The Trabectome is a surgical device that can be used for ab interno trabeculotomy, a minimally invasive glaucoma surgery for the surgical management of adult, juvenile, and infantile glaucoma. The trabecular meshwork is a major site of resistance to aqueous humor outflow. As angle surgeries such as Trabectome follow the physiologic outflow pathway, the risk of complications is significantly lower than filtering surgeries. Hypotony with damage to the macula (hypotony maculopathy), can occur with pressures below 5 mmHg, for instance, after traditional trabeculectomy, because of the episcleral venous pressure limit. The Trabectome handpiece is inserted into the anterior chamber, its tip positioned into Schlemm's canal, and advanced to the left and to the right. Different from cautery, the tip generates plasma to molecularize the trabecular meshwork and remove it drag-free and with minimal thermal effect. Active irrigation of the trabectome surgery system helps to keep the anterior chamber formed during the procedure and precludes the need for ophthalmic viscoelastic devices. Viscoelastic devices tend to trap debris or gas bubbles and diminish visualization. The Trabectome decreases the intra-ocular pressure typically to a mid-teen range and reduces the patient's requirement to take glaucoma eye drops and glaucoma medications (see references). The theoretically lowest pressure that can be achieved is equal to 8 mmHg in the episcleral veins. This procedure is performed through a small incision and can be done on an outpatient basis.[1]
When abdomino-interno trabeculectomy is combined with cataract surgery, it is initially performed for optimal angle visualization. Corneal clarity is often damaged during cataract surgery, and this damage may only be noticeable during gonioscopy, when the light path through the cornea is longer. An iris-lanar clear corneal incision of 1.8mm width is made approximately 2mm in front of the surgical limbus. Cataract surgery uses a larger keratome that requires the incision to be closed, to reduce fluid leakage. No viscoelastic is used, as it can cause bipolar electrodes to carbonize during the incision. The patient's head is then turned away from the surgeon by approximately 40 degrees, and the microscope is turned to the same extent in the opposite direction.
Optimum gonioscopic trabecular meshwork visualization requires an angle of approximately 70 to 80 degrees between the microscope and the patient's eye. An incision is made, which is slightly gaping. This gaping encourages hypotony and enables easy identification of Schlemm's canal from refluxed blood. Trypan blue can also be used to stain the trabecular meshwork [18].
The trabectome handpiece is inserted, with irrigation turned on. If the anterior chamber is too shallow for it to be fully inserted, the irrigation ports in the metal sleeve can form the anterior chamber by resting against the outer edges of the incision, with the tip already inside the eye. Right-handed surgeons find it easiest to perform counterclockwise removal first. The trabectome is engaged in the trabecular meshwork. This is done with the tip angled 45 degrees upward, just in front of the scleral spur. This angle offers a pointed entry into the meshwork. The trabectome is then moved in a strictly parallel fashion, with no movement toward the wall of the canal. The handpiece is turned 180 degrees, completing the clockwise removal. The superior and inferior angle structures can be seen, and almost 180 degrees of meshwork are removed by tilting the goniolens toward the patient's brow and then toward their cheek. This can be done in reverse, depending on which eye is operated on.
Once complete, the trabectome is carefully removed from the eye. Viscoelastic is injected into the eye for pressurization, and to tamponade the reflux heme. If cataract surgery is to follow, the microscope and patient's head are returned to their initial positions. The existing access point is used, and a larger keratome is employed to create a larger incision, with a self-sealing biplanar wound [2].
Training
Microincisional glaucoma surgery [3, 4] is conducted in a space that is approximately 200 times smaller than the space used to implant epibulbar glaucoma drainage devices [5] As such, this type of surgery is particularly challenging to learn. The deep venous plexus distal to the outer wall of Schlemm's canal, the iris root, the ciliary body band and the suprachoroidal space all risk being damaged during surgery. This damage can cause variable sequelae [6, 7].
