"Another good reason to learn an unroofing procedure is that they give more versatility in patient selection, he said. "Unlike the trabecular bypass stent MIGS procedures, the unroofing procedures are not just approved for use in combination with cataract surgery, and so they can be done as a single surgery in patients who are phakic or pseudophakic. currently surgeon preference is the deciding factor on which one is adopted."
The unroofing procedures include three surgeries involving removal of up to 180° of the trabecular meshwork (trabecular removal, also called goniotomy)-Trabectome (NeoMedix), Kahook Dual Blade (New World Medical), Goniotome (NeoMedix)-and two that tear through the full 360° of the TM-Trab 360 (Sight Sciences) and gonioscopic assisted transluminal trabeculotomy (GATT) (trabeculotomy).
Providing some perspectives on how the unroofing procedures compare with each other based on having personal experience with all five, Dr. Francis explained that the Trabectome uses plasma energy to ablate the trabecular meshwork whereas both the Kahook Dual Blade and Goniotome are mechanical cutting tools.
"With the Kahook Dual Blade and Goniotome, a strip of trabecular meshwork is lifted and cut," Dr. Francis said. "The main difference between these two procedures is that the Goniotome can be done with irrigation and aspiration only via a phacoemulsification machine or manual IA (Goniotome IA) or under ophthalmic viscosurgical device (Goniotome) and the Kahook Dual Blade is done only under ophthalmic viscosurgical device."
Comparing the trabecular removal and trabeculotomy techniques, he noted that while the trabeculotomy procedures treat more of the angle, the trabecular removal techniques can help prevent scarring of the cut ends because they remove the intervening tissue.