These thoughts are of kuldeep singh and added and rephrased by Dr Muhammad Azeem, written with the help of ChatGPT.
Trabeculectomy with Mitomycin C is still one of the most effective glaucoma surgeries we have. The results are strong, the science is solid, and decades of data back it. Yet in the United States the number of trabeculectomies being performed has dropped. Studies such as those by Mataki and Caprioli show a slide from 48 to 32 procedures over comparable periods. The numbers speak for themselves. Fewer surgeries mean fewer chances for young ophthalmologists to learn the procedure well.
Why is this happening? There are a few reasons.
1. MIGS changed the landscape.
Minimally invasive glaucoma surgery took off quickly. The appeal is obvious. Short learning curve, faster recovery, fewer complications, smoother postoperative visits. But this jump shifted attention away from trabeculectomy. As MIGS became the early go to, fewer surgeons entered training programs hungry to master trabs in the way the previous generation did.
2. Early postoperative care is demanding.
Trabeculectomy works, but only with focused follow up. It needs a surgeon who is committed and comfortable with bleb management. Not everyone is ready for that, and clinics built around high volume struggle to make room for such detailed monitoring.
3. Financial incentives are not aligned.
Reimbursement often fails to match the skill, time, and responsibility required. Many surgeons gravitate toward procedures that pay more while asking for less. When economics interfere with clinical priorities, important surgeries lose ground.
4. Reduced case numbers weaken the skill pipeline.
Fewer surgeries means weaker exposure. Without a minimum number of cases during training, it is impossible to build good instincts. Precision only develops through repetition. Without that foundation, developing a custom style is impossible. The traditional culture of trabeculectomy built by surgeons who performed it before drops and MIGS became common begins to fade.
This decline is not good for patients or the specialty. Glaucoma needs diversity. Medication, lasers, MIGS, tube shunts, cyclophotocoagulation, and trabeculectomy all have a place. No single tool fits every eye.
The solution is simple. First, our community must restore the scientific foundation. Surgeons should learn trabeculectomy properly and perform enough cases to gain the confidence needed to keep it in their toolbox. Second, platforms like BPOS are essential. These forums help transmit technique, judgment, and culture. Third, reimbursement must reflect the value of the procedure. When the effort is recognized, more surgeons will give it the attention it deserves.
Trabeculectomy should not fade into the background. It remains one of the most powerful glaucoma surgeries we have. By raising awareness, protecting training opportunities, and supporting surgeons who perform it, we can preserve a procedure that still changes lives.
#retina#ilaj#discswelling#kalamotiya#prognosis
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