Sir,

Many thanks for your letter regarding our article on trabeculectomy training challenges. It is not surprising that our concerns are worldwide and will result in progressive deskilling of general trained ophthalmologists.

You raise a number of important points. We greatly believe in supervision of the trainees and nearly all would be operating under supervision (although possibly the supervising consultant did not get recorded). Postoperative supervision of the management post trabeculectomy is also just as critical. The number of trabeculectomies with mitomycin C performed by trainees was actually one (not 21) and thus were mostly performed by consultants. The subsets of IOP ⩽15 mmHg outcomes were trabeculectomy (41%), trabeculectomy with 5FU (39%) and phacotrabeculectomy (38%). We suspect the similar results depends on case selection—phacotrabeculectomies tend to have less severe glaucoma compared with the augmented trabeculectomies that tend to have the more difficult to control glaucoma.

The ‘success rate’ of 30% was set quite strictly, being defined as ⩽15 mmHg on no medication following the traditional trabeculectomy technique. We agree with better techniques such as fornix-based conjunctival flaps, preplaced removable scleral trapdoor sutures, careful use of mitomycin C, and meticulous conjunctival edge closure outcomes can be improved. Unfortunately the trainees have limited number of cases and will probably require further glaucoma fellowship training to reach satisfactory surgical standard.