Surgery option (trabectome vs trabeculectomy)

[lswk]

Dear all,

I am new to this group and would appreciate advices offered.

I am in late 40s. I have been diagnosed with high IOP and using eyedrop for a few years. As background I had cataract surgery done to both my eyes (right eye in 2013, left eye in 2018)

In Jan this year I felt my vision of right eye got more blurred. And in two visual field tests at NHS (taking place in Jan and May) my doctor advised it is likely to have glaucoma progressed in the right eye. The IOP was 24, got his concern as well.

As I am using the eye drop with maximum IOP reduction effect already (Simbrinza twice daily and Ganfort once daily), my doctor advised the need to have surgery (trabeculectomy) to help lower the IOP.

I know there is option of laser treatment (SLT). My doctor indicated it may not be as effective as trabeculectomy.

After the last visit, I will return in 4 weeks (which is next week) to check the visual field, then perhaps confirmed the next step.

I learn that there is a newer surgery option called 'trabectome', which is a minimally-invasive glaucoma surgery as compared with the traditional trabeculectomy. I check that it is offered in a few hospitals in the UK (e.g. Moorfield). I live in London and under NHS care in West Kent Eye Centre (Princess Royal University Hospital in Bromley London, now re-located to Queen Mary's Hospital in Sidcup) due to COVID-19). I will check with my doctor if this option is possible.

I would like to check if there is any related experience with trabectome (e.g. the effect of this surgery, can it be provided under NHS or only under private?)

I would prefer a better surgery option, but is worried it may not be easily/timely arranged, if it is available in limited hospital only.

Thanks in advance for all the advice.

[JanD236]

I’m sorry I can’t help with your main question about the trabectome as I’ve not heard about that.

I’m replying just to say that in my later 40s I had laser treatment which only gave me reduced pressures for about 6 months. When my specialist in Surrey suggested doing it again I referred myself to Moorfields for a second opinion. Their opinion was that as laser treatment only lasts 6 months to 5 years it was not an appropriate treatment given my age as it would have to be carried out far too many times in my lifetime and my eye wouldn’t withstand that.

Instead I had a trabeculectomy at Moorfields. This was about 8 years ago and so far so good, the pressure has remained low.

My other eye is likely to need surgery at some point in the future although I’m on ‘maximal’ eye drops (cosopt and monopost) in that eye and my pressures are holding steady for now. When the time comes I’ll certainly be enquiring about the trabectome option.

[lswk in reply to JanD236]

Dear JanD236, thanks a lot for your sharing, which is helpful.

May I check if you were on NHS (while with specialist in Surrey, and Moorfields)?

I would like to learn how is the referral process to Moorfields? Is it like getting a referral letter from the current specialist and then call in Moorfields to book an appointment?

[JanD236 in reply to lswk]

Hi. I was lucky enough to have private health insurance and that covered the cost of the Surrey private consultant.

I asked my GP to refer me to Moorfields and again I went privately. The insurance company covered the cost of the trabeculectomy but decided they’d no longer pay for ‘routine monitoring’. I go twice a year for this and am self funding which costs me about £250 a visit for the consultation and fields tests.

Before the trab I had a really worrying period of sight loss which my previous consultant seemed at a loss to stop. However, the Moorfields consultant got to grips with it by trying several different drops and giving me the trab in one eye.

I’m now too nervous to move away from that consultant hence I keep paying for the appointments rather than go into the nhs. It’s money well spent I feel.

[lswk in reply to JanD236]

Dear JanD236, thanks a lot for the sharing. It is really helpful.

I do not have much information about Trabectome. Only learned from book/internet that it is a newer technology and seems to be less invasive then the traditional trabeculectomy.

Below link is a news thread that it is being offered in Moorfields from 2013.

moorfields.nhs.uk/news/moor...

Wish you all best with your eyes for ongoing!

[Trish_GlaucomaUK Partner]

Hello lswk,

As you are on the maximum amount of drops and your glaucoma has developed the Trabectome doesn't sound like an option for you.

The Trabectome is suitable for patients with mild to moderate open angle glaucoma who are going to have cataract surgery and wish to reduce their need for glaucoma medications.

The Trabectome is not suitable for advanced glaucoma or where the natural drainage system of the eye is severely damaged.

[lswk in reply to Trish_GlaucomaUK]

Thanks Trish_GlaucomaUK for your advice.

[lswk in reply to Trish_GlaucomaUK]

Hi Trish again,

May I ask if there is any criteria about the level of glaucoma (like the terms mild, moderate or advanced you use)?

I know there is MD (mean deviation) values for the visual field test. It is -30 for total blindness. And my values for right eye is-6.5 in Jan and -7.3 in May. Not sure if these figures can give some indication.

[Trish_GlaucomaUK Partner in reply to lswk]

Hello lswk

A lot of hospitals have generally stopped doing trabectome because in most cases it doesn’t give much of a long term response.

SLT is not a bad first choice intervention for progressing mild to moderate glaucoma if you want to delay surgery. Risks are minimal and downtime is pretty much non-existent. It may not work well if you have been on drops for a long time.

For people with progressing glaucoma on maximal treatment the main interventions would be trabeculectomy or a variation of trabeculectomy called preserflo microshunt. If the disease is relatively mild, and you want to avoid very invasive surgery you can try slt or an angle procedure such as hydrus or istent which I know has been discussed with your consultant. These are all safer options but are less likely to definitively control the glaucoma long term.

The only way to get a handle on this is to discuss the options with your consultant or seek a second opinion elsewhere if they are not able to adequately address your concerns.

The choice of surgery is not solely dependent on the MD. This gives a global measure of visual fields loss, it will not tell you where the field loss is (ie you can have minimal reduction in MD but if the defect is in the central field that will be more severe than a peripheral defect with a bigger reduction in md) and it will not tell you how rapidly the field is deteriorating. Essentially the more rapidly the field is being lost, the need to reduce your IOP as quickly as possible is needed.

I hope this helps.

[lswk]

Hi wbiC, thanks for the information.

I was aware of the eyedrop technique 1 month ago. Now I put the drops to both eyes, and then pressing the inner eye corners for 1 minute. I shall refer to your guideline and see if any improvement.

(The quoted guidelines say press each eye for 2-5 minute. I think it require some patience, to reserve some time for each time of eye-drop then.)

And I also apply one more pillow for sleeping, hoping to reduce the IOP during sleeping.