TVT) Study1,2 (summarized by Leon Herndon, MD, in this issue of Glaucoma Today). This doctor decided that the complication rate for postoperative filtering surgery is unacceptably high. Going forward, all patients requiring interventional glaucoma surgery will undergo the placement of a drainage device.
The announcement has broad implications for the state of glaucoma surgery in 2007. Is this the beginning of the end for trabeculectomy? How about other procedures that depend on a bleb for pressure reduction such as the Ex-Press mini glaucoma shunt (Optonol Ltd., Zug, Switzerland) and the AquaFlow Collagen Glaucoma Drainage Device (STAAR Surgical Company, Monrovia, CA)? If trabeculectomy is no longer sufficiently safe, are the alternatives (Molteno Implant [Molteno Ophthalmic Limited, Dunedin, New Zealand], Baerveldt glaucoma implant [Advanced Medical Optics, Inc., Santa Ana, CA], and Ahmed Glaucoma Valve [New World Medical, Inc., Rancho Cucamonga, CA]) sufficiently efficacious? Can the newer and more novel approaches to glaucoma surgery fill this void?
This edition of GToday is devoted to answering these questions. Our first roundtable discussion of glaucoma surgery addresses the implications of the TVT Study and other developments. In addition, Peng Khaw, PhD, FRCS; Murray Johnstone, MD; Alan Crandall, MD; Robert Noecker, MD; and Bradford Shingleton, MD, share ways for readers to enhance their results with trabeculectomy and avoid some of the common postoperative problems. For an update on canal-based surgeries, read the article by Thomas Samuelson, MD. The new procedures are directed at specific parts of the outflow system: the meshwork with the Trabectome (NeoMedix Corporation, Tustin, CA); segmental parts of the canal using iStents (Glaukos Corp., Laguna Hills, CA); and the entire canal of Schlemm with trabecular tensioning via the canaloplasty procedure (iScience Interventional, Menlo Park, CA). In addition, the Solx Gold Micro-Shunt (OccuLogix, Inc., Mississauga, Ontario, Canada) targets the uveoscleral outflow system. More procedures and devices are sure to follow.
No one can argue that a renaissance in the surgical management of glaucoma is underway, but are we ready to move beyond filtering surgery? Based on the results of the TVT Study and the glaucoma community's legitimate concerns regarding trabeculectomy, let's hope it happens soon!
The iStent and Solx Gold Micro-Shunt are not approved in the US.
1. Gedde SJ, Schiffman JC, Feuer WJ, and the Tube Versus Trabeculectomy Study Group. Treatment outcomes in the Tube Versus Trabeculectomy (TVT) Study after one year of follow-up. Am J Ophthalmol. 2007;143:9-22.
2. Gedde SJ, Herndon LW, Brandt JD, and the Tube Versus Trabeculectomy Study Group. Surgical complications in the Tube Versus Trabeculectomy Study during the first year of follow-up. Am J Ophthalmol. 2007;143;23-31.
