Editors Selection IGR 23-1

Surgical Treatment: Filtering Surgery in Neovascular Glaucoma

Steve Mansberger
Alexander Robin

Comment by Steve Mansberger & Alexander Robin on:

100657 Comparing Surgical Outcomes in Neovascular Glaucoma between Tube and Trabeculectomy: A Multicenter Study, Iwasaki K; Kojima S; Wajima R et al., Ophthalmology. Glaucoma, 2022; 0:

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Ophthalmologists use trabeculectomy or glaucoma tube shunt surgery to control intraocular pressure in patients with neovascular glaucoma (NVG). There is debate about which type of incisional glaucoma surgery is the most successful in this situation. Iwasaki et al. conducted a retrospective clinical cohort study to investigate the outcomes of Baerveldt glaucoma implants (BGI) versus trabeculectomy for the treatment of NVG. The study population included 304 eyes (100 BGI, 204 trab) from patients treated for NVG at five different sites in Japan between 2012 and 2019.

The authors used Kaplan-Meier survival curves extending out to five years to compare procedures. Failure was defined as meeting any of the following requirements on two consecutive visits after three months postoperatively: < 20% reduction in IOP, loss of light perception, hypotony with IOP < 5, or IOP > 21 (criteria A), IOP > 17 (criteria B), or IOP > 14 (criteria C).

The results of the study demonstrated that BGI had a lower failure rate than trabeculectomy at timepoints up to five years for criteria A and B while the groups had equivalent success for criteria C. Additionally, the number of early post-operative complications was not significantly different between the groups. Finally, the BGI-group had less reoperations for glaucoma.

The data provides a compelling argument for BGI over trabeculectomy for the treatment of NVG in patients with a goal IOP > 21 with a five-year success rate (criteria A) of about 80%. There are some limitations to the study. The groups in this retrospective analysis were not equally matched in many important categories including lens status, previous intraocular surgeries, use of intravitreal anti-VEGF agent, and neovascularization of the iris or angle. Most of us would not attempt a trabeculectomy in an NVG eye with active neovascularization because of the high risk of hyphema and scarring. Active NVG that is not controlled by laser or intravitreal injections will usually require a glaucoma tube implant. The authors provide compelling evidence for when to choose a BGI over trabeculectomy. However, a randomized controlled study with similar preoperative characteristics might provide further evidence about the best surgical options for patients with NVG.

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