Advanced Open-Angle Glaucoma: Primary Trabeculectomy vs Medical Management

Pavankumar Kamat

May 25, 2021

Patients with newly diagnosed advanced open-angle glaucoma treated with trabeculectomy or standard medical management had comparable quality of life outcomes following intervention. However, trabeculectomy resulted in a greater reduction of intraocular pressure (IOP) compared with standard medical treatment, which remained sustained. The findings were published in the BMJ.

Although the National Institute for Health and Care Excellence guidelines suggest trabeculectomy as a primary intervention for patients presenting with advanced disease, clinicians are reluctant to use it owing to concerns regarding potential sight-threatening surgical complications and lack of adequate evidence.

453 adults with newly diagnosed advanced open-angle glaucoma in at least one eye (Hodapp classification) across 27 secondary care glaucoma departments in the UK were randomly assigned to receive either mitomycin C-augmented trabeculectomy (n=227) or escalated medical management with IOP-lowering drops (n=226). The mean follow-up duration was 24 months.

At follow-up, the mean Visual Function Questionnaire-25 score was 85.4 (standard deviation [SD], 13.8) in the trabeculectomy group versus 84.5 (SD, 16.3) in the medical management group (mean difference, 1.06; P=.38). Mean IOP was 12.4 (SD, 4.7) mmHg in the trabeculectomy group versus 15.1 (SD, 4.8) mmHg in the medical management group (mean difference, −2.8; P<.001). 39 per cent of patients in the trabeculectomy group versus 44 per cent in the medical management group experienced adverse events (relative risk, 0.88; P=.37). Serious adverse events were uncommon in both groups.

"This study provides the first direct evidence of the outcomes of interventions for patients presenting with advanced glaucoma. These results will inform clinicians and patients in making treatment choices," the authors stated.

King AJ, Hudson J, Fernie G, Kernohan A, Azuara-Blanco A, Burr J, Homer T, Shabaninejad H, Sparrow JM, Garway-Heath D, Barton K, Norrie J, McDonald A, Vale L, MacLennan G. Primary trabeculectomy for advanced glaucoma: pragmatic multicentre randomised controlled trial (TAGS). BMJ. 2021;373:n1014. doi: 10.1136/bmj.n1014. PMID: 33980505

This article originally appeared on Univadis, part of the Medscape Professional Network.

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