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Editors Selection IGR 9-4

Surgery: Medical versus surgical treatment

Comment by Kuldev Singh on:

16976 Role of early trabeculectomy in primary open-angle glaucoma in the developing world, Anand A; Negi S; Khokhar S et al., Eye, 2007; 21: 40-45

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Initial trabeculectomy has a better IOP lowering effect as opposed to medical treatment

Glaucoma care remains a major challenge in many parts of the developing world limited both by the ability to diagnose the disease prior to advanced damage as well as by the lack of safe, effective and affordable treatment methods. Thus the report by Anand et al. (320), based upon a small, but well designed randomized clinical trial comparing medical versus surgical therapy for glaucoma, is particularly refreshing. In addition to comparing these two treatment modalities, the investigators also assess the benefit of health education regarding glaucoma as a factor influencing the choice of therapy. The authors acknowledge that the choice of medications in their study does not include some of the more recently introduced therapeutic agents.

One striking finding in this report is the modest IOP lowering even with initial surgery

The major findings of the study include better IOP lowering with initial trabeculectomy as opposed to medical treatment and an increased willingness of patients to undergo initial surgery with better understanding of the disease, its consequences and the pros and cons of various treatment options. Unlike CIGTS, where patients preferred initial medical therapy with regard to quality of life parameters, there is no statistically significant difference found in patient preference between the two treatment groups in this study. With the small sample size in this trial, however, the power of the study was likely not sufficient to determine such a preference if one was present.

Better understanding of disease glaucoma causes an increased willingness of patients to undergo initial surgery

One striking finding in this report is the modest IOP lowering even with initial surgery. Primarily operated eyes had a mean IOP of 17.9 mmHg at the 12-month postoperative visit. While this was a significant lowering from the baseline of 31.9 mmHg, 12 months is a relatively short period of time in the life of a glaucoma patient and to think that the average IOP is approximately 18 mmHg at one year following a procedure which generally works less well with time leads one to be skeptical that adequate IOP lowering will be obtained over 5 or 10 years.

The conclusions of this study support initial surgical therapy as opposed to medical therapy for patients with moderate glaucomatous optic nerve damage and visual field loss presenting to a clinic in the developing world. This is by no means a new finding. Medical therapy, particularly involving the newer more effective IOP lowering agents, remains difficult to deliver for many logistical reasons, most prominent of which is the cost of therapy, in the developing world. It is important to keep in mind that the developing world is really not just one world. Health care strategies that work in India may or may not be appropriate in Sub-Saharan Africa or areas of Latin America. Large cities in many developing countries often have subsets of patients who have both the resources and expectations to match the most demanding of patients in the developed world. Thus there is no general statement regarding the relative merits of initial surgery versus medical therapy that can be made which captures all clinical situations in the developing world. Nevertheless, this report is an important addition to the body of literature in that it not only addresses the limitations of taking care of glaucoma patients in the developing world but also points out that education of patients may impact what treatment option is ultimately chosen.

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