High efficacy, poor safety results found with trabeculectomy
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Trabeculectomy, although effective at lowering IOP in patients with open-angle glaucoma, has a low safety profile, according to a study by the Department of Medicine in the University of Udine in Udine, Italy.
Researchers conducted a systematic search of peer-reviewed literature until Jan. 10, 2018, using PubMed, Medline, Scopus and Embase. All studies included in this evaluation contained at least one comparison between trabeculectomy (TE) and nonpenetrating glaucoma surgery (NPGS), deep sclerectomy (DS), viscocanalostomy (VC) or canaloplasty (CP).
The primary outcome measures were the mean difference from baseline in IOP at 6, 12 and 24 months at follow-up. Complications after surgery such as hypotony, choroidal detachment or effusion, flat or shallow anterior chamber, cataract formation or progression and hyphema were analyzed.
“At least one comparison between TE and any nonpenetrating filtering procedure had to be present in the selected studies,” Andrea Gabai, MD, and colleagues wrote. “We included studies wherein surgeries could be performed with intraoperative antimetabolites and, for DS, with subscleral implants.”
In the 21 studies included in the overall evaluation, TE was found to be associated with hypotony, choroidal detachment or effusion, anterior chamber shallowing or flattening, and cataract formation or progression. IOP was significantly lower with TE in comparison to NPGS at each patient follow-up period.
Treating glaucoma with TE does not seem advisable when considering the associated surgical complications and costs, the authors said. Each complication was more likely to occur with TE than NPGS.
Results indicated that TE is more effective at lowering IOP, but the risk of complications after the procedure is higher than that of NPGS.
“Further studies with larger samples, longer follow-up and also analyzing aspects that we did not take into account, such as quality of life and costs, are warranted to assess the long-term efficacy and safety of TE and NPGS,” the authors wrote. – by Erin T. Welsh
Disclosure: Gabai reports no relevant financial disclosures. Please see the full study for all other authors’ relevant financial disclosures.
Perspective
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Lisa M. Young, OD, FAAO
Trabeculectomy, the unquestionable gold standard in glaucoma procedures for lowering IOP, uses the formation of a bleb to improve aqueous outflow. Creating the perfect bleb is an art. While it normally takes months to create one surgical masterpiece, it takes years and years of practice to perfect this skill.
Unsurprisingly, Gabai and colleagues found in their meta-analysis of glaucoma surgeries that trabeculectomy is more effective in lowering IOP, but with a higher complication rate as compared with other nonpenetrating glaucoma surgeries.
Dysfunctional blebs and their myriad of complications are undoubtedly the bane of glaucoma surgery. The success of this procedure not only depends on the art of its creation, but external factors can also negatively influence outcomes. These factors include: the age of patient, type of glaucoma, stage of disease, prior ocular surgeries, history of topical therapy and duration of topical therapy — just to name a few.
Until we find a procedure that consistently produces a comparable IOP reduction with an improved safety profile, the beauty of the bleb should be considered similarly to a piece of art, in that it should be left in the “eye” of the beholder.
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