For many ophthalmologists glaucoma surgery is regarded as the last resort for their patients - chaotic, unreliable and with the potential to deplete the residual vision in both the short and the long term. Even glaucoma surgeons can be overheard lamenting their surgical obstacles and comparing their lot to their cataract surgery colleagues. Although cataract surgery is often regarded as the most successful surgical procedure in medicine, even without laser assistance, there is ample proof that glaucoma surgery does work and saves the sight of many every year in spite of its deficiencies. But glaucoma remains the second top cause of blindness hi the world and in Australia, and the most common cause of preventable blindness. So why do the new surgical operations for glaucoma not cause wholesale conversion of glaucoma surgeons when the current ones seem so flawed? One of the most compelling reasons is the disease itself - glaucoma is a highly variable pathology. Rates of progression vary substantially between patients and in the same person over the life of the disease. One treatment paradigm does not suit all patients with glaucoma, and tailor-making treatment is one of the key roles of the treating clinician. Successful treatment of glaucoma prevents loss of neurons and vision - something only conclusively established after a great number of years. The surrogate of lowering intraocular pressure (IOTP) is clearly flawed (although still offers us the best approximation of a 'lead index'). For eyes at low risk of loss of sight from glaucoma, the treatment options seem extensive and effective, but for those with high risk of loss of vision, not so. Eyes at high risk of (further) progression are often those that must endure glaucoma surgery in one of its forms. Actually glaucoma surgery has become more successful over the last decades with less complications, but the number of surgeons performing glaucoma surgery has fallen substantially.3 The glaucoma surgery repertoire has expanded with many more non-penetrating operations, revision procedures, tube and plate implants, and cyclodestructive procedures being performed than at any time in the past.
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