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    Ab interno trabeculectomy demonstrates positive outcomes, even in patients with narrow angles

    Significant reduction in IOP and number of medications required, regardless of degree of angle opening

    Take-home message: Narrow angles have been associated with a higher IOP in glaucoma patients, presumably by causing higher outflow resistance. Here, Dr Loewen presents recent research in which both ab interno trabeculectomy (AIT) with the trabectome and phaco-AIT significantly reduced IOP and number of medications required, regardless of the degree of angle opening.


    Ab interno trabeculectomy with the trabectome (Neomedix, Tustin, CA, USA) is a minimally invasive glaucoma surgery (MIGS) that uses plasma energy to ionise and ablate the trabecular meshwork (TM) to increase conventional outflow.1 Trabectome surgery and other similar MIGS procedures have been relatively contraindicated in glaucoma patients with narrow angles due to perceived technique challenges and presumed resulting complications. 

    Alternative surgical modalities include trabeculectomies and tube shunts; while very effective, they have a high rate of significant complications.2 This has resulted in a surge of interest in MIGS, which boast an almost complete absence of vision-threatening complications,3 to safely lower IOP and potentially improve vision via cataract surgery in the same session.

    A narrow anterior chamber angle has been considered a relative contraindication in these surgeries due to the following: indirect access to the TM, and a belief that peripheral anterior synechiae, descemetisation of the angle, and fibrosis may form more frequently and increase complications.4 This may preclude large numbers of glaucoma patients from trabectome surgery and similar MIGS; women comprise 70% of angle closure glaucoma (ACG) cases, while Asians represent 87% of ACG.5

    Although numerous studies have described the safety and efficacy of the trabectome in the treatment of glaucoma,6,7 the relationship between anterior chamber angle grade and outcomes has only recently been formally examined.8 In this review, we discuss trabectome patient selection, key steps in surgery, and outcomes that include degree of angle opening.8

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