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Is surgery ever indicated as a primary glaucoma treatment option, and if so, in what cases would it be indicated?
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Surgery can be effective as primary treatment
 Brian A. Francis |
While medications for glaucoma are certainly effective, they are entirely dependent on consistent and regular usage. Therefore, if a patient is likely to have poor compliance with medications for whatever reason, then surgery, or at least laser trabeculoplasty, may be indicated. In addition, the long-term use of topical medications may also have side effects that are insidious and unforeseen. In terms of efficacy, if a patient presents with a very high IOP and advanced optic nerve damage, surgery is likely the only method to satisfactorily control the disease. Even if medications are started in these patients, they are usually only a temporizing measure until surgery can be performed.
The health care burden of glaucoma is weighted toward the costs of chronic medical therapy at all stages of the disease. It can therefore be argued that a safe and effective surgical treatment would be beneficial on a societal level. There are several newer glaucoma surgical techniques that are a step in this direction, such as excimer laser trabeculotomy, canaloplasty, trabecular bypass stent (iStent) and trabeculotomy internal approach (Trabectome). These procedures, or future ones, may help to control IOP at physiologic levels and are likely to be more effective earlier on in the treatment algorithm.
Brian A. Francis, MD, is Riffenburgh professor of glaucoma, associate professor of ophthalmology, Doheny Eye Institute, Keck School of Medicine, University of Southern California.
 Robert J. Noecker |
Medical therapy can help delay surgery
No. I am hard-pressed, even in the cases in which I presume surgery will be needed relatively soon, to go straight to the operating room. Medical and/or laser therapy can buy time and, in some cases, be adequate in controlling the eye pressure. Medical therapy can frequently bring a very high eye pressure into an acceptable or low range for at least a short period of time. This time lets the offending event, such as a steroid response, trabeculitis, etc., resolve, either removing the need for surgery or at least reducing the risk of serious complications during or after surgery.
Robert J. Noecker, MD, MBA, is associate professor of ophthalmology, vice chairman of the department of ophthalmology and director of the glaucoma service, UPMC Eye Center.