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Alternative Surgical Approaches to Glaucoma

In an effort to reduce complications associated with conventional glaucoma surgery, new surgical options are being developed by medical device companies. Each approach exploits a specific strategy to reduce the pressure within the eye.

The adoption of new surgical approaches into a physician practice that treats a chronic disease like glaucoma is no simple matter. The slow course of the disease makes it difficult for researchers and developers of new surgical approaches to determine if patients fare better with the new intervention, often taking many years and several large studies to achieve a reasonable degree of certainty.

Additionally, since the most common classic glaucoma surgeries — shunts and trabeculectomy — are associated with some potentially hazardous outcomes, when surgical intervention is considered for a patient the disease is often serious enough that vision is threatened.

While these classic techniques have risks, they also have an established track record. The results, both good and bad, are well known. New surgical techniques offer the promise of less risky treatment, but their problems and long-term effectiveness is less understood.

Three Surgical Alternatives

Several new surgical approaches have been developed in an effort to reduce complications associated with conventional glaucoma surgery. Each approach exploits a specific strategy to reduce the pressure within the eye.

  • The Ex-Press mini glaucoma shunt can be used with conventional trabeculectomy techniques to standardize the operation and perhaps reduce the chances of the eye pressure getting too low in the immediate post-operative period, which is occasionally a problem with conventional approaches.
  • The Trabectome device removes tissue from the drain inside the eye (the trabecular meshwork) using an electro-surgical handpiece that disrupts the tissue.
  • Canaloplasty involves the dilation of the entrance to the outflow pathways in the wall of the eye (Schlem's canal) in addition to constructing an artificial fluid outflow mechanism within the eye wall to reduce the pressure in the eye.

While each of these techniques has potential advantages, there are limited data to support long-term efficacy and even less data that is not derived from studies directly supported by the companies that develop these products.

At the current time the clear indications for these procedures are still being determined. Many questions remain as to how these approaches should best be utilized in the treatment of glaucoma.

Is it right for you?

If you are a glaucoma patient, you might consider one of these new surgical approaches in consultation with your physician if:

  • you do not have advanced disease, and
  • you do not require a very low target intraocular pressure.

It is important to recognize that the long-term effectiveness of these approaches is not yet known. Conventional surgery such as trabeculectomy continues to be an acceptable and appropriate option especially in patients with advanced disease.

Important questions to ask your physician about a new surgical procedure would be:

  1. the number of these procedures they have performed,
  2. their success rate with the procedure, and
  3. if they have any financial conflicts with these emerging technologies.

Article by Christopher A. Girkin, MD, MSPH, Professor of Ophthalmology and Director of the Glaucoma Service at the University of Alabama at Birmingham. Dr. Girkin has authored or coauthored over 130 journal articles, abstracts, and book chapters in major ophthalmic publications covering both neuro-ophthalmology and glaucoma.

Last reviewed on July 01, 2020

This article appeared in the January 2011 issue of Gleams.


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