Trabeculectomy should still play a role in the MIGS era
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WAILEA, Hawaii — New options have enriched the field of glaucoma, but trabeculectomy should continue to be part of the training and practice of glaucoma surgeons because no novel procedure can achieve the same low-range target IOP.
Pressure in the mid-teens, as can be achieved with MIGS procedures, is fine for the majority of patients, but there is a subset of patients who need lower pressures.
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“It’s a small number, but with a huge number of people with glaucoma out there, that’s enough to make a difference in terms of glaucoma blindness,” Kuldev Singh, MD, MPH, said at Hawaiian Eye 2024.
Trabeculectomy is a complex, labor-intensive procedure that requires long training and frequent postoperative visits, but it can be learned and is necessary, he said. However, while tube procedures have remained stable and MIGS procedures have increased from 2014 to 2020, the number of trabeculectomy procedures has declined in fellowship training programs.
This decline is also, at least partly, economy driven. With inflation and an average $15,000 decrease in take-home pay over the last 5 years, doctors are pressed to earn more.
“I was recently at Duke as a visiting professor ... and they said that one of their best fellows who did the most amazing trabeculectomy had just joined a practice where the private equity group had said you can’t do trabeculectomy in this practice,” Singh said. “Unfortunately, the economics are forcing us in some circumstances to go to the doctor vs. patient centered care.”
However, he invited the audience to remember that a doctor-patient relationship is transactional, and “the more you give, the more you receive.”
“Sometimes we do things in our practice that are labor intensive and we are not going to get paid well for them. But most of us are going to make a good living. It’s important to do that, and you’ll be amazed how much you get in return,” he said.
The average age of a patient with glaucoma in the United States is increasing, and as patients get older, many who did well with medications and MIGS will need very low pressures later in life.
“We need trab to be there for those patients,” Singh said. “We still have to keep doing these procedures to keep people from going blind.”
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Singh K. Trabeculectomy in the MIGS era. Presented at: Hawaiian Eye 2024; Jan. 13-19, 2024; Wailea, Hawaii.
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