BLOG: Trabs must die
Click Here to Manage Email Alerts
In the cover story of this issue of Healio | OSN, we explore trabeculectomy as a time-honored glaucoma procedure.
In the article, some of the best minds in glaucoma argue that trabeculectomy must continue as an available procedure to our patients. At the risk of being wrong, I would argue that we should face reality and think differently, embracing and encouraging newer technologies that show greater long-term promise.
Let’s face it, patients hate trabeculectomies. While they currently provide the strongest IOP control, it comes at a cost of extra office visits, ocular discomfort from sutures and longer restrictions from activities than microincisional alternatives. The impact of all of this is a real loss of quality of life, real costs for travel and real worry. And most trabs do die eventually, taking with them valuable conjunctival real estate and leaving behind fewer options.
The only ones who hate trabeculectomies more than patients are the doctors who perform and follow them. Trabeculectomies are very “analog.” Many variables influence how well they are constructed, how they flow and how long they last. To succeed with trabeculectomy, a surgeon must perform not one procedure but many procedures, which makes it impossible to delegate postoperative care to a non-surgeon. Antimetabolites add to trabs’ life span but also to their risk. Bleb failure happens with little warning. The many non-reimbursed follow-up visits do help trabs survive, but knowing what to do and when is as much art as science. And those visits happen on weekends and off-hours. In the best-case scenario — if the trabeculectomy survives — there is a forever risk of bleb leaks and endophthalmitis. If microincisional procedures came first, nobody would ever adopt the new procedure called trabeculectomy.
Which brings us to training. If today’s ophthalmology residencies do not prepare surgeons to do trabeculectomies, and if glaucoma fellowship graduates are performing fewer and fewer, shouldn’t we plan now for the coming reality of a world without this procedure? Should we not acknowledge that even first-generation microincisional procedures like the Xen stent (Allergan), PreserFlo (Glaukos) and others are more in line with what patients want, surgeons can do and payers cover?
A growing number of well-done studies show that, yes, trabs lower pressure best but by just a few points. That difference might be crucial for a few patients, but our best hope for the future may be the treatments in development using novel (or newly revisited) outflow pathways, femtosecond and excimer lasers, and drug delivery. Yes, trabs are necessary for now, but should a procedure persist if its perils rival its benefits?
Follow @DrHovanesian on X .
Collapse