Acta Ophthalmologica 2014

Rates of visual field loss before and after

trabeculectomy
Valérie Bertrand,1 Steffen Fieuws,2 Ingeborg Stalmans1 and Thierry Zeyen1
1
Department of Ophthalmology, University Hospitals Leuven, Leuven, Belgium
2
Interuniversity Center for Biostatistics and Statistical Bioinformatics, Catholic University of Leuven and University of Hasselt,
Leuven, Belgium

ABSTRACT. the VF before and after trabeculectomy

Purpose: To compare the rates of change in the visual field (VF) in patients with were evaluated without consideration
glaucoma before and after trabeculectomy. of optic disc changes. Although several
Methods: Of 52 eyes of 52 patients with different types of chronic glaucoma who studies concluded that progression did
underwent first trabeculectomy were evaluated retrospectively. Pre- and postopera- not stop after trabeculectomy, it is
tive-automated visual fields measured by the same technique were compared to important to analyse to what extent
detect differences in rates of change. Rates of VF loss before and after trabeculec- the rates of change in the visual field
tomy were calculated using mean deviation (MD). Linear mixed models were used could be slowed down after a trabecu-
to compare the rates of change in the VF before and after trabeculectomy. lectomy. Therefore, we compared the
Results: The mean follow-up period pre- and post-trabeculectomy was 3.9 years rates of change in the VF before and
(min 0.9, max 10.7) and 3.8 years (min 2.0, max 8.0), respectively. The intraocular after primary trabeculectomy in
pressure (IOP) decreased from 18.1 mmHg (SD = 4.7) before trabeculectomy to patients with glaucoma.
11.1 mmHg (SD = 2.9) at the last follow-up after trabeculectomy. The rate of
MD loss was reduced with 56% on average, from )0.36 dB ⁄ year before surgery to Material and Methods
)0.16 dB ⁄ year after surgery (p = 0.15).
Conclusion: Trabeculectomy considerably decreased the rates of change in the Subject selection
glaucomatous visual field.
All first trabeculectomies performed
Key words: glaucoma – intraocular pressure – mean deviation – rates of change – trabeculecto- by two surgeons (TZ and IS) at the
my – visual field university hospitals of Leuven
between January 2002 and February
2009 were analysed retrospectively.
Acta Ophthalmol. 2014: 92: 116–120
ª 2013 The Authors
Ethics committee approval was
Acta Ophthalmologica ª 2013 Acta Ophthalmologica Scandinavica Foundation. Published by Blackwell Publishing obtained. One eye per patient was
Ltd. included in the study. When bilateral
doi: 10.1111/aos.12073 trabeculectomy was performed, the
right eye was included unless <3 VFs
were available before or after trabecu-
lectomy. Other exclusion criteria are
summarized in Fig. 1. This report
2002; Sihota et al. 2004; Ehrnrooth included 52 eyes in total, as showed in
et al. 2005; Kotecha et al. 2009). Table 1. Indications for trabeculecto-
Introduction The European and US guidelines my were uncontrolled IOP despite
The goal of glaucoma therapy is to describe progression as a worsening of maximal-tolerated medical therapy
prevent further impairment of the structural and ⁄ or functional defects and ⁄ or VF progression and ⁄ or optic
visual field and preserve-related quality (European Glaucoma Society 2008; disc progression (Table 1). The surgi-
of life. However, it is known that pro- American Academy of Ophthalmology cal technique was the same for both
gression cannot be completely halted Glaucoma Panel 2010). Both optic disc surgeons and was described elsewhere
by trabeculectomy. Previous studies imaging (structural) and visual field (Stalmans et al. 2006). Antimetabo-
mentioned further progression in 26– testing (functional) are complementary lites were used at the discretion of the
41% after trabeculectomy (Nouri- (Termote & Zeyen 2010). In this retro- surgeon: either 5-fluorouracil (one
Mahdavi et al. 1995; Shigeeda et al. spective study, the rates of change in eye) or mitomycin C (33 eyes).

