Abstract
Plasma-mediated ab interno trabeculectomy with the trabectome was first approved by the US Food and Drug Administration in 2004 for use in adult and pediatric glaucomas. Since then, increased clinical experience and updated outcome data have led to its expanded use, including a range of glaucomas and angle presentations, previously deemed to be relatively contraindicated. The main benefits are a high degree of safety, ease, and speed compared to traditional filtering surgery and tube shunts. The increasing burden of glaucoma and expanding life expectancy has resulted in demand for well-trained surgeons. In this article, we discuss the results of trabectome surgery in standard and nonstandard indications. We present training strategies of the surgical technique that include a pig eye model, and visualization exercises that can be performed before and at the conclusion of standard cataract surgery in patients who do not have glaucoma. We detail the mechanism of enhancing the conventional outflow pathway and describe methods of visualization and function testing.
Highlights
The trabecular meshwork (TM) is the main resistance of the conventional outflow route of aqueous humor in primary and - to an even greater extent - in secondary open angle glaucoma[1]
The main differences are the amount of access to angle structures measured in degrees of angle arc, method of TM removal (ablation in ab interno trabeculectomy (AIT) versus disruption), and whether an implant remains in the eye or not
Suture or catheter trabeculotomy in gonioscopy-assisted transluminal trabeculotomy (GATT) and Trab[360] (Sight Sciences, Menlo Park, CA, USA) can disrupt 360 degrees of TM through a single access site, whereas trabectome surgery (Neomedix Inc., Tustin, CA, USA) or goniotomy can achieve near 180 degrees of TM ablation or incision through a single clear corneal wound
Summary
The trabecular meshwork (TM) is the main resistance of the conventional outflow route of aqueous humor in primary and - to an even greater extent - in secondary open angle glaucoma[1]. Non-matched studies of phaco-trabectome and trabectome outcomes do not take into account that the second group has an IOP reduction as the primary indication and a higher baseline compared to the group with cataract surgery patients, many of which may have stable glaucomas, but would like to take advantage of reduced eye drop dependency. Another recent review of 60 patients undergoing trabectome surgery after failed trabeculectomy demonstrated a 36% reduction in IOP and a 14% decrease in the number of IOP-lowering medications, with 25% of patients requiring further surgery in the course of follow-up[43] These studies are limited by their retrospective nature and the relatively small number of patients included, the results suggest that the distal outflow tract is patent and functioning, contradicting the assumption that an unused outflow system atrophies. Among all 3828 patients reported by the meta-analysis, there are case reports of a few, rare complications, including cyclodialysis cleft (2 cases), aqueous misdirection (4 cases), choroidal hemorrhage (1 case), and endophthalmitis (1 case)[25]
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