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Editors Selection IGR 9-4

Surgical Treatment: Beta radiation for glaucoma surgery

Comment by Keith Barton on:

24385 Beta radiation for glaucoma surgery, Kirwan JF; Rennie C; Evans JR, Cochrane Database of Systematic Reviews, 2009; CD003433

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This report by Kirwan et al. (1310) consists of a systematic review, the stated purpose of which was to assess the effectiveness of beta radiation during glaucoma surgery (trabeculectomy). The authors searched the Cochrane Central Register of Controlled Trials, MEDLINE (January 1966 to October 2008) and EMBASE (January 1980 to October 2008) on 24 October 2008. From the above databases, the authors selected randomized controlled trials comparing trabeculectomy with beta radiation to trabeculectomy without beta radiation. Four trials that randomized 551 patients were found to be suitable for inclusion. Two of these were performed in Caucasians (n = 126), one in black Africans (n = 320) and one in Chinese subjects (n = 105). The authors concluded that trabeculectomy with beta radiation had a lower risk of surgical failure than trabeculectomies without (pooled risk ratio, RR, 0.23, confidence interval, CI, 0.14 to 0.40). However, beta radiation was associated with a higher risk of cataract (RR 2.89, CI 1.39 to 6.0) Two of the four studies analyzed were judged to be of the highest methodological quality. Although relatively few studies were analyzed, this is a useful review. All four studies reported some treatment effect from beta radiation, i.e., improved trabeculectomy success in terms of better IOP control. As might be expected, the failure rates at 12 months in the control groups varied according to race (30% for Africans and 12-14% for Caucasians, with Chinese in between) in a post-hoc analysis performed by the authors. Although the numbers of complications were low, bleb leaks and hypotony were not associated with the use of beta radiation. Beta radiation is an attractive alternative

The elevated risk of cataract limits its potential to pseudophakic patients or phakic patients with cataract already scheduled for surgery

to liquid anti-proliferative drugs such as 5FU and MMC. As it is contained in a solid radioactive applicator, there is no risk of spillage and, notwithstanding the logistical problems associated with using a radioactive applicator, it may be more suited to developing countries than the above substances. The elevated risk of cataract limits its potential to pseudophakic patients or phakic patients with cataract already scheduled for surgery.

The authors suggest further investigation and this is warranted, given that a number of those who have used beta radiation in the past, have observed more diffuse and less dysfunctional blebs than those seen after MMC exposure, and given that the comparative efficacy of the two modalities is uncertain.

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