Lens extraction combined with circumferential ab interno trabeculotomy to treat pigmentary glaucoma

To evaluate the 24-month outcomes of lens extraction combined with circumferential, 360-degree trabeculotomy in patients with progressive pigmentary glaucoma. This prospective, interventional case series included 32 eyes of 32 patients with progressive pigmentary glaucoma. All patients underwent phacoemulsification combined with gonioscopy-assisted transluminal trabeculotomy (GATT). Outcome measures included intraocular pressure (IOP), number of glaucoma medications, and success rates at 24 months. Qualified success was defined as IOP ≤ 18 mm Hg with a 20% IOP reduction from baseline, without requiring further glaucoma surgery. The mean preoperative IOP was 21.4 (SD 6.3) mm Hg on a mean of 2.2 (SD 1.5) glaucoma medications. At 24 months, mean IOP was reduced to 13.0 (SD 3.5) mm Hg (a 39% reduction), and mean medication use was reduced to 0.8 (SD 1.0). The Kaplan-Meier estimated probability of qualified success at 24 months was 75.0% (95% CI: 61.4% − 91.6%). Combined lens extraction and GATT effectively lowers IOP and medication use in pigmentary glaucoma. By targeting the source of pigment dispersion, lens extraction may halt the disease process, making this a very promising strategy. The role of iridotomy in reducing iridolenticular contact in pigmentary glaucoma is established, but its effectiveness is variable and its use remains controversial. Combining lens extraction with trabeculotomy addresses both the underlying cause of pigment dispersion by eliminating iridolenticular contact and the pathological effect on the trabecular meshwork. By halting further pigment liberation, lens extraction may improve the long-term success of trabecular outflow surgery in patients with pigmentary glaucoma. Lens extraction is a safe and effective procedure that should be considered a key component in the surgical management of pigmentary glaucoma, enabling effective angle surgery in pigmentary glaucoma.