EyeWorld Asia-Pacific June 2011 Issue

34 EW GLAUCOMA June 2011 New strategies for glaucoma surgery by Michelle Dalton EyeWorld Contributing Editor An example of a failed trabeculectomy Source: Leon W. Herndon, MD AT A GLANCE • Newer techniques are making traditional surgery safer; trabeculectomy remains the single most commonly performed glaucoma surgery • Phacoemulsification alone and phaco-trab are being used earlier in the treatment strategy as a means of lowering IOP • Blebless surgery will continue to gain acceptance • Surgical strategies continue to differ between phakic and pseudophakic patients The advent of blebless procedures and adjuncts to trabeculectomy means more surgeons might consider surgery earlier in their management strategy G laucoma is primarily one of those chronic diseases that cannot be “cured”, where the most a clinician can hope for is to stave off progression of the disease long enough to preserve a patient’s sight throughout the remainder of the patient’s life. Surgery has been typically successful for decades, and although there are risks involved, most patients can be managed with a combination of medical and laser or surgical therapies. These days, however, with the advent of numerous ab-interno procedures and modifications to bleb-inducing procedures, surgical options may be considered not as a last resort but as part of a strategic management strategy. While trabeculectomy remains the gold standard for the surgical management of glaucoma, technologic advances in other areas are helping to make the procedure safer and helping physicians diagnose earlier, experts say. “Diagnostics continue to evolve,” said Robert J. Noecker, MD, vice chair, University of Pittsburgh Medical Center Eye Center, Pittsburgh, Pa., USA. Whereas 5 years ago, spectral- domain optical coherence tomography was state of the art, these days it’s considered routine, he said, adding that the ability to image the nerve fiber layer is “helping diagnose people earlier. We’re slowly chipping away at that standard phrase that half the people with glaucoma don’t know they have it.” Why surgery is viable Adjuncts in trabeculectomy surgery such as the EX-PRESS Glaucoma Filtration Device (Alcon, Fort Worth, Texas, USA/Hünenberg, Switzerland) “standardize the non- standard procedure,” Dr. Noecker said. “There will be some situations in surgery where I don’t want to manipulate the iris,” said Thomas K. Mundorf, MD, Mundorf Eye Center, Charlotte, NC, USA. “Most of my surgical patients will need an iridectomy. The EX-PRESS helps speed up the surgery a bit and offers a nice alternative to standard trabeculectomy. An upside is that the post-op care is not significantly impacted.” Agreed Louis B. Cantor, MD, chairman and professor Views from Asia-Pacific Ivan GOLDBERG, MD Clinical Associate Professor, University of Sydney Eye Associates, Floor 4, 187 Macquarie Street, Sydney NSW 2000, Australia Tel. no. +612-92311833 Fax no. +612-93375557 eyegoldberg@gmail.com I n contrast with cataract extraction surgery, which has become more predictable with enhanced visual results faster than ever before, techniques to control intraocular pressure (IOP) for patients with glaucoma have not improved as dramatically. Enhancements to the 40-year-old trabeculectomy procedure (notably better bleb construction, especially with wider application of anti-metabolites and more recently with help from anti-VEGF agents, along with improved safety and speed offered by the EX-PRESS shunt) have helped, but have not yet achieved desirable reproducibility with long-lasting effectiveness. Hence the ongoing attempt to find the “ideal” glaucoma operation. As this article explains, there are several approaches that are being explored concomitantly, all claiming notable successes with improved safety, especially when control is achieved without a bleb. Time will tell which of these procedures will offer the best short- and long-term effectiveness/safety profile, and for which glaucoma patients: there are bound to be major differences. In addition, we will need to determine what works best for the various patient sub-groups when combined with cataract extraction surgery or when used alone. As we understand better the mechanisms by which IOP is controlled successfully by the many newer procedures, and as our technologies improve to allow separation of glaucoma patients by identifying the site(s) of aqueous outflow resistance (e.g., improved anterior segment OCT or ultrasound imaging) so we will become increasingly able to offer the appropriate technique to each patient. Anticipated keenly over the next 5-10 years, such progress will change our paradigm for glaucoma management. More predictable and safer techniques, tailor-made for an individual patient would lead to an accelerated offering of surgery to glaucoma patients at an earlier stage in their life-long management. We have much to which we can look forward. Editors’ note: Prof. Goldberg is a consultant for Alcon, Allergan (Irvine, Calif., USA), Merck (Whitehouse Station, NJ, USA), and Pfizer (New York, NY, USA), but has no direct financial interests related to his comments.