Evidence for Surgery

I have summarised all the latest evidence pertaining to glaucoma: please do follow this link for detailed summary of these studies Evidence Based Approach to the Management of Glaucoma. I have tried to further breakdown the salient features of these studies, rationalising why I choose the various options in the various clinical scenarios. Please note, whilst we have long term data for trabeculectomy and tube surgeries, the data for minimally invasive glaucoma surgery (MIGS) is lacking as they are newer interventions. Theoretically, MIGS make a great deal of sense and there is evidence pertaining their use. Furthermore, my experience with MIGS have been extremely positive. Hence, lets apply the evidence to various clinical scenarios:

Original trabeculectomy has failed = do a tube

• Look up the original TVT study
• Five-year data showed that in patients who’d had previous trabeculectomy, cataract surgery or both, achieved lower end pressures and required less number of drops if a tube surgery is performed rather than a repeat trabeculectomy

In advanced primary open angle glaucoma = do a trab

• Look up the original TVT study
• Patients presenting with advanced glaucomatous optic neuropathy requiring a primary surgical intervention, should be offered a trabeculectomy

In narrow angle glaucoma = consider clear lens extraction

• Refer to the EAGLE study
• In patients with narrow angle glaucoma and pressures greater than 30mmHg, those undergoing clear lens extraction had less of sight and less further surgical intervention than those undergoing laser peripheral iridotomies

In patients with multiple drops, without glaucomatous optic neuropathy = CYPASS/Xen are a good options

• Please look at the COMPASS and APEX studies
• In both studies, patients began with pressures in the low twenties and ended with pressures in the low teens