Bimanual trabecular aspiration in pseudoexfoliation glaucoma: An alternative in nonfiltering glaucoma surgery

The primary cause of intraocular pressure (IOP) elevation in pseudoexfoliation glaucoma is obstruction of the intertrabecular spaces by exfoliation material. Previously, the authors reported on a new concept of nonfiltering glaucoma surgery—trabecular aspiration—designed to increase trabecular outflow in pseudoexfoliation glaucoma. In the current study, a description of the modified instrument, its refined surgical technique, and longterm clinical results will be given to substantiate the efficacy of trabecular aspiration in the surgical management of pseudoexfoliation glaucoma. The study design was a prospective and nonrandomized study. A total of 68 eyes of 54 patients suffering from medically uncontrolled pseudoexfoliation glaucoma were treated by bimanual trabecular aspiration. Thirty-four eyes of 28 pseudoexfoliative patients treated by standard trabeculectomy constituted the control group. Trabecular debris and pigment were cleared with a suction force of 100 to 200 mmHg under light tissue-instrument contact using a modified intraocular aspiration probe. The aspiration cannula is 400 μm in diameter and horizontally angulated at 45°. Irrigation of the anterior chamber was performed via a separate irrigation cannula. The IOP and number of medications before and after surgery were measured. In 42 eyes of 36 patients, trabecular aspiration was performed in combination with cataract extraction and lens implantation. The IOP dropped from 32.4 ± 7.2 mmHg (range, 23–52 mmHg) under maximal tolerated medical therapy before surgery to 18.7 ± 1.7 mmHg (range, 16–23 mmHg) at 2 years after surgery, with 54% of patients being controlled without medication. In 22 eyes of 19 patients, trabecular aspiration was performed as primary surgical intervention. The IOP dropped from 31.3 ± 7.1 mmHg (range, 23–42 mmHg) before surgery to 16.8 ± 3.4 mmHg (range, 12–23 mmHg) at 18 months after surgery, with 45% of patients not taking medication. Bimanual trabecular aspiration is safe and efficacious in decreasing IOP both with and without cataract extraction in pseudoexfoliation glaucoma. However, there seems to be a slight regression in effect over time attributed to undisturbed liberation of exfoliative debris. Argon-laser trabeculoplasty before trabecular aspiration reduces the IOP-lowering effect of this procedure. A prospective, randomized, multicenter study is warranted to finally assess the potential of trabecular aspiration in pseudoexfoliation glaucoma.