To master this surgery, it is important to be able to visualize the angle, identify the correct target, avoid trauma and maximize meshwork removal. Microincisional glaucoma surgery does not yet have dedicated simulators or synthetic models such as those used in cataract surgery wet labs. Therefore, most aspiring surgeons in this field practice on glaucoma patients. This is despite reported complications being almost ten times as common toward the end of training [8].
A safe and low-cost training environment has recently been created, using pig eyes mounted on a model head. This allows trainee surgeons to track their progress objectively. The pig eyes are infused with diluted fluorescein to trace outflow. Fluorescein can diffuse through the trabecular meshwork, which allows flow speeds to be estimated in non-treated parts of the eye. A disadvantage of this method is that over time, diffusion also takes place through intact vascular endothelium, staining the extravascular space. Fluorescent beads can be used as an alternative, and are suitable in less time-sensitive, more beginner-friendly studies of ablation. However, unlike fluorescein, this method does not account for flow speeds or volume estimates.
Set-up
There are several surgical steps that can be simulated and practiced for cataract procedures. These include positioning the patient's head, setting up the microscope, gonioscopic visualization of the angle and identification of Schlemm's canal. For the surgery to be performed correctly, the patient's headrest must be close enough to the microscope stand to accommodate the tilted view, and greater distance from it. Trainees can tell their patient that they would like to take a brief look at the angle of the eye. The surgeon should be seated temporally, and the patient's head tilted away by 30 degrees. The microscope should be set up by centering its head, confirming that the tilt knob is covered with a handle. The equipment is then tilted toward the surgeon by 30 degrees. The microscope should be manually lowered, bringing the limbus into focus.
To practice gonioscopic visualization of the angle, the correct handedness of the modified Swan Jacob gonioprism should be confirmed. This is done by placing it on the eye and moving the microscope focus down, toward the nasal angle. The iris root, ciliary body band and trabecular meshwork can be seen through the microscope. They should all be distinguished from Schwalbe's line and the Sampaolesi line. Schlemm's canal should be identified by using a 0.12 forceps to tap lightly on the posterior lip of the primary cataract incision, creating blood reflux. After several seconds, the goniolens should be replaced onto the cornea, to visualize a partially venous, blood-filled Schlemm's canal.
Outflow enhancement
By removing the primary resistance (the trabecular meshwork), aqueous humor can pass more freely into collector channels and aqueous veins. The Goldmann equation states that Intraocular Pressure = [Aqueous Humor Formation/Outflow] + Episcleral Venous Pressure. This equation states that free-flowing aqueous humor should cause intraocular pressure to drop to the same level as in the episcleral veins [26]. However, this is rare, and the average postoperative intraocular pressure is around 16 mmHg [27]. Spectral domain optical coherence tomography can be used to view collector channel diameter change, collapse or patency.
Like human eyes, pig eyes have more outflow along the nasal drainage system than the temporal angle. Trabecular meshwork removal from the nasal can enhance outflow beyond physiological levels. It can also cause fluorescein to flow circumferentially, through small connections between Schlemm's canal-like segments, typical of a pig's angular aqueous plexus [3-5]. Reconstruction of outflow tracts via spectral domain optical coherence tomography have confirmed a correlation between aqueous spaces and collectors where flow was seen. However, these studies have also confirmed the existence of non-perfused vascular structures that could be part of the arterial or venous vascular system, or poorly perfused collector channels.
Recent discoveries have shown valve-like structures that appear to guard collector channel orifices and collapsible aqueous veins 9, 10. These findings contradict the view that collector channel openings are round and unobstructed. Structural data has shown that flaps are suspended by string-like attachments. This research suggests that these attachments should be maintained during surgery, or that the flaps at the opening of collector channels should be removed. Electron microscopic images of the outer wall suggest that most are removed during trabectome procedures, together with their attachments and the trabecular meshwork [30].
Applications and results
Phacoemulsification combined with ab interno trabeculectomy
As many patients have both cataract and glaucoma, phacoemulsification is often combined with trabectome surgery, for the cost-effective treatment of both conditions [11]. Combined phaco-trabectome surgery can result in an intraocular pressure reduction of approximately 18% [12]. A recent study of phaco-trabectome surgery patients found the most significant reduction in cases of severe glaucoma, steroid-induced glaucoma [33,34] and pseudoexfoliative glaucoma [13, 14].
