Beware GATT complications
My experience from the Gonioscopy Assisted Transluminal Trabeculotomy (GATT) at Glaucoma Associates of Texas (GAT)
My experience from the Gonioscopy Assisted Transluminal Trabeculotomy (GATT) at Glaucoma Associates of Texas (GAT)
As a long-time Glaucoma patient, I am simply relaying my experience for the benefit of other patients out there considering the GATT procedure as an alternative to daily eye drops. After summarizing my negative experience with the GATT procedure and the permanent damage to my vision, I review the available documentation online that conveys the prevalence of severe Hyphema (blood in eye) that is known to cause pain and blindness. I summarize available literature regarding the "success" rate of the procedure. It turns out that patients generally must continue eye drops even after the GATT procedure. And I end with a day-by-day account from my 15 days following the procedure in Apr 2024.
In late April 2024, an Ophthalmologist at Glaucoma Associates of Texas (GAT) performed the GATT procedure on my left eye. Have only had Glaucoma in my left (non-dominant) eye. After treating my Glaucoma with prescription eye drops for over 20 years, my main Ophthalmologist referred me to Glaucoma Associates of Texas (GAT). We quickly resolved that GATT was the right procedure for me.
But it was a horrible experience. And I have to live with the resulting visual impairment for the rest of my life. Incurred severe "black eye," evident from the photograph below, and five days of pain in the eye, unable to focus up close or to go outside without extreme pain in the eye ball! It turned out to be caused by a resulting Hyphema, with blood evident about half-way up the eyeball. The doctors at GAT saw how bad it was on Day 2, Day 3, and even Day 8. And yet they would do nothing for it!...except continue the regimen of steroid eye drops. They blew it off as "normal" and "common." Wait. What? GAT considers this result as "normal"…and yet continues to do the procedure anyway!
Without question, the GATT procedure and/or the resulting Hyphema caused permanent visual loss for me. Before/after retinal imaging and visual field tests illustrate the damage. And am now only able to see 20/40, after lens correction, a loss of 3 rows on the Snellen eye chart. So that's about 40 years worth of Glaucoma damage inflicted on me in two weeks! And I have to continue on 3 drops per day to maintain the IOP (eye pressure).
Healthline in 2018 considers "hemorrhaging inside the affected eye" as a severe case/risk. Hyphemas are known to potentially cause blindness. There is a procedure called Anterior Chamber Washout (AC Washout) that can be performed to remove the persistent blood from the eye. And I would prefer that GAT follow the recommendations of their own Dr. Davinder Grover and Dr. Ronald Fellman in 2018, Review of Ophthalmology:
If the patient has a significant layered hyphema postoperatively, consider washing it out. Everyone has a different preference when it comes to something like this, but we believe that blood in the eye after surgery is a bad thing, so we’re pretty aggressive. If the patient has a significant layered hyphema at the one-week point, we have a low threshold for washing it out.
The surgeon eventually admitted that my bleeding was severe, at a level seen in <1 out of 100 cases. Since they performed the procedure on Monday, they had a perfect opportunity to schedule an AC Washout for later in the week…after the blood had a chance to clot, but before the blood congealed or caused corneal staining. But yet they chose not to. So, I feel like they gambled with my vision. And they lost. But I must live with the consequences.
Sure, there may have been some risk with the AC Washout. There were obviously known risks with GATT, but yet they did that anyway to prevent eventual long-term gradual vision loss. The severe Hyphema was clearly visible, present (now), causing pain and discomfort for the patient (now), and a known risk of permanent damage to the eye (now).
Recall that my Hyphema rendered me totally blind in the eye…all day…through Day 10. From mid- to late-2024, the following reports were found online to understand the severity of my situation and indications for AC Washout, i.e. surgical evacuation of the Hyphema. And yet GAT just left me to suffer through it, and to "take my chances" with permanent visual impairment.
https://academic.oup.com/book/42042/chapter-abstract/355787822
Source: Complications of Glaucoma Surgery, 2013, by Dr. Robert Feldman and Nicholas Bell.
The severity of hyphema after trabeculectomy varies greatly… Loss of vision from hyphema in the operated eye, even if only temporary, can be functionally, and possibly psychologically, debilitating to the patient.
https://consultqd.clevelandclinic.org/goniotomy-and-gatt-arent-just-for-mild-to-moderate-glaucoma
Within the first month after surgery, 21 of the 40 GATT eyes (53%) had hyphema present at some point…, persistent hyphema was reported in 3 of the 40 GATT eyes…
https://pmc.ncbi.nlm.nih.gov/articles/PMC8302281
A total of 53 eyes of 53 patients were enrolled in the study…
Microhyphema was observed in 48 (90.6%) of the eyes, while macrohyphema in 5 (9.4%) of the eyes. Hyphema was transient and cleared spontaneously in all but two eyes which required anterior chamber washing.
https://pmc.ncbi.nlm.nih.gov/articles/PMC9914959
A common early complication observed in about 50% of patients was hyphema during the first few days after the surgery…
The most frequently described complication was hyphema the day folloawing the procedure. In all cases it resolved spontaneously within a week.
https://eyestucson.com/glaucoma-filtering-surgery-trabeculectomy
Bleeding within the eye (hyphema), usually resolves within one week.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10585214
These hyphemas are often transient and self-limited, though AC washout can be performed if the hyphema is visually significant in a monocular patient, does not resolve in a timely manner, or if there are risks of other impending complications such as corneal blood staining.
The rate of hyphema after GATT has been reported to be 51 % at POD1 [Post-Op Day 1], 16–30 % at POW1 [Post-Op Week 1], and 1–6% at POM1 [Post-Op Month 1].
