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Trabeculectomy procedures on the decline as alternatives proliferate
Laser trabeculoplasty and shunting are gaining ground in treatment of Medicare patients.
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From 1995 to 2004, when multiple new IOP-lowering medications were introduced; aqueous shunting, laser trabeculoplasty, and cyclophotocoagulation procedures rose in use, while trabeculectomy procedures declined by more than 50% as a first-time procedure, according to a study evaluating trends in U.S. glaucoma surgery.
Pradeep Y. Ramulu, MD, PhD, and colleagues examined surgical choices for Medicare glaucoma patients over the 9-year period. In 1995, 305,450 glaucoma procedures were paid for by Medicare, and in 2004, 303,948 cases were paid, with similar numbers for the years in between.
Researchers analyzed the frequency of laser trabeculoplasty, trabeculectomy with or without scarring, other fistulization procedures, aqueous shunt to reservoir, revision of aqueous shunt, cyclophotocoagulation, laser iridotomy, peripheral and sector iridectomy, and laser iridoplasty.
The findings of the retrospective, observational, population-based study were recently published in Ophthalmology.
“The study shows that there’s a trend away from trabeculectomy over time, and there’s a significant trend toward other procedures, particularly in the last few years,” Dr. Ramulu said in a telephone interview with Ocular Surgery News. “The amount of laser trabeculoplasty, diode laser and aqueous shunting has gone up dramatically. Whether this is a substitute of trabeculectomy or this is greater acceptance of these techniques in eyes that have had previous surgery is not clear.”
Aqueous shunts
Dr. Ramulu said that surgical procedures for glaucoma other than trabeculectomy are increasing in usage, including the use of aqueous shunts.
The study found that, from 1995 to 2004, the use of shunting devices rose 184%, from 2,728 to 7,744, with the ratio of trabeculectomy to shunting procedures decreasing from 23:1 to 4.6:1.
This could partly be explained by the relatively recent introduction of the devices to the market. The increase may also be attributed to improved efficacy and increased surgical confidence in the newer devices, the study authors said.
In addition, shunting may have been the most appropriate treatment in more cases because of the rise in neovascular glaucoma resulting from an increase in the number of patients with diabetes, and more pseudophakia as individuals began to undergo cataract surgery at an earlier age.
Laser trabeculoplasty and other surgeries
Another procedure that grew in use over the study period, laser trabeculoplasty, had previously experienced a marked decline linked to the rise in medical therapeutic innovations and possible dissatisfaction. In the early 1990s, new therapeutic options such as prostaglandin analogues, alpha agonists and carbonic anhydrase inhibitors dominated the market before gradually leveling off, Dr. Ramulu said.
“Clinicians have looked at the frequency of trabeculectomy and laser trabeculoplasty, and everyone’s noted a drop when the prostaglandins were introduced to the market,” he said.
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Study co-author Alan L. Robin, MD, OSN Glaucoma Section Member, said in a telephone interview that another factor in the rise of laser trabeculoplasties could be the introduction of selective laser trabeculoplasty (SLT), which many clinicians think can be repeated more frequently because of a belief that there is less thermal energy used.
But Dr. Robin said the whole story involving selective laser trabeculoplasty and argon laser trabeculoplasty (ALT) has yet to be told.
“Comparing ALT to SLT, there are really no good studies that are prospective, long term and have an adequate sample size,” he said.
From 1995 to 2001, the number of laser trabeculoplasties decreased 57%, from 151,244 to 75,647. From 2001 to 2004, the number of trabeculoplasties performed more than doubled, with 157,490 performed in 2004. Dr. Ramulu speculated that the resurgence of trabeculoplasty was largely due to the advent of SLT.
“I think things have largely rebounded because of selective laser trabeculoplasty, which has made laser trabeculoplasty interesting again, as a lot of people have bought a new instrument and are remembering that this may be a good option in lieu of medicines,” Dr. Ramulu said.
The number of laser iridotomies showed little fluctuation in the study period, increasing proportionately to the growth in the population of U.S. citizens over the age of 65.
Cyclophotocoagulation procedures rose by 248% in the study period, from 3,264 procedures in 1995 to 11,356 procedures in 2004. This increase possibly reflected increased use of endocyclophotocoagulation, which is often combined with procedures such as cataract extraction.
Trabeculectomy
At the same time that laser trabeculoplasty began to grow, fistulization procedures declined, Dr. Ramulu said. According to the study, trabeculectomy performed in eyes without previous surgery decreased by 53%, from 51,690 cases in 1995 to 24,178 in 2004.
However, more trabeculectomies were performed in eyes with scarring, increasing by 9%. Fistulization procedures other than trabeculectomy, including the Scheie and Holt procedures and iridencleisis, fell 83% over the study period, decreasing from 2,833 in 1995 to 478 in 2004.
Dr. Ramulu said trabeculectomy is still an excellent surgical procedure for glaucoma and will most likely remain a viable surgical option in the near future, but he predicted that physicians will increase their use of other surgical options, particularly with repeat operations. He said he expects the glaucoma surgical field will continue to expand with new surgical options.
The study authors concluded that technology usage patterns are shaped more by advances in technology than by demographics or reimbursement issues. They also noted that the study was limited because Medicare data were examined, which means that most patients were older than 65 years and may have had later stages of glaucoma disease.
“The bottom line is that the total number of surgical procedures has significantly declined — not just trabeculectomy,” Dr. Robin said. “While the numbers of some have gone up, the total does not at all make up for the decline in filtering surgery. Likewise, procedures such as the ExPress drainage device (Optonol) could be miscoded as ‘shunts.’”
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Reference:
- Pradeep Y. Ramulu, MD, PhD, can be reached at 600 N. Wolfe St., Maumenee B1 10 Baltimore, MD 21287; e-mail: pramulu1@jhmi.edu.
- Alan L. Robin, MD, can be reached at 6115 Falls Road, Suite 333, Baltimore, MD 21209; 410-377-2422; 410-377-7960; e-mail: arobin@glaucomaexpert.com.
- Ramulu PY, Corcoran KJ, Corcoran SL, Robin AL. Utilization of various glaucoma surgeries and procedures in Medicare beneficiaries from 1995 to 2004. Ophthalmology. 2007;114(12):2265-2270.
- Erin L. Boyle is an OSN Staff Writer who covers all aspects of ophthalmology.