Glaucoma: Back to basics
September 2022

by Liz Hillman
Editorial Co-Director

While there has been a revolution within the last decade in terms of glaucoma management—surgical and medical—Leon Herndon Jr., MD, would argue that trabeculectomy is still the most basic of glaucoma management procedures.

“I think when you say ‘basic,’ the connotation is that it’s simple. It’s not. Trabeculectomy itself is not a challenging surgery, but the management postop is very challenging,” Dr. Herndon said. “It’s the gold standard. Even though first popularized in late 1970s, there is still nothing else out there that’s going to get the pressure as low as a trabeculectomy will.”

Even among the myriad of options for glaucoma patients now available, Dr. Herndon said that he thinks some patients are still going to need a trab, and he worries that fewer surgeons will be able to perform and manage this in the future.

“I believe in MIGS and intervening earlier with safer procedures, but if you look at the data, the number of trabeculectomies being performed even in training programs is going down. In a few years we’ll have relatively few physicians who know how to do a trabeculectomy,” he predicted.

There are a couple of reasons why Dr. Herndon thinks trabeculectomy is going down. One is the Tube Versus Trabeculectomy Study, which Dr. Herndon said demonstrated that tube surgery was a reasonable option for patients with severe disease, thus leading to some procedures being replaced with glaucoma drainage tubes. MIGS, in more recent years, has also taken up some of this space, Dr. Herndon added.

“It depends on your practice. My practice is typically a very advanced glaucoma practice, and these aren’t the types of patients you are going to be doing MIGS on and in some cases tubes. If you need pressures in the single digits, there is only one way you’re going to get there—trabeculectomy,” he said. “I think nationwide the numbers are going down with trabeculectomy, but I think there are several pockets in the country where providers see a lot of advanced glaucoma, and you still need to do a trabeculectomy. I think any glaucoma surgeon in his or her practice can’t get away from severe glaucoma, and the concern is that if you’re not training and getting your fingers wet doing trabeculectomy, once you get out in practice, you’re going to do a disservice to patients with severe disease if you do [a MIGS] because it’s the only thing you know how to do.”

Dr. Herndon reiterated that he’s a believer in doing fewer trabeculectomies, but “there are patients who clearly need a trabeculectomy, and they might not be getting the care they need in the next 10–15 years.”

Dr. Herndon said a “cataract cowboy or cowgirl” is not likely going to do trabs, leaving the procedure within the purview of glaucoma trained surgeons or comprehensive ophthalmologists who don’t otherwise have glaucoma specialists nearby. MIGS, Dr. Herndon continued, are mainly indicated for mild to moderate disease. If the glaucoma is more advanced, performing a MIGS procedure rather than a filtering procedure, which can achieve lower pressures, could be a disservice to the patient.

If patients truly have severe disease and need significant pressure lowering, Dr. Herndon’s message is: If you can’t do a trabeculectomy and its postop management, it’s important to refer.

“Trabeculectomy is not dead. It’s a sight-saving procedure, and if someone isn’t comfortable doing it, please find someone who is,” he said.

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In terms of when he, as a surgeon trained in filtering procedures, is comfortable returning a patient to a referring physician for care post-trabeculectomy, that’s generally after 2 months.

“Ideally, I like to make sure pressures are well controlled and the bleb is functioning fine, and many of my patients are referred in from glaucoma specialists who know how to handle this postop period. The most crucial period of time is the first 2 months. I like to get them through that time, then I am comfortable referring them back,” he said.

Dr. Herndon said that glaucoma is a practice that builds over time with long-term patient relationships. He knows he can’t hold on to all of his patients, and this is why he thinks it’s important for more ophthalmologists to get comfortable handling the common postop issues that these patients might face. The two main complications are pressures being too low or too high.

As a takeaway, Dr. Herndon said to not be scared of trabeculectomy.

“[Trabeculectomy] requires a lot of follow up. It’s not a money maker in many cases,” he said. “But it’s what’s in the best interest of the patient in saving sight. Don’t be afraid to consider trabeculectomy if there is no one in the near vicinity who can do it for the patient. You have to put the patient first and strive to get low pressures for these more severe patients.”

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About the physician

Leon Herndon Jr., MD
Director of the Glaucoma Service
Duke Eye Center
Durham, North Carolina

Relevant disclosures

Herndon: None

Contact

Herndon: leon.herndon@duke.edu