Surgical Considerations

15.5.1 Nonpenetrating Drainage Surgery. For some surgeons, nonpenetrating glaucoma surgery (NPGS) provides an alternate surgical approach to trabeculectomy for moderate lowering of IOP in glaucoma patients. Lower IOP can be achieved with trabeculectomy than with NPGS, but short-term complications are fewer with NPGS. Further, NPGS is technically more challenging with a longer operative time. Despite potential advantages, there is still need for further evaluation of the technical details and standardization of the technique to improve the learning curve and efficiency of the procedure before NPGS is adopted widely.

15.5.2 Sequence of Laser Surgery and Trabeculectomy. The appropriate sequence of surgical therapy in patients whose IOP is uncontrolled by maximum tolerable and effective medical treatment is debatable. After follow-up of 4 to 7 years, the Advanced Glaucoma Intervention Study,4 a randomized, controlled trial sponsored by the Na-tionalEye Institute and initiated in 1988 to compare visual outcomes of two sequences of surgical therapy, has suggested that initial trabeculectomy, rather than laser tra-beculoplasty, may be preferable in white patients. In contrast, laser trabeculoplasty may be preferable for a first surgical intervention in African American patients. Longer follow-up and confirmatory data from other studies will be essential for determining whether the race-related differences in treatment outcome persist over the long term.

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