116

Fig. 1. Flowchart of exclusion criteria.
Table 1. Type of glaucoma and indications for trabeculectomy.
Type of glaucoma
CACG
NTG
PDG
PEX
POAG
Secondary glaucoma by inflammation
Indication
Uncontrolled IOP
VF progression
Optic disc progression
Uncontrolled IOP + VF progression
Uncontrolled IOP + optic disc progression
VF + optic disc progression
Uncontrolled IOP + VF + optic disc progression
CACG, chronic angle-closure glaucoma; IOP, intraocular pressure; NTG, normotensive open-
angle glaucoma; PDG, pigmentary glaucoma; PEX, pseudoexfoliation glaucoma; POAG, pri-
mary open-angle glaucoma; VF, visual field.
Visual field analysis
Before surgery, all patients had a
minimum follow-up of 1 year and ‡3
reliable VFs. After surgery, all
patients were followed up for
‡2 years in our clinical centre with ‡3
reliable VFs. The VF was examined
by either the Octopus G1 program
with dynamic strategy, or the Hum-
phrey 24-2 SITA standard program.
The same instrument and program
were used for each patient through-
out the study. VFs were considered
unreliable when the incidence of
Acta Ophthalmologica 2014
ments prior to trabeculectomy with the
same glaucoma treatment using a
Goldmann applanation tonometer.
Postoperatively, IOP was also
expressed as the mean IOP of the last
three measurements during follow-up
with the same glaucoma treatment. If
there were less than three measure-
ments on the same treatment prior to
surgery or at the end of follow-up, the
average of two measurements (eight
eyes) or the last IOP measurement (six
eyes) was used. Visual acuity (VA) was
recorded as LogMAR units. Preopera-
tive VA was taken as the best corrected
visual acuity (BCVA) recorded the last
consultation prior to surgery. Postop-
erative VA was taken as the BCVA
recorded at the end of follow-up. Other
pre- and postoperative data were col-
lected included date of birth, gender,
antiglaucoma eyedrops (last modifica-
tion before surgery and at the end of
follow-up), dates of all surgical inter-
ventions, including laser treatments
and cataract surgery.
No % Statistical methodology
Wilcoxon signed rank test were used to
5 10 compare variables before and after tra-
11 21 beculectomy. However, as some
3 6 patients had more visual fields than oth-
3 6
ers, a linear mixed model (Verbeke &
24 46
6 11 Molenberghs 2000) was used to com-
pare the rates of change before and after
22 42 trabeculectomy. Two linear phases were
5 10 distinguished with a potential change
3 6 point at the moment of trabeculectomy.
12 23 Formally, Yij = ai + b1itij + b2it*ij + eij,
3 6
where Yij denoted the MD from the i-th
1 2
6 11
subject measured at time-point j, t was
the time since trabeculectomy (thus neg-
ative values for t refer to the period
before trabeculectomy) and t* was
equal to t but took value zero if t < 0.
ai, b1i, b2i were the MD at the time of
surgery for subject i, the rate of change
false-positive errors or the incidence
before trabeculectomy and the effect on
of fixation loss were >30%. Excel
the rate of change by trabeculectomy
files with the MD of all the VFs,
(hence, the rate of change after trabecu-
both from Humphrey and Octopus
lectomy was given by b1i – b2). Note
were obtained from the EyeSuite soft-
that the parameter of interest in this
ware (Monhart 2009). The sign
model was b2 because this parameter
before the value of the Octopus MD
indicated if the rate of change after tra-
was changed. The rate of change was
beculectomy deviated from the rate of
calculated in decibel (dB) per year
change before trabeculectomy. Note
(Chauhan et al. 2008).
that a linear mixed model can intuitively
be considered as performing a regres-
IOP, visual acuity and other data
sion model for each patient separately
Preoperative IOP was expressed as the and combining the estimates for each
mean IOP of the last three measure- patient for the intercept and the rates of
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Acta Ophthalmologica 2014

change into average estimates, taking Table 2. Demographics and characteristics.