Ab interno trabeculectomy-only procedures for pseudophakic or phakic eyes
Trabectome surgery alone provides an alternative to more invasive procedures. It is suitable for patients who have previously undergone cataract surgery, as well as those who have no visually significant cataract. Studies have shown that lens status or performance of phacoemulsification in the same session has no significant impact on intraocular pressure reduction [38,39].
When comparing patients undergoing trabectome-only with those undergoing phaco-trabectome procedures, research has shown greater benefit in phakic or pseudophakic eyes after phaco-trabectome procedures [40]. However, phakic patients undergoing trabectome showed a greater reduction in intraocular pressure, compared to patients undergoing phacoemulsification combined with trabectome. These results suggest that phacoemulsification may not have a significant impact on intraocular pressure reduction [39].
Goniosynechiolysis and ab interno trabeculectomy for narrow angles and angle closure
Historically, angle-based glaucoma surgery in patients with narrow angles was thought more likely to result in synechiae and fibrosis. This was considered a contraindication to trabectome surgery. However, studies of trabectome and phaco-trabectome patients have proven that trabectome surgery can be successful even in these cases. Patients with an angle at Shaffer grade 2 or less (narrow) showed an average intraocular pressure reduction of 42% one year after trabectome surgery, and of 24% one year after phaco-trabectome. Patients with an angle at Shaffer grade 3 or above (open) showed an average intraocular pressure reduction of 37% reduction one year after trabectome surgery, and of 25% reduction one year after phaco-trabectome. These results suggest that trabectome surgery is a viable option for patients with narrow angles [15]
Failed trabeculectomy or tube shunt
Reoperation after failed trabeculectomy or tube shunt is very challenging. Trabectome surgery is a minimally invasive alternative to a repeat filter or shunt. Studies of patients undergoing trabectome surgery after a failed tube shunt have shown a statistically significant reduction in intraocular pressure after one year [42].
When comparing patients undergoing trabectome surgery after failed trabeculectomy with those undergoing phaco-trabectome, research has shown a greater reduction in intraocular pressure after trabectome than after phaco-trabectome [43]. Further research has shown trabectome surgery after failed trabeculectomy to result in an intraocular pressure reduction of 36%, and a 14% decrease in the number of pressure-lowering medications. 25% of patients were seen to require further surgery [44].
Ab interno trabeculectomy at the time of tube shunt implantation
Trabectome surgery has also proven to be a valuable adjuvant at the point of both valved and non-valved tube shunt implantation. When comparing patients undergoing Baerveldt tube implantation alone with those undergoing the same procedure combined with trabectome surgery, both groups showed similar intraocular pressure and visual acuities after the procedures. The combined patients required fewer pressure-lowering drops. These results show that trabectome surgery could improve post-operative quality of life by reducing necessary medication [16]. Results from Ahmed tube implantations showed a similar trend [46].
Ab interno trabeculectomy for severe glaucoma
When trabectome surgery results are correlated with glaucoma severity, patients with more medication, higher intraocular pressure and worse visual field experience a larger reduction in intraocular pressure than those with less aggressive glaucoma [33,37]. Studies have shown patients with the most advanced glaucoma to have a pressure reduction three times greater than those with mild glaucoma. Individuals with advanced glaucoma have been shown to have a lower success rate than those with mild glaucoma. This risk of failure is important when trabectome surgery is considered as a less risky alternative to traditional procedures. Other factors which have been linked to intraocular pressure reduction are age, Hispanic ethnicity, steroid-induced glaucoma and cup disk ratio [37]. Contradictory results have, however, been presented in the cases of ethnicity and the cup disk ratio [17].
Complications
The trabectome is very safe, particularly when compared to incisional glaucoma surgery. Recent research has shown the most common complications to include hyphema, peripheral anterior synechiae, corneal injury and temporary spikes in intraocular pressure. Less common complications include transient hypotony lasting less than 3 months, iris injury, cystoid macular edema and cataract progression. There are case reports of a few, rare complications, including cyclodialysis cleft, aqueous misdirection, choroidal hemorrhage and endophthalmitis [18].
