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Comment by Franz Grehn on:

46501 Treating patients presenting with advanced glaucoma - Should we reconsider current practice?, King AJ; Stead RE; Rotchford AP, British Journal of Ophthalmology, 2011; 95: 1185-1192

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This paper discusses the current evidence on the question, whether pri-mary surgery may be preferable to medical treatment in advanced glaucoma cases.

The present knowledge on surgery (trabeculectomy) versus medical treatment as tested in randomized prospective trials shows significantly better IOP control in surgery. Also the cross-over to surgery in medically treated cases underlines the high efficacy of trabeculectomy for IOP control. A secondary analysis of the CIGTS report resulted in better long term visual field outcome in those patients who had more advanced disease (> 10 dB loss) despite average outcome of all patients was similar. In the AGIS post hoc analysis, a IOP control of < 18 mmHg in all visits resulted in a preservation of the visual field over seven years in advanced glaucoma cases. Taken from these and other studies carefully analyzed in the review of King et al., surgery as a primary approach in advanced cases is to be considered.

Visual acuity is better in medically treated cases until a late follow up time point, but the incidence of cataract surgery must be taken into account in this analysis.

There are, however, several factors beyond good IOP control that have to be calculated in advanced cases:

• The complication rate of surgery is not insignificant, although some studies (CIGTS) do not support this statement. However, cataract formation generally accelerated after glaucoma surgery and failure of previously functioning filtering blebs has been found in a considerable percentage of cases even after modern clear cornea phaco surgery.
• It is not known in how far an advanced stage of glaucoma damage impairs the outcome of trabeculectomy. The comparison of surgery versus medical treatment in eyes with central islands has not been done. In addition the SAP assessment of visual field in central island is difficult. The wipe out dilemma in far advanced cases has never been solved because the cohort of visual field defects taken for these studies were too heterogenous.
• According to the review of King et al., the QoL issues are not different in the two treatment modalities and patients preferred surgery in the second eye in one study.
• Economic considerations cannot be evaluated from the literature as nowadays day care surgery is routinely used. From this point of view,surgery may be less costly than medical treatment. However, medical treatment is often added at a later stage after surgery depending on the individual physicians decision and may increase cost of surgical cases at later follow-up.

In summary, the review of King et al. provides a very comprehensive and balanced summary of the available data. A couple of arguments are in favor of early surgery for advanced cases of glaucoma. However, the available evidence is not sufficient to support a recommendation of primary surgery in these cases.

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