EWAP DECEMBER 2022 33 GLAUCOMA W hile there has been a revolution within the last decade in terms of glaucoma management—surgical and medical—Leon Herndon Jr., MD, would argue that trabeculectomy is still the most basic of glaucoma management procedures. “I think when you say ‘basic,’ the connotation is that it’s simple. It’s not. Trabeculectomy itself is not a challenging surgery, but the management postop is very challenging,” Dr. Herndon said. “It’s the gold standard. Even though first popularized in late 1970s, there is still nothing else out there that’s going to get the pressure as low as a trabeculectomy will.” Even among the myriad of options for glaucoma patients now available, Dr. Herndon said that he thinks some patients are still going to need a trab, and he worries that fewer surgeons will be able to perform and manage this in the future. “I believe in MIGS and intervening earlier with safer procedures, but if you look at the data, the number of trabeculectomies being performed even in training programs is going down. In a few years we’ll have relatively few physicians who know how to do a trabeculectomy,” he predicted. There are a couple of reasons why Dr. Herndon thinks trabeculectomy is going down. One is the Tube Versus Trabeculectomy Study, which Dr. Herndon said demonstrated that tube surgery was a reasonable option for patients with severe disease, thus leading to some procedures being replaced with glaucoma drainage tubes. MIGS, in more recent years, has also taken up some of this space, Dr. Herndon added. “It depends on your practice. My practice is typically a very advanced glaucoma practice, and these aren’t the types of patients you are going to be doing MIGS on and in some cases tubes. If you need pressures in the single digits, there is only one way you’re going to get there—trabeculectomy,” he said. “I think nationwide the numbers are going down with trabeculectomy, but I think there are several pockets in the country where providers see a lot of advanced glaucoma, and you still need to do a trabeculectomy. I think any glaucoma surgeon in his or her practice can’t get away from severe glaucoma, and the concern is that if you’re not training and getting your fingers wet doing trabeculectomy, once you get out in practice, you’re going to do a disservice to patients with severe disease if you do [a MIGS] because it’s the only thing you know how to do.” Dr. Herndon reiterated that The case for trabs: ‘Trabeculectomy is not dead’ by Liz Hillman Editorial Co-Director Contact information Herndon: leon.herndon@duke.edu Trabeculectomy flap being created. Source: Leon Herndon, MD This article originally appeared in the September 2022 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp.
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