Related Research Articles
Glaucoma is a group of eye diseases that result in damage to the optic nerve and cause vision loss. The most common type is open-angle glaucoma, in which the drainage angle for fluid within the eye remains open, with less common types including closed-angle glaucoma and normal-tension glaucoma. Open-angle glaucoma develops slowly over time without pain. Peripheral vision may begin to decrease, followed by central vision, resulting in blindness if not treated. Closed-angle glaucoma can present gradually or suddenly. The sudden presentation may involve severe eye pain, blurred vision, mid-dilated pupil, redness of the eye, and nausea. Vision loss from glaucoma, once it has occurred, is permanent. Eyes affected by glaucoma are referred to as being glaucomatous.
Eye surgery, also known as ophthalmic or ocular surgery, is surgery performed on the eye or its adnexa, by an ophthalmologist. Eye surgery is part of ophthalmology. The eye is a fragile organ, and requires due care before, during, and after a surgical procedure to minimize or prevent further damage. An eye surgeon is responsible for selecting the appropriate surgical procedure for the patient, and for taking the necessary safety precautions. Mentions of eye surgery can be found in several ancient texts dating back as early as 1800 BC, with cataract treatment starting in the fifth century BC. It continues to be a widely practiced class of surgery, with various techniques having been developed for treating eye problems.
The aqueous humour is a transparent water-like fluid similar to blood plasma, but containing low protein concentrations. It is secreted from the ciliary body, a structure supporting the lens of the eyeball. It fills both the anterior and the posterior chambers of the eye, and is not to be confused with the vitreous humour, which is located in the space between the lens and the retina, also known as the posterior cavity or vitreous chamber. Blood cannot normally enter the eyeball.
Phacoemulsification is a cataract surgery method in which the internal lens of the eye which has developed a cataract is emulsified with the tip of an ultrasonic handpiece and aspirated from the eye. Aspirated fluids are replaced with irrigation of balanced salt solution to maintain the volume of the anterior chamber during the procedure. This procedure minimises the incision size and reduces the recovery time and risk of surgery induced astigmatism.
Cataract surgery, which is also called lens replacement surgery, is the removal of the natural lens of the human eye that has developed a cataract, an opaque or cloudy area. The eye's natural lens is usually replaced with an artificial intraocular lens (IOL).
The trabecular meshwork is an area of tissue in the eye located around the base of the cornea, near the ciliary body, and is responsible for draining the aqueous humor from the eye via the anterior chamber.
Schlemm's canal is a circular lymphatic-like vessel in the eye. It collects aqueous humor from the anterior chamber and delivers it into the episcleral blood vessels. Canaloplasty may be used to widen it.
A glaucoma valve is a medical shunt used in the treatment of glaucoma to reduce the eye's intraocular pressure (IOP).
Trabeculectomy is a surgical procedure used in the treatment of glaucoma to relieve intraocular pressure by removing part of the eye's trabecular meshwork and adjacent structures. It is the most common glaucoma surgery performed and allows drainage of aqueous humor from within the eye to underneath the conjunctiva where it is absorbed. This outpatient procedure was most commonly performed under monitored anesthesia care using a retrobulbar block or peribulbar block or a combination of topical and subtenon anesthesia. Due to the higher risks associated with bulbar blocks, topical analgesia with mild sedation is becoming more common. Rarely general anesthesia will be used, in patients with an inability to cooperate during surgery.
Bimatoprost, sold under the brand name Lumigan among others, is a medication used to treat high pressure inside the eye including glaucoma. Specifically it is used for open angle glaucoma when other agents are not sufficient. It may also be used to increase the size of the eyelashes. It is used as an eye drop and effects generally occur within four hours.
Glaucoma is a group of diseases affecting the optic nerve that results in vision loss and is frequently characterized by raised intraocular pressure (IOP). There are many glaucoma surgeries, and variations or combinations of those surgeries, that facilitate the escape of excess aqueous humor from the eye to lower intraocular pressure, and a few that lower IOP by decreasing the production of aqueous humor.
