Pearls for Trabeculectomy: A Guide for Trainees

Intraoperative tips and postoperative principles for guarded filtration surgery.

Nawaf Almeshari, MD, and Rizwan Malik, MD, PhD, FRCOphth

Glaucoma Today

Key Takeaways Given the declining rates of trabeculectomy cases worldwide, learning the nuances of this surgery has become more challenging. With a systematic approach and appropriate experience, trabeculectomy remains a reproducible and effective surgery. Attention to small cues and technical details guides the surgeon through the steepest parts of the learning curve. Trabeculectomy remains the benchmark against which every glaucoma filtration procedure is measured. Even as minimally invasive options multiply, guarded filtration surgery continues to achieve some of the lowest IOPs of any current glaucoma procedure and remains an indispensable option for advanced and refractory disease.1,2 Meticulous technique can help to lower the risk of complications associated with this surgical approach.3 With the widespread adoption of MIGS, however, ophthalmology trainees may be performing fewer trabeculectomies.4,5 In an 11-year period, US glaucoma fellows experienced a 55.9% decline in trabeculectomy exposure, coinciding with a 128.6% rise in MIGS procedures.5 This pattern is also evident at our center, King Khaled Eye Specialist Hospital & Research Center (KKESH), where total trabeculectomy volume decreased from 116 cases performed in 2019 to 47 cases performed in 2024 (Figure 1). Importantly, trabeculectomy can be performed in virtually any surgical setting, making it an essential technique for trainees to master and a particularly valuable option in resource-limited environments. This article distills practical, step-by-step tips for trabeculectomy with mitomycin C (MMC). PATIENT SELECTION Careful patient selection is an important determinant of trabeculectomy outcomes. Beyond the standard clinical indications such as inadequate IOP control on maximum tolerated medical therapy, progressive optic nerve damage, and visual field loss, patient-related factors must be considered. Our preference is not to offer trabeculectomy to patients who are unable to attend weekly follow-up visits in the first 3 postoperative weeks, because this period is critical for IOP titration, suture management, and the early detection of complications, such as hypotony and bleb failure.

COLLAB CORNER: Takeaways From a Private Practice Owner

Marc R. Bloomenstein, OD, FAAO; and Rachael Wruble, OD, FAAO

Eyetube

Marc Bloomenstein, OD, FAAO, chats with Rachael Wruble, OD, FAAO, who owns a private practice in North Carolina and is cold-starting another. Dr. Wruble says that one of the defining features that makes her practice stand out from others is having up to four ODs with different specialties providing care at any given time, making possible a diverse range of care. Her practice's motto: "If you take care of patients, they'll take care of you." (Dr. Bloomenstein is a consultant for Glaukos. Dr. Wruble has no financial disclosures.)

Unlocking Clinical Trial Enrollment with AI Screening

It’s not a patient population problem. It’s a signal-extraction problem.

Sunil Gupta, MD, and Joshua Koo, MS, BS

Retina Today

KEY TAKEAWAYS Current clinical trial screening methods rely on physician memory or a manual pre-screener, often leading to missed eligible patients, high screen failure rates, and lagging trial enrollment. An investigational AI model can automatically flag eligible candidates, allowing the physician to initiate the trial conversation and potential formal screening on the same day. Using the AI system allowed the Retina Specialty Institute to bring a protocol live in about 4 weeks. Every practice that runs clinical trials knows a particular kind of frustration. You open a new protocol for geographic atrophy, wet AMD, or diabetic macular edema, confident that patient volume will fill it. And then you watch enrollment crawl. The reflex is to assume the shortfall is a supply problem: not enough patients. However, in a busy retina clinic, the eligible patients are there—the problem isn’t patient scarcity, it’s patient identification. On any given clinic day, dozens of patients have the conditions our open protocols were written to study, and the information needed to identify them as trial candidates is already in the record: acuity measurements, medical and treatment histories, laterality notes, and OCT scans. However, we still need a dependable way to identify that information quickly for each patient.