Why Trabeculectomy is the Most Common Glaucoma Surgery

Why Trabeculectomy For Glaucoma?

Ask most glaucoma surgeons what their “go to” glaucoma surgery is and the vast majority will answer, “trabeculectomy.”  There are a number of very powerful reasons for this:

It’s what glaucoma surgeons were taught in residency.

Because trabeculectomy has been around since 1968 every eye surgeon as well as his or her residency attending (instructor) has been taught how to perform this surgery.  Doctors will often value what they were taught in residency more than what they learn after graduation.  As such, most newer, safer, more innovative glaucoma surgeries are viewed with suspicion.  This is not necessarily a bad thing.  Most doctors want to be sure that a surgery is tried and tested before offering it.  This becomes a problem, however, when surgeons refuse to try new surgeries simply because they are comfortable doing what they’ve always done or are uncomfortable with learning a new technique.

It’s the glaucoma surgery they are best at.

This is due to the fact that trabeculectomy was likely the first glaucoma surgery they were taught in residency.  Whether its a surgical procedure or a golf swing, we all tend to improve our technique under the guidance of an experienced instructor.  It’s much harder for a surgeon to become adept at a surgery first performed after residency.  Additionally, as one of the first glaucoma surgeries learned, it’s quite natural that surgeons would end up doing more trabeculectomies than other newer surgeries.  One well-established truth in medicine is that the more a surgeon operates the better he or she becomes.  Thus, most eye surgeons are simply more skilled at trabeculecomy than they are with other glaucoma surgeries because they have performed more trabeculectomies than they have other glaucoma surgeries.

It’s the Community Standard.

Because trabeculectomy has been around for so many decades it has become the de facto standard surgical treatment for glaucoma.  Standards play a positive role in protecting patients from the risks of unproven treatments.  On one hand, this is a good thing as very few patients want their surgeons experimenting on them. It becomes a problem, however, when surgeons are  resistant to offer newer FDA approved glaucoma surgeries because they fear doing something that has not yet become the standard treatment in their community.  Indeed, one of the major barriers to surgical innovation is that many surgeons do not want to be among the first to try a newer technique even when the medical literature suggests that it could be a safe or effective option to the more established treatments. 

It’s Covered by Every Insurance.

In the USA insurance coverage is the single most important factor in determining which surgeries are offered to patients.  The longer surgeries are available the more likely it is that they will be covered by insurance companies.  Having been around longer than all other modern glaucoma surgeries it should come as no surprise that trabeculectomy is covered by more insurances than all other glaucoma surgeries. 

It’s Fast.

Do you know anyone who has time to do everything they need to do each day?  No?  Neither do I.  Even fifty years ago surgeons were stereotyped as busy by nature…and that was before all the paperwork and government mandated hassles of modern medicine.  Add to that the increased number of patients with glaucoma and the pressure to reduce operating room time is nothing short of intolerable.  Trabeculectomy requires only twenty to forty minutes to complete.  That’s half the time required by some of the newer glaucoma surgeries such as canaloplasty  

It Works.

This is the reason given by most glaucoma surgeons and it’s true.  Trabeculectomy has a better chance of lowering the IOP into the low teens than any other glaucoma surgery.  Sound too good to be true?  Perhaps, but trabeculectomy is also more likely to result in complications than other glaucoma surgeries that are not as effective at lowering the IOP.  If the IOP absolutely must be reduced into the “single digits” (below 10mmHg) without the use of drops then trabeculectomy may be the only reasonable surgical choice.  Not everyone, however, requires such extreme IOP lowering in order to control their glaucoma.

Is trabeculectomy the right surgery for you?  Perhaps.  Perhaps not.  Notice that only one of the five reasons above is what could be considered patient-focused – “it works”.  As such, it’s important to know when trabeculectomy is a reasonable next step in your glaucoma treatment and when other options might be better suited to your needs.  Your glaucoma surgeon can guide you with this decision but it is important for you to be well-informed.  After all, these are your eyes and you (more so than your surgeon) will have to live with the choices you make.

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