This article is more than 5 years old. Information may no longer be current.
Do you prefer implants or trabeculectomy when treating patients with advanced glaucoma?
Click Here to Manage Email Alerts
Baerveldt implants may be safer
 Brian Francis |
Many surgeons recommend trabeculectomy in advanced glaucoma patients because you can achieve a lower IOP. But I think there are other factors to consider, as many are at high risk for complications.
When we talk about advanced glaucoma patients, we are talking about patients who probably have split fixation and advanced field loss and thus have an elevated risk for visual field progression or vision loss if surgical complications arise. Some potential complications of trabeculectomy, such as hypotony, choroidal effusion and choroidal hemorrhage, can be visually devastating in this patient population. We conducted a study on more than 350 patients who underwent trabeculectomy to look at the incidence of vision loss, and we found that the greatest risk factors for unexplained, permanent loss of more than four Snellen lines were hypotony with choroidal effusion and split fixation on visual field. So, in some ways, I believe a Baerveldt implant is safer. Additionally, you can achieve pressures comparable to those following trabeculectomy using a Baerveldt implant and aqueous suppressants.
Hypotony may still occur with the Baerveldt tube when it opens 6 to 8 weeks postoperatively, so we watch patients carefully during this time. In some, we do a staged implantation consisting of two parts. During stage one, we mount the plate but do not put the tube into the eye, waiting for the capsule to grow around the plate and then inserting the tube in a second-stage procedure. That way, you can monitor for hypotony intraoperatively and fill the anterior chamber as the tube starts to filter. Additionally, a study was conducted last year in which surgeons performed a complete Baerveldt implantation with ligature and performed laser suture lysis at 5 weeks postop to open the tube. Under these circumstances, one can measure IOP after the tube opens and fill the anterior chamber with balanced salt solution to combat any hypotony.
Brian Francis, MD, MS, is the Riffenburgh Professor of Glaucoma at the Doheny Eye Institute at the Keck School of Medicine, University of Southern California, Los Angeles. Dr. Francis has no direct financial interest in the products discussed in this article, nor is he a paid consultant for any companies mentioned.
Trabeculectomy remains the gold standard
 Malik Y. Kahook |
If I had to choose between trabeculectomy and tube shunts as primary surgery for a glaucoma patient requiring surgical intervention, all other factors being equal, my choice would be trabeculectomy. This procedure is still the gold standard and has been for decades. My preference stems from trabeculectomy’s extensive clinical history, as well as my own experience and comfort with performing the procedure. In clinical practice, I find that drainage device implants do not lower IOP to the same degree as trabeculectomy. Additionally, primary trabeculectomy surgery does not preclude me from subsequently performing drainage device implantation.
However, certain patients may be better served through glaucoma drainage device implantation. For example, patients who wish to wear contact lenses after glaucoma surgery could have issues with anterior blebs after trabeculectomy. I choose drainage device surgery for these patients, which allows them unencumbered use of contact lenses due to the more posterior bleb often associated with this surgical approach. In my hands, individuals with active uveitic glaucoma or neovascular glaucoma also tend to have better surgical outcomes with glaucoma drainage device implantation compared with trabeculectomy.
But as I said, trabeculectomy remains the “go-to” primary surgery for lowering IOP. My hope is that future devices will combine the pressure-lowering efficacy of trabeculectomy with the reproducibility and safety that can be achieved using precision devices.
Malik Y. Kahook, MD, is associate professor and director of clinical research in the Department of Ophthalmology at the University of Colorado School of Medicine. Dr. Kahook is a consultant for or provides research for Actelion, Alcon, Allergan, Genentech, Ivantis, Merck & Co., QLT, the state of Colorado, and the U.S. Food and Drug Administration. He also has ownership and patent rights for Shape Ophthalmics.