What is the role of trabeculectomy in the management of primary open-angle glaucoma (POAG)?

Updated: Mar 16, 2020
  • Author: Kristin Schmid Biggerstaff, MD; Chief Editor: Inci Irak Dersu, MD, MPH  more...
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Answer

Trabeculectomy surgery usually is performed after MTMT and ALT have failed to control IOP adequately. If IOP is so high that ALT and SLT are likely to be ineffective in reaching target IOP, then proceeding from MTMT to penetrating surgery may be indicated.

A superficial flap of sclera is dissected anteriorly to the trabecular meshwork, and a section of trabecular meshwork is removed underneath the flap.

This alternate outflow pathway is created to increase passage of aqueous from the anterior chamber to the subconjunctival space, creating a filtering bleb and, thereby, lowering IOP.

Either releasable sutures or laser suture-lysis may be used to control aqueous drainage and corresponding IOP postoperative. Alternatively, to maximize surgical success, antimetabolites (eg, 5-fluorouracil, mitomycin C) may be applied during or after surgery to decrease fibroblast proliferation and scar formation.

Risks and complications of filtering surgery include the following: hypotony, blebitis/endophthalmitis, hyphema, suprachoroidal hemorrhage or effusions, encapsulation of the bleb with resultant transient IOP elevation, loss of 1 or more lines of visual acuity, and increased risk of cataract formation.

With the risk of severe complications from trabeculectomy and the need for frequent postoperative follow-up care (ie, usually weekly for 1 month, initially), some patients with transportation, financial, or long-distance issues concerning postoperative follow-up care may be better served by tube shunt surgery instead. See the Tube versus Trabeculectomy Study below.

Vision loss may be a serious complication after trabeculectomy, with severe and ongoing unexplained loss ("snuff-out") experienced by as many as 2% of patients. Attendant risk factors such as split fixation on visual fields prior to surgery, preoperative number of quadrants with split fixation, and postoperative choroidal effusions with eventual resolution are possible. [21]


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