Buphthalmos is enlargement of the eyeball and is most commonly seen in infants and young children. It is sometimes referred to as buphthalmia. It usually appears in the newborn period or the first 3 months of life. and in most cases indicates the presence of congenital (infantile) glaucoma, which is a disorder in which elevated pressures within the eye lead to structural eye damage and vision loss.
Pseudoexfoliation syndrome, often abbreviated as PEX and sometimes as PES or PXS, is an aging-related systemic disease manifesting itself primarily in the eyes which is characterized by the accumulation of microscopic granular amyloid-like protein fibers. Its cause is unknown, although there is speculation that there may be a genetic basis. It is more prevalent in women than men, and in persons past the age of seventy. Its prevalence in different human populations varies; for example, it is prevalent in Scandinavia. The buildup of protein clumps can block normal drainage of the eye fluid called the aqueous humor and can cause, in turn, a buildup of pressure leading to glaucoma and loss of vision. As worldwide populations become older because of shifts in demography, PEX may become a matter of greater concern.
Trabeculoplasty is a laser treatment for glaucoma. It is done on an argon laser equipped slit lamp, using a Goldmann gonioscope lens mirror. Specifically, an argon laser is used to improve drainage through the eye's trabecular meshwork, from which the aqueous humour drains. This helps reduce intraocular pressure caused by open-angle glaucoma.
Micro-invasive glaucoma surgery (MIGS) is the latest advance in surgical treatment for glaucoma, which aims to reduce intraocular pressure by either increasing outflow of aqueous humor or reducing its production. MIGS comprises a group of surgical procedures which share common features. MIGS procedures involve a minimally invasive approach, often with small cuts or micro-incisions through the cornea that causes the least amount of trauma to surrounding scleral and conjunctival tissues. The techniques minimize tissue scarring, allowing for the possibility of traditional glaucoma procedures such as trabeculectomy or glaucoma valve implantation to be performed in the future if needed.
Phacolytic glaucoma (PG) is a form of glaucoma which is caused due to a leaking mature or immature cataract. Inflammatory glaucoma which occurs in phacolysis is a condition which is a result of the leakage of protein within the lens into the capsule of a mature or hyper mature cataract and involves a simple procedure to be cured that is referred to as cataract extraction.
Secondary glaucoma is a collection of progressive optic nerve disorders associated with a rise in intraocular pressure (IOP) which results in the loss of vision. In clinical settings, it is defined as the occurrence of IOP above 21 mmHg requiring the prescription of IOP-managing drugs. It can be broadly divided into two subtypes: secondary open-angle glaucoma and secondary angle-closure glaucoma, depending on the closure of the angle between the cornea and the iris. Principal causes of secondary glaucoma include optic nerve trauma or damage, eye disease, surgery, neovascularization, tumours and use of steroid and sulfa drugs. Risk factors for secondary glaucoma include uveitis, cataract surgery and also intraocular tumours. Common treatments are designed according to the type and the underlying causative condition, in addition to the consequent rise in IOP. These include drug therapy, the use of miotics, surgery or laser therapy.
Uveitic glaucoma is most commonly a progression stage of noninfectious anterior uveitis or iritis.
The crystalline lens inside the human eye has been implicated as a causative factor in many forms of glaucoma. Lens induced glaucomas or Lens related glaucomas are either open-angle or closed-angle glaucomas that can occur due to a neglected advanced cataract or a dislocated lens. It is a type of secondary glaucoma. The angle-closure glaucoma can be caused by a swollen or dislocated lens. The open-angle glaucoma can be caused by leakage of lens proteins through the capsule of a mature or hyper mature cataract or by a hypersensitivity reaction to own lens protein following surgery or penetrating trauma.
