Sir,

We read with interest the paper by Troutbeck et al.1 There are not many articles published so far showing the outcome of the trainee and consultant's trabeculectomies. We recently carried out a study on this subject.

We agree that with the new antiglaucoma medications, the need for the trabeculectomy is reduced. The cases that require trabeculectomy are usually either not responding to maximum medical treatment or not suitable for it due to side effects, medical comorbidities, or poor compliance. Therefore, these cases are challenging. Troutbeck et al1 mentioned in their study that the trainee performed trabeculectomies as a sole operator with or without supervision. Direct supervision throughout the trabeculectomy should improve the technique as well as predict and reduce early postoperative complications.

We note in this study that the trainee commonly performed phacotrabeculectomies or trabeculectomy with antimetabolites (5 flurouracil: 36 cases, mitomycin C: 21 cases). It would be interesting to know the outcomes of the trabeculectomies without antimetabolites. In this paper, it seems trainee and consultants operated on almost equal number of cases who required mitomycin C (21 and 20, respectively) although it is mentioned that these cases were exclusively performed by consultants. Use of antimetabolites is more often associated with early and late postoperative complications (eg, hypotony, increased incidence of bleb interventions and corneal toxicity). This affects long-term intraocular pressure (IOP) control. Therefore, these cases are best managed by experienced surgeons.

In this study, the trainee performed only 1.6 trabeculectomies per year. Our departmental audit in Scotland showed that the trainee performed 6–12 trabeculectomies per year. We agree with Troutbeck et al1 and Franks et al2 that trabeculectomies are now more frequently carried out by specialized glaucoma surgeons.3, 4 A multicentre audit presented in the Scottish Ophthalmological Club (SOC) in February 2005 showed significant reduction in the number of trabeculectomies performed by general ophthalmologists.

The success rate (30%) in this study by Troutbeck et al1 seems low.3, 4 We believe that careful case selection for trainee, intraoperative supervision and close postoperative monitoring can achieve good long-term IOP control and increase the success rate.