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What are the reasons for the slow, difficult implementation of glaucoma surgery?
 Matteo Piovella |
Glaucoma surgery is one of the greatest challenges for ophthalmologists and one of the most difficult issues for patients to confront. The indications and evaluation of results are not as straightforward as they are for other types of surgery.
The glamorous advances of cataract surgery during the past few decades make the comparison with glaucoma surgery difficult and almost embarrassing. Standardization, predictability and reproducibility are still low, and results are often disappointing and frustrating for both the patient and the surgeon.
Surgery is one of the options for glaucoma, but there is no agreement on when – if at all – it is the right time to use this option. Glaucoma remains asymptomatic for a long time, and an early diagnosis is unfortunately rare. In many cases, more advanced stages of the disease still pose the question of whether surgery is better than medical therapy. The latter appears less traumatic, but we all know that compliance is a big issue. We also know that years of drops instilled in the eye produce important changes to the sclera and conjunctiva that jeopardize the outcomes of surgery when needed.
If we compare cataract with glaucoma surgery, we see on one hand a technique – phacoemulsification – that is universally recognized as the gold standard. On the other hand, we see a plethora of procedures and devices, none of which have been so far indicated as the best option. We are still exploring indications, evaluating results and comparing methods, and this is certainly a limitation to the diffusion of the various techniques. In most cases, each hospital preferentially adopts one method to gain enough experience and achieve the best possible outcomes.
Another problem of glaucoma surgery is the stability of results. Success in terms of pressure lowering might be achieved at first, but tends to fade over the years.
The delayed and difficult implementation of glaucoma surgery is also due to a specific policy of hospital administrators and health authorities. In the past 15 years, cataract surgery has absorbed the majority of resources available to satisfy the needs of a continuously growing number of people. Consequently, few centers are still qualified to provide high standards in glaucoma surgery. There is a lack of experience and a lack of training in this specialized field. In addition, the availability of new medications has greatly reduced or postponed the need for surgery for a large number of patients.
People today live longer – far too long to make medical therapy sufficient to control a progressive disease such as glaucoma. We are already witnessing a dramatic increase in the demand for glaucoma treatment. Some interesting and comforting data are coming from studies that show how the removal of the crystalline lens in patients with a shallow chamber and a narrow angle can prevent the conditions that would lead to ocular hypertension. In this way, two big problems are avoided: a potential evolution to glaucoma and the complications of a future cataract operation in eyes that are difficult to manage to standard positive outcomes. This is where the two worlds of glaucoma and cataract surgery come into contact and act synergistically to maintain a healthy and functional eye.
Most European national health systems have adopted a policy of low, inadequate reimbursement of ocular surgery. This is certainly not only due to the high numbers involved, but also the risk there is with any new technology. The most updated device for glaucoma surgery is automatically excluded because it exceeds the budget. But there is no cheap way out of progressive, sight-threatening diseases, and our governments must be fully aware of this.
We have achieved extraordinary results with cataract surgery, with a rate of success that is astonishing when compared with that of 30 years ago. Today, we must direct our efforts to improve the long-term outcomes and the quality of life of those who are fighting the “silent thief” of sight.