into account differences in numbers of
Mean (No) SD Median Min Max
observations between patients. The esti-
mates for each patient separately Gender M ⁄ F (%) 48 (25)
obtained from the model are empirical Right Eye (%) 76 (40)
Bayes (EB) estimates, that is, they are a Age 70.1 11.1 72.2 42.3 89.1
weighted average of the observed data FU pre (years) 3.9 2.2 4.0 0.9 10.7
FU post (years) 3.8 1.4 3.5 2.0 8.0
for a specific patient and the average of
No. VF pre 5.8 2.6 5.5 3.0 12.0
the total sample. The more observations No. VF post 5.9 2.4 5.0 3.0 12.0
a patient has the more weight is given to IOP pre (mmHg) 18.1 4.7 17.0 12.0 33.0
the individual data in the calculation of IOP post (mmHg) 11.1 2.9 11.0 6.0 17.0
the EB estimates. Information more Mean percentage IOP reduction (%) 36.4 17.3 35.7 )21.4 69.6
than 7 years before trabeculectomy was Absolute change in IOP (mmHg) 7.0 4.6 6.0 )3.0 20.0
not used in the models. All analyses VA pre (logMAR) 0.19 0.21 0.10 1.00 0.00
have been performed using SAS soft- VA post (logMAR) 0.22 0.17 0.20 0.80 0.00
No. antiglaucoma eyedrops pre 2.1 0.9 2.0 0.0 4.0
ware, version 9.2 of the SAS System for
No. antiglaucoma eyedrops post 0.4 0.8 0.0 0.0 3.0
Windows. Copyright ª 2002 SAS Insti- Laser trabeculoplasty 19 (10)
tute Inc. SAS and all other SAS Insti- Yag-laser iridotomy 17 (9)
tute Inc. product or service names are Phakic at the time of operation 75 (39)
registered trademarks or trademarks of Cataract extraction during FU 23 (12)
SAS Institute Inc., Cary, NC, USA.
SD, standard deviation; FU, follow-up; pre, preoperative; post, postoperative; VF, visual field;
No, number; IOP, intraocular pressure; VA, visual acuity.
Results
A total of 52 eyes of 52 Caucasian
patients who underwent first trabecu-
lectomy were evaluated retrospectively
(Fig. 1). Demographic details and
details of pre- and postoperative sta-
tus are shown in Table 2. The mean
age at the time of surgery was
70 years (range 42–89 years). The
mean follow-up period before surgery
was 3.9 years (range 0.9–10.7) and the
mean follow-up period after surgery
was 3.8 years (range 2.0–8.0).
The mean preoperative IOP was Δ p

18.1 mmHg (SD = 4.7). The mean

postoperative IOP at the end of follow-
up was 11.1 mmHg (SD = 2.9). After
trabeculectomy, the IOP was reduced Fig. 2. Average slopes of visual field loss, expressed as MD, before and after trabeculectomy.
on average with 7.0 mmHg Dashed lines refer to the pointwise 95% confidence interval for the average slope. The vertical
dotted line represents the moment of trabeculectomy. D = difference between pre- and post-tra-
(SD = 4.6), which corresponded with
beculectomy.
a relative reduction of 36% (SD = 17).
The mean postoperative IOP of all the
patients at the end of the follow-up was
below the initially, individually calcu-
lated target IOP. The mean number of
antiglaucoma eyedrops decreased from
2.1 before surgery to 0.4 after surgery
(p < 0.001). The mean logMAR
BCVA before trabeculectomy was 0.19
(SD = 0.21), that is, 0.65 on Snellen
decimal scale, and the mean LogMAR
BCVA after trabeculectomy was 0.22
(SD = 0.17), that is, 0.60 on Snellen
decimal scale (p = 0.13). During the
follow-up period, 12 of the 39 phakic
eyes underwent cataract surgery. The
slopes of VF loss, expressed as MD,
before and after trabeculectomy were Fig. 3. Plot with rate of change per patient. Each line represents the MD values for the specific
on average )0.36 dB ⁄ year (standard number of VFs for each patient.