Manual small incision cataract surgery (MSICS) is an evolution of extracapsular cataract extraction (ECCE); the lens is removed from the eye through a self-sealing scleral tunnel wound. A well-constructed scleral tunnel is held closed by internal pressure, is watertight, and does not require suturing. The wound is relatively smaller than that in ECCE but is still markedly larger than a phacoemulsification wound. Comparative trials of MSICS against phaco in dense cataracts have found no difference in outcomes but MSICS had shorter operating times and significantly lower costs. MSICS has become the method of choice in the developing world because it provides high-quality outcomes with less surgically induced astigmatism than ECCE, no suture-related problems, quick rehabilitation, and fewer post-operative visits. MSICS is easy and fast to learn for the surgeon, cost effective, simple, and applicable to almost all types of cataract.
References
1. van der Merwe EL, Kidson SH (2010) Advances in imaging the blood and aqueous vessels of the ocular limbus. Exp Eye Res 91:118–126 2. Polat JK, Loewen NA (2016) Combined phacoemulsification and trabectome for treatment of glaucoma. Surv Ophthalmol. https://doi.org/10.1016/j.survophthal.2016.03.012 3. Kaplowitz K, Schuman JS, Loewen NA (2014) Techniques and outcomes of minimally invasive trabecular ablation and bypass surgery. Br J Ophthalmol 98:579–585 4. Kaplowitz K, Loewen NA (2013) Minimally Invasive and Nonpenetrating Glaucoma Surgery. In: Yanoff M, S. DJ (eds) Ophthalmology: Expert Consult. Elsevier, pp 1133–1146 5. Christakis PG, Tsai JC, Kalenak JW, et al. (2013) The Ahmed versus Baerveldt study: three-year treatment outcomes. Ophthalmology 120:2232–2240 6. Kaplowitz K, Bussel II, Honkanen R, et al. (2016) Review and meta-analysis of ab-interno trabeculectomy outcomes. Br J Ophthalmol. Review and meta-analysis of ab-interno trabeculectomy outcomes 7. Kaplowitz K, Abazari A, Honkanen R, Loewen N (2014) iStent surgery as an option for mild to moderate glaucoma. Expert Rev Ophthalmol 9:11–16 8. Martin KR, Burton RL (2000) The phacoemulsification learning curve: per-operative complications in the first 3000 cases of an experienced surgeon. Eye 14 ( Pt 2):190–195 9. Xin C, Wang RK, Song S, et al. (2016) Aqueous outflow regulation: Optical coherence tomography implicates pressure-dependent tissue motion. Exp Eye Res. https://doi.org/10.1016/j.exer.2016.06.007 10. Johnstone M (2016) 3. Intraocular pressure control through linked trabecular meshwork and collector channel motion. In: Knepper PA, Samples JR (eds) Glaucoma Research and Clinical Advances 2016 to 2018. Kugler Publications, p 41 11. Iordanous Y, Kent JS, Hutnik CM, Malvankar-Mehta MS (2013) Projected Cost Comparison of Trabectome, iStent, and Endoscopic Cyclophotocoagulation Versus Glaucoma Medication in the Ontario Health Insurance Plan. J Glaucoma. Projected Cost Comparison of Trabectome, iStent, and Endoscopic Cyclophotocoagulation Versus Glaucoma Medication in the Ontario Health Insurance Plan 12. Minckler D, Mosaed S, Dustin L, et al. (2008) Trabectome (trabeculectomy-internal approach): additional experience and extended follow-up. Trans Am Ophthalmol Soc 106:149–59; discussion 159–60 13. Widder RA, Dinslage S, Rosentreter A, et al. (2014) A new surgical triple procedure in pseudoexfoliation glaucoma using cataract surgery, Trabectome, and trabecular aspiration. Graefes Arch Clin Exp Ophthalmol 252:1971–1975 14. Ting JLM, Damji KF, Stiles MC, Trabectome Study Group (2012) Ab interno trabeculectomy: outcomes in exfoliation versus primary open-angle glaucoma. J Cataract Refract Surg 38:315–323 15. Bussel II, Kaplowitz K, Schuman JS, et al. (2015) Outcomes of ab interno trabeculectomy with the trabectome by degree of angle opening. Br J Ophthalmol 99:914–919 16. Knowlton P, Bilonick R, Loewen N (2016) Baerveldt tube shunts with trabectome surgery in a matched comparison to Baerveldt tube shunts 17. Roy P, Loewen RT, Dang Y, et al. (2016) Stratification of phaco-trabectome surgery results using a glaucoma severity index 18. Kaplowitz K, Bussel II, Honkanen R, et al. (2016) Review and meta-analysis of ab-interno trabeculectomy outcomes. Br J Ophthalmol 100:594–600
Vold SD, Dustin L, and the Trabectome Study Group. Impact of laser trabeculoplasty on Trabectome® outcomes. Ophthalmic Surg Lasers Imaging. 2010 Jul-Aug;41(4):443-51. doi:10.3928/15428877-20100525-06. Epub 2010 May 28.
