The Trabectome (NeoMedix) procedure is becoming an increasingly popular surgical option for my glaucoma patients who concurrently suffer from visually significant cataracts; however, it can be performed as a stand-alone as well.
The Trabectome is an FDA-approved device for the minimally invasive surgical treatment of open-angle glaucoma. The procedure is designed to improve fluid drainage from the eye, with clinical results that show a 33% decrease in postoperative IOP. This ab interno trabeculotomy combines an electrosurgical device with irrigation, aspiration and a protective footplate to ablate and remove a 60° to 120° strip of trabecular meshwork and the inner wall of Schlemm’s canal.
The surgeon starts with a clear corneal incision and then places a gonio lens onto the cornea to verify the angle anatomy. The Trabectome device is advanced across the anterior chamber and inserted into Schlemm’s canal anterior to the scleral spur. Ablation of the trabecular meshwork is performed up to 120° of the angle with continuous irrigation and aspiration.
Once complete, the surgeon will irrigate and aspirate the remaining viscoelastic material from the anterior segment. If performed as a stand-alone procedure, a dissolving suture can be applied and the anterior chamber re-pressurized. Otherwise, the surgeon can continue on to the cataract procedure.
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This procedure is a great option for patients who have early-to-moderate stages of glaucoma. Ideal candidates for this procedure include those who demonstrate progression despite maximal medical therapy, are already using one or two IOP-lowering medications, require target pressures in the mid-teens or exhibit cataract development.
This procedure has several advantages. First, it’s non-penetrating; there is no disturbance of the conjunctiva. It also requires no bleb and is easily combined with cataract extraction. We are seeing lower complication rates with this procedure, which is a huge advantage with any surgery. And, the outcomes result in a reduction of glaucoma medications. This procedure also requires fewer follow-up appointments than other glaucoma procedures.
That said, there are some distinct disadvantages to the procedure as well. Notably, some 20% experience a postoperative IOP spike. Additionally, postoperative hyphema is typical. Also, it can result in synechia formation around the cleft and/or cause an injury to Descemet’s membrane. And, the cost of equipment can be an obstacle for many providers.
Preoperatively, candidates require a full glaucoma work-up with ancillary testing (visual fields, pachymetry, optical coherence tomography, etc.). Postoperative care is similar to traditional cataract surgery, with the exception of topical miotics prescribed b.i.d. to q.i.d. for three to four weeks.
