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Editors Selection IGR 26-1
Surgical Treatment: Trabeculectomy vs tube shunt in uveitic glaucoma: similarly high failure rates
Comment by Eleonora Micheletti on:
128063 The Rate of Failure of Trabeculectomy and Tube Shunt Surgery in Eyes with Uveitic Glaucoma and Ocular Hypertension, Groth SL; Newcomb CW; Yang W et al., Ophthalmology. Glaucoma, 2025; 8: 580-588
This multicenter retrospectic cohort study provides valuable real-world evidence on surgical outcomes in uveitic glaucoma, a population that is frequently underrepresented or absent in major glaucoma trials. Using the large SITE database and propensity score–adjusted Cox regression, the authors demonstrate that trabeculectomy with mitomycin-C (Trab-MMC) and tube shunt (TS) surgery are associated with similarly high failure rates over 5 years when used as primary incisional procedures. The cumulative failure rates—approaching one-third of eyes by 3–5 years—underscore the therapeutic challenges inherent in managing this disease.
An important clinical distinction is that, despite comparable overall failure rates, Trab-MMC achieved a substantially higher proportion of complete successes (IOP control without medications) at 1, 2, and 3 years. This finding is consistent with previous evidence that trabeculectomy may achieve lower medication-free IOP levels than TS, which is particularly relevant in a relatively young patient population.
Key strengths of the study include its relatively large sample size, inclusion of both pediatric and adult patients, and the use of propensity scoring and inter-eye correlation to address confounding.
Important limitations that should be acknowledged include its retrospective design; incomplete characterization of tube type, ligature or flow-restriction strategies, and antifibrotic use; lack of information on perioperative prophylactic anti-inflammatory therapy; absence of visual field or structural data to distinguish ocular hypertension from glaucoma; lack of characterization of hypotony (clinical or numerical); and no assessment of corneal outcomes or diplopia/ocular motility disorders. These limitations are particularly relevant given the known endothelial and motility risks associated with TS, as well as the absence of standardized diplopia assessment. The IOP failure threshold (>21 mmHg) is pragmatic but may underestimate failure in eyes requiring lower targets.
Overall, the findings suggest that TS and Trab-MMC demonstrate broadly similar failure rates in uveitic glaucoma, with a potential advantage of Trab-MMC in achieving medication-free control. The study supports the need for prospective, uveitis-specific trials with more detailed characterization of TS technique, corneal outcomes, and glaucoma severity.
References
- Gedde SJ, Schiffman JC, Feuer WJ, et al. Treatment outcomes in the Tube Versus Trabeculectomy (TVT) Study after five years of follow-up. Am J Ophthalmol. 2012;153(5):789-803.e2. https://doi.org/10.1016/j.ajo.2011.10.026
- Gedde SJ, Feuer WJ, Shi W, et al. Treatment outcomes in the Primary Tube Versus Trabeculectomy (PTVT) Study after three years of follow-up. Ophthalmology. 2020;127(3):333-345. https://doi.org/10.1016/j.ophtha.2019.10.002
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