Vizzeri G, Weinreb RN. Cataract surgery and glaucoma. Curr Opin Ophthalmol. 2010 Jan;21(1):20-4. Review.
Mosaed S, Dustin L, Minckler DS. Comparative outcomes between newer and older surgeries for glaucoma. Trans Am Ophthalmol Soc. 2009 Dec;107:127-33. Review.
Liu J, Jung J, Francis BA. Ab interno trabeculotomy: Trabectome™ surgical treatment for open-angle glaucoma. Expert Rev Ophthalmol.2009;4(2):119-128.
Minckler DS, Hill RA. Use of novel devices for control of intraocular pressure. Exp Eye Res. 2009 Apr;88(4):792-8. Epub 2008 Nov 30. Review.
Patel SP, Sit AJ. A practical model for trabecular meshwork surgery. Arch Ophthalmol. 2009 Mar;127(3):311-3.
Godfrey DG, Fellman RL, Neelakantan A. Canal surgery in adult glaucomas.Curr Opin Ophthalmol. 2009 Mar;20(2):116-21. Review.
Minckler D, Mosaed S, Dustin L, Francis B, and the Trabectome Study Group. Trabectome (trabeculectomy – internal approach): Additional experience and extended follow-up. Trans Am Ophthalmol Soc 2008;106:149-160.
Nguyen QH. Trabectome: a novel approach to angle surgery in the treatment of glaucoma. Int Ophthalmol Clin. 2008 Fall;48(4):65-72. Review.
Francis BA, Minckler D, Dustin L, Kawji S, Yeh J, Sit A, Mosaed S, Johnstone M; Trabectome Study Group. Combined cataract extraction and trabeculotomy by internal approach for coexisting cataract and open-angle glaucoma. J Cataract Refract Surg. 2008 Jul;34(7):1096-103.
Filippopoulos T, Rhee D. Novel surgical procedures in glaucoma. Advances in penetrating glaucoma surgery. Curr Opin Ophthalmol. 2008 Mar;19(2):149-54. Review.
Gunderson E. Trabeculotomy Ab Interno, using the Trabectome: a promising treatment for patients with open-angle glaucoma. Insight. 2008 Jan-Mar;33(1):13-15.
Mosaed S. Ab interno trabeculotomy with the Trabectome surgical device. Techniques in Ophthalmology: 5(2):63-66, 2007.
Francis BA, See RF, Rao NA, Minckler DS, Baerveldt G. Ab interno trabeculectomy: development of a novel device (Trabectome™) and surgery for open-angle glaucoma. J Glaucoma. 2006 Feb;15(1):68-73.
Minckler D, Baerveldt G, Ramirez MA, Mosaed S, Wilson R, Shaarawy T, Zack B, Dustin L, Francis B. Clinical results with the Trabectome, a novel surgical device for the treatment of open-angle glaucoma. Trans Am Ophthalmol Soc. 2006;104:40-50.
Minckler DS, Baerveldt G, Alfaro MR, Francis BA. Clinical results with the Trabectome for treatment of open-angle glaucoma. Ophthalmology. 2005 Jun;112(6):962-7.
This page is based on this Wikipedia article Text is available under the CC BY-SA 4.0 license; additional terms may apply. Images, videos and audio are available under their respective licenses.
