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Editors Selection IGR 10-3

Surgical Treatment: Medication reduction after surgery

Comment by Ike Ahmed on:

24501 Viscocanalostomy versus trabeculectomy for primary open angle glaucoma: 4-year prospective randomized clinical trial, Gilmour DF; Manners TD; Devonport H et al., Eye, 2009; 23: 1802-1807

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Gilmour et al. (1300) reaffirm the superiority of trabeculectomy over viscocanalostomy in terms of reduction of medication use in a prospective randomized trial. Although there appears to be a difference in IOP reduction and absolute success, the study was underpowered to adequately show such. Interestingly, bleb needling was required in 30% of trabeculectomy eyes, versus 4% in the viscocanalostomy eyes, with anti-metabolite used in most of these needlings. An argument could be made than unlike postoperative laser suture lysis or laser goniopuncture, the use of needling and antimetabolites constitute a major intervention analogous to a re-operation with its inherent risks. Looking at the results in this manner would significantly decrease the success rate of trabeculectomy. Potentially serious complications, such as hypotony and choroidal detachments were found to be more common in the trabeculectomy group. As has been noted in other studies, the use of postoperative Nd:YAG goniopuncture in viscocanalostomy can provide further IOP lowering with high safety, yet in this study was only performed in one patient. This study adds further thought into the decision-making factors in approaching a patient requiring surgical intervention. Does one select a more potent procedure (trabeculectomy) with its increased risks and requirement for potential serious postoperative adjunctive procedures/medications and long-term bleb related issues, or a somewhat less potent procedure (viscocanalostomy) with less risk, postoperative procedures and potential bleb issues? The answer of course lies with individualizing care to the given patient. A much larger study also looking at functional outcomes (i.e., visual field preservation) and with longer follow-up would certainly increase the level of evidence in this area.

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