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Surgery better than medications in preserving mGCIPL structure in advanced glaucoma
A retrospective analysis of eyes with advanced open angle glaucoma showed that the structure of the macular ganglion cell layer and inner plexiform layer was better preserved in surgically treated eyes than in medically treated eyes.
Changes were evaluated over a period of 5 years in 43 surgically treated patients and 43 medically treated patients who met the inclusion criteria of the study. Surgery was trabeculectomy in all eyes, and medical treatment consisted of one, two, three or four anti-glaucoma agents.
The average IOP was just above 10 mm Hg in both groups within 5 years, but IOP fluctuation was significantly less in the surgically treated group. There was no significant difference in the mean deviation (MD) changes over 5 years.
In the medically treated group, significant changes in macular ganglion cell layer and inner plexiform layer (mGCIPL) thickness occurred over 5 years, and the decrease in thickness was significantly larger than in the surgically treated eyes. The thinning rate in the surgically treated group was surprisingly similar to that of normal eyes, the authors noted.
A significant correlation was found between mGCIPL thickness changes and IOP fluctuation.
“The greater IOP fluctuation may account for the marked difference in the thinning rate of the mGCIPL between the medically and surgically treated advanced glaucoma groups,” the authors wrote. – by Michela Cimberle
Disclosure: The authors reported no relevant financial disclosures.
Perspective
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Is trabeculectomy still the preferred surgical treatment for glaucoma? In my experience, it is slowly being phased out, but may still be a valuable intervention for certain glaucoma patients. I am seeing fewer patients with trabeculectomy, especially new cases. Although Inuzuka and colleagues don’t specifically address this question, they do offer some insight into potential benefits of trabeculectomy over medical treatment.
In this study it seems plausible that trabeculectomy has a major advantage in minimizing fluctuation in IOP spikes compared to medical therapy. But the trade-off is that the patient must undergo a surgery fraught with potential complications. Additionally, although the ganglion cell layer thickness was shown to be better preserved in the trabeculectomy group, the visual function was not shown to be different from the medical group. I think this information will be most useful for re-emphasizing the need to minimize IOP swings throughout the day, but I do not foresee a resurgence of trabeculectomy anytime soon.