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 Acta Ophthalmologica 2014

error (SE) = 0.11) and )0.16 dB ⁄ year mean IOP reduction after trabeculecto- progression of glaucoma at 5 years
(SE = 0.08), respectively (Fig. 2). The my and the slowing of MD loss (differ- after trabeculectomy. On the other
resulting average difference between ence in the rate of change between pre- hand, it is important to know to what
the two slopes equals 0.20 dB ⁄ year and post-trabeculectomy) (Fig. 5). extend the rates of visual field loss can
(SE = 0.14), or a reduction of the rate be slowed down after trabeculectomy.
of MD loss with 56% on average Our study evaluated the rates of
(p = 0.15). The plot in Fig. 3 shows
Discussion MD loss before and after trabeculecto-
the intra- and interpatient variability in Trabeculectomy has become the stan- my and showed that there was a con-
MD, and the interpatient variability in dard filtering operation for uncon- siderable reduction in the rate of MD
MD changes. The scatterplot in Fig. 4 trolled glaucoma, and the beneficial loss after surgery. The average differ-
illustrates that the rate of MD change effect of reducing the IOP has been ence between the rates of MD loss
is slower after trabeculectomy (dots shown in several studies. However, in before and after surgery was 0.20 dB ⁄
above the diagonal) in the majority of many cases, VF defects continue to year (p = 0.15), a reduction of 56%
the patients (29 ⁄ 52). There was no sig- progress despite surgery. Kotecha et al. on average. Although this difference
nificant (Spearman q = )0.08, (2009) concluded that approximately was not statistically significant, an
p = 0.57) association between the one-third of eyes continued to show overall reduction of 56% of MD loss
after surgery can be considered clini-
cally significant. This reduction com-
pares with the 43% of reduction after
starting medical and laser treatment
reported in the EMGT study (Heijl
et al. 2009). Tung JD, ARVO Abstract
[4409], [2011] found a comparable
reduction of MD loss in 29 eyes after
trabeculectomy (0.26 dB ⁄ year versus
0.20 dB ⁄ year in our study). Their rate
of MD loss before trabeculectomy
was similar ()0.31 dB ⁄ year versus
)0.36 dB ⁄ year in our study), but they
found a lower rate of MD loss after
trabeculectomy ()0.05 dB ⁄ year versus.
)0.16 dB ⁄ year in our study). Note,
however, that their result is still within
the 95% confidence interval for the
MD loss after trabeculectomy in our
study, going from )0.01 dB ⁄ year to
)0.31 dB ⁄ year. It might have been that
Fig. 4. Scatter plot of the estimates of the rates of change for each patient before and after tra- Tung et al. included patients with more
beculectomy. The dashed lines represent no changes in VF. Each dot represents a patient. Dots aggressive disease and that the effect of
above the diagonal refer to a slowing of VF loss, dots under the diagonal to accelerated VF surgery is more pronounced in this
loss after trabeculectomy.
group. Our number of patients was too
small to analyse subgroups with various
degrees of preoperative progression.
It is possible that the lack of statis-
tical significance is explained by the
relatively small number of included
eyes and visual fields. As shown in the
flowchart (Fig. 1), a large number of
eyes were excluded because of a too
short follow-up period (<2 years)
after trabeculectomy or a too small
number of reliable VFs (<3) before
or after trabeculectomy. The main
reason for these findings is that our
clinical centre is mainly a referral cen-
tre. Many peripheral ophthalmologists
refer glaucoma patients for trabeculec-
Fig. 5. The relationship of mean IOP reduction after trabeculectomy and the slowing of VF loss
(difference of rate of change of MD between pre- and post-trabeculectomy). Each patient is
tomy to our centre, so few VFs are
tagged with a specific symbol according to the number of IOP measurements (3 or <3). The Y- performed in our hospital and most of
axis represents the difference between the estimates for the rate of change of MD pre- and post- the patients return to their ophthal-
trabeculectomy. A positive value on the Y-axis refers to a slowing of VF loss, a negative value to mologist within 2 years after trabecu-
accelerated VF loss after trabeculectomy. A linear trend is used to depict the shape of relation. lectomy. However, despite the low

