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Editors Selection IGR 20-4

Surgical Treatment: Trabectome Outcomes in Steroid-induced Glaucoma

Nils Loewen

Comment by Nils Loewen on:

70763 Outcome of primary trabeculotomy ab interno (Trabectome) surgery in patients with steroid-induced glaucoma, Ngai P; Kim G; Chak G et al., Medicine, 2016; 95: e5383


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Steroid-induced glaucoma (SIG), a secondary open angle glaucoma, can cause high IOP that neither the patient nor the steroid prescribing provider notice.1 Any corticosteroids can cause the overexpression of myocilin in the trabecular meshwork (TM),2 stress actin fibers,3 reduced phagocytosis4 and increased stiffness.5 Thankfully, less than 5% of the population experience a more than 5 mmHg IOP increase. About 1% -5% of SIG patients experience progression with non-surgical therapies.1

Ngai et al. presented a retrospective cohort study with 12 months follow-up, showing Trabectome alone significantly reduced IOP of 20 SIG patients from 33.8 ± 6.9 to 15.0 ± 3.5 mmHg and medication from 3.9 ± 0.8 to 2.3 ± 1.4.6 A strength of this study was that same session phacoemulsification was excluded to focus on IOP as the primary indication although an additional IOP reduction was neither seen in POAG7,8 nor in SIG.9 Ngai's results in SIG matched our findings:9 using the same criteria, one-year success rates were comparable. Only a few cases with uncontrolled IOP received secondary glaucoma surgeries. No major vision-threatening complications were encountered in either study. While there was no control group, our study of 60 SIG patients also included 484 coarsened exact-matched individuals (one-to-many) and showed that despite a higher baseline IOP in SIG, the IOP reduction is the same.

Ab interno trabeculectomy with the Trabectome provides a bleb free, micro-incisional approach that removes the tissue primarily affected by steroids in these patients, namely the TM. This publication further increases the spectrum of indications for Trabectome surgery which can include more advanced stages,10 and additional types of glaucoma, regardless whether secondary,11,12 refractory 13,14 or accompanied by a narrow angle.15

References

  1. Razeghinejad MR, Katz LJ. Steroid-induced iatrogenic glaucoma. Ophthalmic Res 2012;47:66-80.
  2. Fingert JH, et al. Evaluation of the myocilin (MYOC) glaucoma gene in monkey and human steroid-induced ocular hypertension. Invest Ophthalmol Vis Sci 2001;42:145-152.
  3. Hoare M-J, et al. Cross-linked actin networks (CLANs) in the trabecular meshwork of the normal and glaucomatous human eye in situ. Invest Ophthalmol Vis Sci 2009;50:1255-1263.
  4. Zhang X, Ognibene CM, Clark AF, Yorio T. Dexamethasone inhibition of trabecular meshwork cell phagocytosis and its modulation by glucocorticoid receptor beta. Exp Eye Res 2007:275-284.
  5. Raghunathan VK, et al. Dexamethasone Stiffens Trabecular Meshwork, Trabecular Meshwork Cells, and Matrix. Invest Ophthalmol Vi.s Sci 2015:4447-4459.
  6. Ngai P, et al. Outcome of primary trabeculotomy ab interno (Trabectome) surgery in patients with steroid-induced glaucoma. Medicine 2016;95, e5383.
  7. Parikh HA, Bussel II, Schuman JS, Brown EN, Loewen NA. Coarsened Exact Matching of Phaco-Trabectome to Trabectome in Phakic Patients: Lack of Additional Pressure Reduction from Phacoemulsification. PLoS One 2016;11, e0149384.
  8. Neiweem AE, Bussel II, Schuman JS, Brown EN, Loewen NA. Glaucoma Surgery Calculator: Limited Additive Effect of Phacoemulsification on Intraocular Pressure in Ab Interno Trabeculectomy. PLoS One 2016;11, e0153585.
  9. Dang Y, et al. Steroid-induced glaucoma treated with trabecular ablation in a matched comparison with primary open-angle glaucoma. Clin Experiment Ophthalmol 2016;44:783-788.
  10. Dang Y, et al. Combined analysis of trabectome and phaco-trabectome outcomes by glaucoma severity. F1000Res 2016;5:762.
  11. Akil H, et al. Clinical Results of Ab Interno Trabeculotomy Using the Trabectome in Patients with Pigmentary Glaucoma compared to Primary Open Angle Glaucoma. Clin Experiment Ophthalmol 2016. doi:10.1111/ceo.12737
  12. Ting JLM, Damji KF, Stiles MC; Trabectome Study Group. Ab interno trabeculectomy: outcomes in exfoliation versus primary open-angle glaucoma. J Cataract Refract Surg 2012;38:315-323.
  13. Loewen RT, et al. Impact of a Glaucoma Severity Index on Results of Trabectome Surgery: Larger Pressure Reduction in More Severe Glaucoma. PLoS One 2016;11, e0151926.
  14. Mosaed S, Chak G, Haider A, Lin KY, Minckler DS. Results of Trabectome Surgery Following Failed Glaucoma Tube Shunt Implantation: Cohort Study. Medicine 2015;94, e1045.
  15. Bussel II, Kaplowitz K, Schuman JS, Loewen NA; Trabectome Study Group. Outcomes of ab interno trabeculectomy with the trabectome by degree of angle opening. Br J Ophthalmol 2015;99:914-919.

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