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Editors Selection IGR 9-1

Surgical Treatment: 120 degree ab-externo trabeculotomy versus trab with MMC

Comment by Sameh Mosaed on:

45574 Success rates of trabeculotomy for steroid-induced glaucoma: A comparative, multicenter, retrospective cohort study, Iwao K; Inatani M; Tanihara H, American Journal of Ophthalmology, 2011; 151: 1047-1056

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In this retrospective cohort study, Iwao et al. (811) aimed to compare the long term success rate of 120 degree ab-externo trabeculotomy to trabeculectomy with MMC, on patients with steroid induced glaucoma and primary open angle glaucoma (POAG). One hundred and twenty-one patients with steroid induced glaucoma who underwent trabeculotomy were compared to 108 patients with POAG who underwent trabeculotomy, and 42 subjects with steroid induced glaucoma who underwent trabeculectomy with MMC. Failure rates were defined as the need for additional glaucoma medications, IOP greater ≥21 mmHg, or worsening of vision to NLP (criterion A), and IOP ≥18 mmHg (criterion B). At three years, the probability of success for trabeculotomy for steroid induced glaucoma was higher than for POAG (78.1% vs. 55.8%) for criterion A, and proportionately even higher for criterion B (56.4% vs. 30.6%). These findings support the histochemical evidence that steroid induced glaucoma is primarily a result of increased trabecular resis- tance, whereas POAG may be the result of a complex interplay of multiple factors, trabecular resistance being only one of these. The authors also compared the results of trabeculotomy vs. trabeculectomy with MMC for steroid induced glaucoma and found that the success rates were comparable at three years. Not surprisingly, for the subjects with steroid induced glaucoma, the post operative complications were higher in the trabeculectomy group, with development of choroidal detachments (4.8% ), flat anterior chamber (2.4%), and hypotony maculopathy in 16.7% of eyes. None of these complications were seen in the trabeculotomy group. Cataract progression was noted in fewer eyes with trabeculotomy than trabeculectomy. When considering the application of these findings to any particular patient, it is of note that this study was performed on a purely Japanese patient population, and subject to the pitfalls of any retrospective chart review. However, 17 different clinical centers were involved, with various surgeons performing both limbal and fornix ‐ based trabeculectomies. This study supports the consideration of trabeculotomy as a surgical alternative to trabeculectomy for steroid induced glaucoma, with reasonable long term IOP control and fewer serious complications.

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