Unlike other specialists, we glaucomatologists frequently share clinical war stories with our peers. We wear the battle scars of glaucoma surgical complications as a badge of courage. We become acclimated to dealing with difficult problems and poor outcomes. We adopt a “win some, lose some” approach. We acknowledge medications' side effects, choroidal effusions, failed filtration, tube shunt erosion, and blebitis as a part of the battle.
In the past, we generally performed surgery solely for advanced glaucoma, because complication rates were relatively high and postoperative vision loss and surgical failure were common. We tolerated the very real complication of glaucomatous progression due to noncompliance or inadequate medical treatment in some cases. Today, glaucoma still too often claims the vision of my patients. My guess is that my experience mirrors that of clinicians in many tertiary care glaucoma practices.
Fortunately, recent improvements in medical and surgical glaucoma therapeutic modalities have positively affected our chances of success. The advent of prostaglandin analogues has greatly minimized, although certainly not eliminated, the side effects of glaucoma topical therapy. Fixed-combination products have enhanced patients' medical adherence. The excellent safety profile of selective laser trabeculoplasty makes it an option for first- or second-line treatment, and endoscopic and transillumination techniques have expanded the role of cyclophotocoagulation in glaucoma management.
Incisional glaucoma surgical techniques have also improved. We now view full-thickness procedures largely from a historical perspective. The safety of filtering surgery has been enhanced by advances in our use of antifibrotic agents, scleral flap dissection, conjunctival closure, and stent technologies. More minimally invasive glaucoma procedures offer the hope of fewer complications and better outcomes as well.
As our understanding of glaucoma grows and the quality of medical and surgical therapy improves, the complications of interventional glaucoma therapy are decreasing significantly. Nevertheless, we must strategically plan how best to serve our patients. They are less tolerant of complications, and their expectations far exceed those of past generations.
Diligent preparation continues to play a vital role in determining outcomes. We must carefully record and systematically evaluate patients' medical histories to choose the proper medication. The appropriate selection of patients for surgical procedures requires great thought. Our surgical technique must be meticulous, efficient, and consistently repeatable. We should consider surgical modifications and the benefits of combining incisional glaucoma surgery with cataract extraction on a case-by-case basis.
Quality postoperative management remains key to glaucoma surgical outcomes. Optimizing the outcome of filtering surgery requires our determination and good clinical judgment as well as our performance of detailed eye examinations. Experience with modulating wound healing in the postoperative setting is also beneficial. Adopting a team approach allows the patient to help direct the treatment process.
As we learn more about glaucoma, diagnose it earlier, and gain more therapeutic options, we may be able to retire our war zone mentality toward its management.
Steven D. Vold, MD
Chief Medical Editor
