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Editors Selection IGR 16-3

Surgical treatment: Current trends in surgery

Comment by Rupert Bourne on:

59097 Recent trends in glaucoma surgery in Scotland, England and Wales, Murphy C; Ogston S; Cobb C et al., British Journal of Ophthalmology, 2015; 99: 308-312

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Murphy et al. present the numbers of trabeculectomy and aqueous shunt procedures performed over 20 years from 1993 to 2012 in England, Scotland and Wales. Highest rates of trabeculectomy were achieved in 1995, followed by a sharp decline by a factor of three until 2000. Since then, rates have remained stable at approximately 33 trabeculectomies per 100,000 population aged 60+ years. The authors noted that numbers of aqueous shunts, a much more infrequently performed operation throughout, began to rise in 2003 with a steep rise from 2009 to 2012 (2012: four shunts per 100,000 aged 60+ yrs). By 2012, the ratio of trabeculectomy to aqueous shunt was 10:1 in this age group. In children, a national trend towards increased use of aqueous shunts and decreased use of trabeculectomy was observed, in 2012, the ratio was 2:1.

trabeculectomy still remains an important surgical option for glaucoma despite growing numbers of alternative laser and shunt procedures

This work followed a robust methodology involving national hospital statistics. Although errors can and do occur with validity of diagnostic/operative coding, and these statistics only include the state-run National Health Service, it is likely that we are seeing a valid picture of national trends, which fits with similar observations in the United States¹ and Canada,² where tube implantation has become increasingly popular.

The trabeculectomy rate among those aged 60+ years remains static since 2000 yet the population in this age group increased by 18% between then and 2012, so the crude numbers of trabeculectomies performed per year continued to rise. Although the numbers of aqueous shunts implanted is much smaller, they are becoming more commonly used and this may reflect a growing perception that the role of shunts is not only limited to refractory glaucoma. The same explanation may underly the observation also made by this study, that ciliary body laser photocoagulation procedures had doubled between 2003 and 2012 in this older age group. Against this surgical backdrop, a 67% increase in NHS prescriptions for glaucoma occurred between Yr2000 (4.8 million) and 2012 (7.9 million) in the United Kingdom!³

The national surgical picture painted by this study is an important resource for commissioners of care in the UK's National Health Service where the demands on resources are increasingly intense. It demonstrates that trabeculectomy still remains an important surgical option for glaucoma despite growing numbers of alternative laser and shunt procedures, and emphasizes the importance of maintaining adequate resources for glaucoma surgery that includes high standards of surgical training.

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