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Editors Selection IGR 11-4

Surgical Treatment: Goniotomy-assisted Trabeculotomy

Comment by Sameh Mosaed on:

76848 Gonioscopy-assisted Transluminal Trabeculotomy: An Ab Interno Circumferential Trabeculotomy: 24 Months Follow-up, Grover DS; Smith O; Fellman RL et al., Journal of Glaucoma, 2018; 27: 393-401

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In the May 2018 issue of Journal of Glaucoma, Grover et al. published the 24-month results of the GATT procedure in their article entitled, 'Gonioscopy-assisted Transluminal Trabeculotomy: 24 Months Follow Up.' This is a follow-up to the 2014 study published in Ophthalmology that presented the initial results of the procedure, and includes data from patients in that publication, but also includes additional subjects and longer-term follow-up. This is a retrospective chart review of 198 patients who had at least 18-month follow-up data, with most achieving 24-month follow-up. The authors provide data for the entire group, as well as for six subcategories: POAG with no prior CE, POAG combined with CE/IOL, POAG with prior CE/IOL, secondary open-angle glaucoma (SOAG) with no prior CE, SOAG combined with CE/IOL, SOAG with prior CE/IOL. The POAG group had a 9.2 mmHg reduction in IOP, representing a 37.3% reduction from baseline. The SOAG group had a 14.1 mmHg reduction in IOP, representing a 49.8% reduction from baseline. Of all the groups, the pseudophakic POAG group had the highest proportion of failure. This was thought to be the result of having a higher proportion of advanced glaucoma patients in this group, with lower target IOP, resulting in more re-operations for IOP control. As a result, the authors suggest considering an alternative treatment if the HVF MD is worse than -15 dB. This finding that patients with more advanced glaucoma tended to do substantially worse with GATT when compared to patients with mild to moderate glaucoma is postulated to result from downstream collector channel and intrascleral plexus sclerosis in these advanced POAG patients. This finding is somewhat contradictory to some studies published on other trabecular bypass procedures, such as a recent study by SF Ahmed et al. showing that IOP reduction and overall success following Trabectome was relatively similar in advanced cases as compared to early disease. However, comparisons between these studies are impossible to draw, given the retrospective nature and variable reporting standards. Larger controlled, prospective studies on trabecular bypass procedures will help elucidate patient populations that benefit most from these interventions.

The authors report that hyphema was the most common complication, occurring at a rate of about 30% within the first week, with nearly all cases resolving by 30 days post op. The evolution of the surgical technique and decision-making resulting from the author's initial experience include: leaving a modest amount of viscoelastic in the anterior chamber to reduce large hyphema from hypotony, and considering the inability to discontinue anticoagulants as a contraindication to GATT.

One key issue that Grover et al. touch upon in this paper is that when the GATT is performed using a thermally-blunted 5-0 prolene suture, the cost of the suture is only 5$. This is in stark contrast to the other trabecular bypass procedures where implants or required disposables cost several hundreds of dollars per case. In a strained global healthcare delivery environment, development and optimization of such a low-risk, inexpensive surgical option such as the GATT is imperative, and these results are highly encouraging.

Development and optimization of such a low-risk, inexpensive surgical option such as the GATT is imperative, and these results are highly encouraging

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