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Editors Selection IGR 9-1
Surgical Treatment: Ethnic Differnces in Trabectome Outcomes
Comment by Sameh Mosaed on:
78271 Ab interno trabeculectomy with Trabectome: outcomes in African American versus Caucasian patients, Nazarali SA; Damji KF, Canadian Journal of Ophthalmology, 2018; 53: 361-364
In this prospective case-control study, 82 African-American patients were compared with 82 Caucasian patients who underwent ab-interno trabeculectomy with the Trabectome over an eight-year period. The data were collected from the Trabectome database, representing the results from dozens of different Trabectome surgeons from US and international centers. Nearest-neighbor matching was used to match data by glaucoma type, age, and baseline IOP. All subjects had at least 12 months followup. Thirty-four percent of the cases in both groups were comprised of combined Trabectome+ phaco cases, where 66% were Trabectome alone cases.
The authors found that there were no statistical differences in the outcomes between the two groups in terms of IOP, number of medications, or complication rates. IOP was reduced from 21.2 mmHg in both groups to 16.1 mmHg in the African-American group and 15.7 mmHg in the Caucasian group.
African-American patients are known to have poorer outcomes with incisional glaucoma surgery as compared with Caucasian patients as supported by decades of evidence in the literature. This is true for trabeculectomy, as well as for tube shunt implantation, ex-PRESS glaucoma filtration devices, and canaloplasty. The basis of these race-based differences are thought to be related to more robust wound-healing responses in patients of African descent. However, little data exists on the outcomes of angle-based surgeries in this population, which may be affected less by wound-healing responses than conjunctival or tenonbased procedures. Late postoperative scarring can result in PAS formation and closure of the trabecular-bypass cleft created by the Trabectome, however, it appears more likely that downstream outflow resistance is the limiting factor in cases of failed TM bypass procedures. The data from this study suggests that race does not significantly reduce the success rate or IOP reduction seen in patients from African descent, implying that postoperative wound healing plays a diminished role in outcomes of TM bypass surgery.
The limitations of the study include use of the multi-center database which can lead to incomplete data collection and lack of a controlled protocol for degrees of ablation, postoperative medication usage, and variability in surgeon technique. Nevertheless, this study provides some confidence that TM bypass procedures may rely less on post-operative wound healing and may level the proverbial playing field among races for surgical success.
References
- The Advanced Glaucoma Intervention Study (AGIS): 4. Comparison of treatment outcomes within race: Seven-year results. Ophthalmology. 1998;105:1146-1164.
- The Advanced Glaucoma Intervention Study (AGIS): 9. Comparison of glaucoma outcomes in black and white patients within treatment groups. Am J Ophthalmol. 2001;132:311-320.
- Freedman J, Ferri S. Long-term comparison using Ex-Press glaucoma shunt in black and white patients. Can J Ophthalmol. 2014;49:200-204.
- Gedde SJ, Schiffman JC, Feuer WJ, et al. Treatment outcomes in the Tube Versus Trabeculectomy (TVT) study after five years of follow-up. Am J Ophthalmol. 2012;153:789-803.
- Ishida K, Netland PA. Ahmed Glaucoma Valve implantation in African American and white patients. Arch Ophthalmol. 2006;124:800-806.
- Taubenslag KJ1, Kammer JA. Outcomes Disparities between Black and White Populations in the Surgical Management of Glaucoma. Semin Ophthalmol. 2016;31(4):385-393.
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