Transient hyphema and transient IOP elevation were the most common complications, and 10% GATT eyes required surgical evacuation of hyphema.
https://my.clevelandclinic.org/health/diseases/22586-hyphema
Only around 5% of people with hyphema need surgery to repair it. If you have severe bleeding and pressure inside your eye that doesn’t start to improve within 24 hours — or if your symptoms are severe enough to permanently damage your eye — you might need surgery.
Hyphemas are medical emergencies because they can cause complications that lead to permanent eye damage and vision loss.
The most common postoperative complication was transient hyphema (39%; median duration, 5 d).
https://www.nweyes.com/post-operative-hyphema
A certain amount of bleeding is expected in these procedures as significant trauma to the trabeculum occurs.
* Hyphema may be seen in up to 25% of trabeculectomy cases.
* The majority of post-operative hyphemas however are small, can be managed medically and are expected to clear over several days.
https://eyewiki.aao.org/Hyphema#Medical_Management
A majority of hyphemas will resolve with medical management alone. Approximately 5 percent of patients with traumatic hyphema require surgery. The patient can typically be monitored for the first 4 days with medical treatment alone to allow for spontaneous resolution. After that point, surgical intervention may be indicated in the setting of uncontrolled glaucoma, corneal blood staining, the persistence of a large or total hyphema, and active bleeding in the anterior chamber.
https://www.aao.org/eyenet/article/goniotomy-makes-a-comeback-in-adults
A micro-hyphema is the most common goniotomy complication, and it usually clears by week one…
Note that the doctors' criteria for success are very different from ours…as patients.
https://www.aao.org/eyenet/article/goniotomy-makes-a-comeback-in-adults
A micro-hyphema is the most common goniotomy complication, and it usually clears by week one…
“Goniotomy treats the trabecular meshwork [TM], the portion of the drainage system where the majority of pathology with glaucoma exists,” said Dr. Kamat. “I consider the procedure a success if I get a 20% to 30% decrease of pressure and I’m able to stop a [glaucoma] drop or two.” Dr. Makadia noted, “I usually get about a 20% pressure reduction, and patients can usually stop at least one medication.”
https://memorialsameday.com/procedure/trabeculectomy
Trabeculectomy has proven to reduce intraocular pressure in three out of four patients [75%], but many people need more trabeculectomy surgery as well as other glaucoma treatments.
https://www.ophthalmologyglaucoma.org/article/S2589-4196(23)00031-5/fulltext
Fifty-nine patients (74 eyes), age 57.1 ± 18.5 years (37.8% female) underwent the GATT procedure…Mean number of medications decreased from 3.2 ± 1.0 preoperatively to 2.3 ± 1.0 at 4 years (P < 0.01).
The cumulative failure rate at 4 years was 53.9%, and the cumulative reoperation rate was 42.0%. No significant differences between patients with primary open-angle glaucoma and other types of glaucoma were found.
My photo from Apr 30, Day 2, after patch removal shows the significant Level II Hyphema at almost 50% of the eyeball, clearly impacting the visual axis.
On Wed (May 1, Day 3), I am really scared about still being blind! While yet going outside into daylight caused excruciating pain in Left eyeball. And I couldn't even read up close for more than 30 seconds without experiencing an extremely high level of pain in the Left eyeball, presumably as it was trying to focus while being half-full of blood, even though it could not see anything! …
Significant pain and blindness continued thru Friday (Day 5). On weekend, Days 6-7, I could only start to acknowledge the boundary of a bright screen in a dark setting. Could not "see" anything. Not far away. Not up close. Not even large neon Exit signs. And of course, I cannot read road signs at all with the Left eye. I returned to work on Monday, in the office. But that level of blindness continued thru Tuesday, May 7 (Day 9)…
Only on Wednesday (Day 10) could I roughly delineate my visible surroundings. Can only see the boundaries of imagery or icons on a screen. Still cannot read anything! Not even large neon Exit signs within 5 feet! On Thursday (Day 11), can start to comprehend the contents of a large television screen. But still cannot read any text. On Friday (Day 12), there was notable improvement in vision. And was encouraged that I can read some of the text and wording on a large movie screen. On Saturday, May 11 (Day 13), maybe slight improvement in vision when upright and steady. Can read large text with distinct background only, as vision is still very blurry. But after only getting up from a chair or bed, the "shakeup" in my eye causes complete blindness again to where I can only notice boundaries of bright light, with zero readability. On Sunday, May 12 (Day 14), vision in steady state may have improved slightly from "blurry" to "cloudy." But still cannot even begin to read text from a book or computer, and cannot read road signs. On Monday, May 13 (Day 15), the visibility of Hyphema in front eye is finally visibly clearing. Vision is notably improved, e.g. can read the large neon Exit sign from ~50 feet away.
It turns out that my vision in that eye is still permanently impaired (20/40 at best, with lens correction). To be honest, I would not have expected 20/40 in non-dominant eye to be very problematic. But it bothers me much more than I expected it would. After 11 months, many times throughout the day as I shift focus, looking up or down, left or right, the "big blur" from the left side is…distracting. And reading a book is difficult with the left eye only seeing blurred lines of text. Although able to distinguish capitalized words/letters, the full text cannot be comprehended in the damaged eye…at all.
Please Note:
All opinions expressed on this site are my own. I am just a patient revealing what happened to me at Glaucoma Associates of Texas (GAT). And I simply want future patients to understand the potential risks of the Gonioscopy-Assisted Transluminal Trabeculotomy (GATT) procedure.
myGATTatGAT
mailto:john@myGATTatGAT.com
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