new procedures with trabeculectomy. In theory, nonpenetrating surgery should avoid some of the complications associated with penetrating filtering surgery. However, the procedures are technically challenging, and most results suggest that the IOP reduction achieved with nonpenetrating procedures is less than that achieved with trabeculectomy. Proponents of nonpenetrating procedures argue that with fewer potential complications, surgery may be considered earlier in the disease process, and that the target IOP may therefore not need to be as low.
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Cillino S, Di Pace F, Casuccio A, et al. Deep sclerectomy versus punch trabeculectomy with or without phacoemulsification: a randomized clinical trial. J Glaucoma. 2004;13(6):500–506.
Gilmour DF, Manners TD, Devonport H, Varga Z, Solebo AL, Miles J. Viscocanalostomy versus trabeculectomy for primary open angle glaucoma: 4-year prospective randomized clinical trial. Eye. 2009;23(9):1802–1807.
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Special Considerations in the Surgical Management of Elderly Patients
When deciding whether to proceed with surgery in an elderly patient, the surgeon must take into account a number of issues specific to this population. The first issue is determining the appropriateness of surgery. The surgeon must consider the severity of the disease and the risk of functional vision loss in relation to the patient’s life expectancy. Also, the surgeon must assess the patient’s ability to comply with medical therapy. A patient who is poorly compliant (due to memory loss, poor vision, tremor, or arthritis) preoperatively stands a high risk of being noncompliant in the postoperative phase and may well jeopardize the outcome as a result. In addition, the surgeon must consider whether the presence of a major systemic disease would affect the patient’s ability to physically withstand the stress of surgery.
Once the decision has been made to proceed with surgery, the surgeon should determine which procedure is most likely to be successful and result in the fewest complications. The surgeon should consider the patient’s ability to return to the clinic or office for multiple follow-up visits. If a patient is not mobile or has no easy transportation options, a glaucoma drainage device or nonpenetrating procedure may be a reasonable choice, as these procedures tend to require fewer postoperative visits than does trabeculectomy. Further, a limbus-based conjunctival flap is less likely to leak than a fornixbased flap and might be considered for patients with transportation issues. The use of anticoagulants and antiplatelet medications should also be considered, as the risk of serious complications from intraocular hemorrhage is increased with their use. Finally, the surgeon must consider compromised healing in elderly persons and be circumspect about the use of antifibrotics in this group of patients, whose tissues tend to be thinner and more fragile than those of a younger patient and whose diets may be more limited.