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Acta Ophthalmologica 2014
number of included eyes, none of the
exclusion criteria is expected to lead
to biased estimates for the comparison
of the MD slope before and after tra-
beculectomy, except for 4 of the 39
excluded eyes post-trabeculectomy
because their visual fields were
reduced to central 10 degrees after tra-
beculectomy. As these excluded four
eyes might have had lower MD values
post-trabeculectomy compared with
the included cases, the reported differ-
ence in slopes might have been slightly
overestimated.
Clinicians need to be cautious when
evaluating progression in an individ-
ual patient by estimating rates of MD
loss on a small number of observa-
tions. The imprecision of the esti-
mated rate of change depends on the
reliability of the MD measurements,
the length of the time interval and the
number of VF measurements.
The degree of IOP reduction after
trabeculectomy plays an important
role in the progression of glaucoma
(Kotecha et al. 2009). The analyses of
the AGIS data concluded that low
intraocular pressure is associated with
reduced progression of visual field
defects, supporting evidence from
earlier studies of a protective role for
low intraocular pressure in visual field
deterioration (AGIS Investigators
2000). However, our study did not
find any correlation between IOP
reduction after trabeculectomy and
slowing of VF loss after surgery. This
is in agreement with other studies that
similarly failed to show such a corre-
lation (Nouri-Mahdavi et al. 1995;
Martinez-Bello et al. 2000; Tezel et al.
2001; Oliver et al. 2002). One plausi-
ble explanation for the controversial
findings regarding the role of IOP
control in glaucoma progression in
different studies has been suggested by
Palmberg (2001). It is reasonable to
assume that treatment was more
aggressive for those patients who
deemed to be at greater risk of pro-
gression.
In this study, the effect of cataract
and cataract extraction on visual field
changes were not taken into account.
Cataract might cause an underestima-
tion of the effect of trabeculectomy on
the rate of change in the visual field
counterbalanced by cataract extraction
that might cause an overestimation.
In our study, a trabeculectomy result-
ing in at least 36% reduction in IOP
120
was effective in considerably reducing
the rates of change in the visual field in
our population. Note that this finding
applies to our group of patients with an
average IOP reduction of 36%, without
ruling out other groups of patients with
less IOP reduction.
This study has several weaknesses.
First, the retrospective nature and the
asymmetrical minimum follow-up
required for inclusion pre- and post-
trabeculectomy, respectively, 1 and
2 years. Another related weakness is
the lack of long follow-up pre- and
post-trabeculectomy associated with a
large number of visual fields, leading
to relatively imprecise estimated rates
of change.
In conclusion, this retrospective study
of 52 eyes confirmed that progression
continues after trabeculectomy, albeit at
a slower rate. Trabeculectomy was
effective in considerably reducing the
rates of change in the visual field in our
population.
Acknowledgements
The authors thank Matthias Monhart
(EyeSuite Progression Analysis, Haag-
Streit, Switzerland) for all the help
with assembling and converting of the
data.
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Received on July 25th, 2011.
Accepted on December 4th, 2012.
Correspondence:
Valérie Bertrand
Department of Ophthalmology
University Hospitals Leuven
Kapucijnenvoer 33
B-3000 Leuven
Belgium
Tel: +32 16 33 23 70
Fax: +32 16 33 23 67
Email: valerie.bertrand@student.kuleuven.be