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Editors Selection IGR 24-4
Surgical Treatment: Outcomes of gonioscopy-assisted Trabeculotomy
Comment by Xiulan Zhang & Zefeng Yang on:
117011 Gonioscopy-Assisted Transluminal Trabeculotomy Outcomes Under Different Levels of Glaucoma Severity: A Multicenter, Comparative Study, Magacho L; Franco CGVS; I EA et al., American Journal of Ophthalmology, 2024; 264: 75-84
Gonioscopy-assisted transluminal trabeculotomy (GATT) is a minimally invasive, conjunctiva-sparing surgery, initially considered effective for mild to moderate primary open-angle glaucoma (POAG).1 Recent evidence shows it is also safe and effective for advanced cases.2,3 At this point, comparing GATT outcomes across different glaucoma severities can help surgeons identify its suitability for different patients.
In this multi-center retrospective study by Magacho et al., GATT (Phaco-GATT or GATT stand-alone) was performed on 270 eyes (90 mild, 75 moderate, 105 advanced POAG). At 12 months postoperatively, GATT reduced IOP significantly across all groups, from 18.6 mmHg (mild), 19.7 mmHg (moderate), and 21.0 mmHg (advanced) preoperatively, to around 11.9 mmHg in all groups. Relative success rates remained high (88.1% to 93.8%) in all groups. However, complete success rates declined with increasing severity (61.8% in mild, 43.8% in moderate, and 37.6% in advanced cases), even though the researchers believed that glaucoma severity is not a major variable associated with surgical success. This study addresses a common limitation of previous research that often reports average outcomes without stratifying by glaucoma severity.
GT, also called ab interno trabeculotomy, can be performed with different degrees. Previous studies comparing 120°, 240°, and 360° GT (GATT) with or without phacoemulsification cataract extraction and intraocular lens implantation (PEI) have shown similar efficacy in reducing IOP and medication use in POAG.4-7 This suggests that 120° GT with or without PEI, which is associated with a simpler procedure and fewer complications, is sufficient for treating POAG. In juvenile-onset open-angle glaucoma (JOAG), 240° and 360°GT showed similar efficacy in IOP reduction, both superior to 120°GT (unpublished data), similar to previous study.8 This suggests that a broader surgical range provides better results in JOAG. Therefore, larger, prospective studies, ideally RCTs, are still needed to confirm the necessity of GATT.
References
- Chan PPM, Larson MD, Dickerson JE Jr, et al. Minimally Invasive Glaucoma Surgery: Latest Developments and Future Challenges. Asia Pac J Ophthalmol (Phila). 2023;12(6):537-564.
- Dar N, Naftali Ben Haim L, Yehezkeli V, et al. Gonioscopy-assisted transluminal trabeculotomy in patients with advanced glaucoma. Indian J Ophthalmol. 2023;71(8):3024-3030.
- Aktas Z, Ucgul AY, Bektas C, Sahin Karamert S. Surgical Outcomes of Prolene Gonioscopy-assisted Transluminal Trabeculotomy in Patients With Moderate to Advanced Open-Angle Glaucoma. J Glaucoma. 2019;28(10):884-888.
- Song Y, Zhu X, Zhang Y, et al. Outcomes of Partial Versus Complete Goniotomy With or Without Phacoemulsification for Primary Open Angle Glaucoma: A Multicenter Study. J Glaucoma. 2023;32(7):563-568.
- Zhang Y, Yu P, Zhang Y, et al. Influence of Goniotomy Size on Treatment Safety and Efficacy for Primary Open-Angle Glaucoma: A Multicenter Study. Am J Ophthalmol. 2023;256:118-1125.
- Hirabayashi MT, Lee D, King JT, et al. Comparison Of Surgical Outcomes Of 360° Circumferential Trabeculotomy Versus Sectoral Excisional Goniotomy With The Kahook Dual Blade At 6 Months. Clin Ophthalmol. 2019;13:2017-2024.
- Sato T, Kawaji T. 12-month randomised trial of 360° and 180° Schlemm's canal incisions in suture trabeculotomy ab interno for open-angle glaucoma. Br J Ophthalmol. 2021;105(8):1094-1098.
- Qiao Y, Tan C, Chen X, et al. Gonioscopy-assisted transluminal trabeculotomy versus goniotomy with Kahook dual blade in patients with uncontrolled juvenile open-angle glaucoma: a retrospective study. BMC Ophthalmol. 2021;21(1):395.
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