Trabeculectomy and Minimally Invasive Glaucoma Surgery

Abstract and Introduction

Abstract

Purpose of Review: This review discusses recent findings in surgical management of glaucoma, focusing on trabeculectomy and minimally invasive glaucoma surgery (MIGS). We discuss how the role these procedures play in conjunction with phacoemulsification.

Recent Findings: New findings of the Primary Trab Vs Tube study and findings regarding the Hydrus, Xen 45, Kahook dual blade, Ab-interno Canaloplasty and head-to-head MIGS studies are summarized.

Summary: Patients with glaucoma greatly benefit from combining cataract surgery with a MIGS procedure that can be tailored to disease severity and medication use. Certain MIGS combined with phacoemulsification in severe and refractory glaucoma can potentially delay incisional glaucoma, although trabeculectomy- mitomycin C (MMC) still remains the best option in certain patient populations. We provide an update in the MIGS treatment paradigm based on newer, stronger evidence.

Introduction

Glaucoma is the number one cause of blindness worldwide.^[1] The only proven treatment to prevent the vision loss associated with glaucoma is to lower intraocular pressure (IOP).^[2] Surgical options designed to lower IOP can be divided into traditional transscleral incisional procedures [e.g. trabeculectomy with mitomycin C (trab-MMC) and tube shunt placement] and minimally invasive glaucoma surgeries (MIGS). Although MIGS is generally considered safer than traditional transscleral incisional surgeries and allows surgeons to keep the transscleral options for the future, most MIGS procedures are unable to decrease IOP to the same degree as traditional transscleral incisional surgeries. Therefore, trabeculectomy is still considered the gold standard procedures for IOP lowering, although surgeon preference is shifting as to which procedure is ideal in a given scenario.^[3]

This review discusses new findings in the co-management of glaucoma and cataracts, focusing on the enduring utility of trabeculectomy in the treatment of moderate to advanced glaucoma, as well as recent effectiveness and safety data for several MIGS procedures/devices. We also discuss the potential interplay of MIGS and incisional procedures in the management of glaucoma and cataracts, and how the attributes of each type of surgery are best suited for different stages of disease progression. Our literature review emphasizes studies published since January 2018.