The past decade has witnessed a paradigm shift in glaucoma surgery, from subconjunctival filtration procedures toward physiologic, angle-based outflow enhancement. Microinvasive glaucoma surgeries (MIGSs) have expanded our options, promising faster recovery, fewer complications, and greater patient satisfaction. However, their global diffusion remains uneven; high device costs, proprietary instrumentation, and regulatory limitations restrict access in low- and middle-income countries (LMICs). Amid this evolving landscape, surgeons have increasingly turned toward procedures that combine physiologic logic with practical feasibility, foremost among them, gonioscopy-assisted transluminal trabeculotomy (GATT).1 GATT exemplifies how innovation can be both high-impact and resource-sensitive. Its suture-based modification2 aligns well with LMIC realities, where cost and accessibility often limit adoption of commercial MIGS devices. The ability to perform an effective, conjunctiva-sparing procedure using standard ophthalmic instruments, 5-0 or 6-0 Prolene suture, MVR blade, and goniolens, democratizes access to advanced glaucoma surgery. In this sense, GATT bridges the gap between traditional filtration and device-dependent MIGS, redefining surgical innovation through the principles of equity, economy, and scalability. The mechanistic premise of GATT, addressing the conventional outflow resistance at the trabecular meshwork (TM) and Schlemm’s canal (SC), explains why it works best in eyes with preserved collector channel patency. GATT achieves circumferential trabeculotomy via an ab interno approach, enhancing aqueous outflow while preserving conjunctiva and sclera for potential future filtration procedures. From a clinical perspective, GATT is most appropriate when the desired target intraocular pressure (IOP) is not extremely low, typically 12–15 mmHg. It is particularly advantageous in patients where conjunctival preservation is important (e.g. younger individuals or those likely to require future trabeculectomy or tube shunt implantation). Conversely, in eyes with advanced or end-stage glaucoma where single-digit IOPs are essential for disease stabilization, traditional trabeculectomy or tube surgery remains preferable for their superior IOP-lowering potential. When significant cataract coexists, combining GATT with phacoemulsification offers a pragmatic and efficient strategy, addressing both visual rehabilitation and IOP control in one surgical session. Phacoemulsification itself can modestly lower IOP and improve access to the angle, while GATT augments this effect through direct enhancement of the trabecular outflow pathway.3 The synergy between the two procedures minimizes cumulative surgical trauma, reduces total operative time, and optimizes postoperative recovery. Intraoperatively, performing GATT after cataract extraction has several technical advantages. The removal of the crystalline lens deepens the anterior chamber, improves corneal clarity, and enhances gonioscopic visualization. The reflux of blood into Schlemm’s canal following viscodilation serves as a useful landmark for canal identification. Moreover, viscoelastic used during phacoemulsification can aid in smooth cannulation and minimize trabecular damage. Early reports, including several Indian series, indicate that phaco-GATT achieves substantial IOP reduction (30–40%) with significant medication sparing, while maintaining a favorable safety profile. Postoperative inflammation and transient hyphema4 are common but typically self-limited, with visual recovery paralleling that of routine phacoemulsification. By leveraging standard ophthalmic instruments and avoiding costly implants, this technique (Phaco-GATT) maintains affordability without compromising efficacy.5 With growing surgical familiarity, combined cataract-GATT procedures could well become the default for moderate glaucoma with coexistent lens opacity—integrating visual rehabilitation and physiologic IOP control in a single, efficient step. Before one jumps on the Phaco-GATT bandwagon, one must remember that from a surgical standpoint, GATT requires proficiency in intraoperative gonioscopy, steady hand–eye coordination, and delicate tissue handling. Cannulation of SC can be technically demanding, particularly in eyes with angle pigmentation or peripheral anterior synechiae. Microscope tilt coordination, patient cooperation, and adequate corneal clarity are essential for optimal visualization. Structured wet-lab training, simulator-based modules, and peer-reviewed surgical audits can flatten the learning curve and enhance safety during the adoption phase. The next frontier for GATT lies in refining patient selection using imaging and physiological insights. With the advent of anterior segment OCT (ASOCT), aqueous angiography, and canalography, surgeons may soon be able to assess canal patency, collector channel integrity, and segmental flow preoperatively. This would enable a shift from a “one-size-fits-all” trabeculotomy to a personalized outflow reconstruction strategy. Integrating such technologies within Indian tertiary centers can optimize case selection, improve predictability, and yield population-specific data on different glaucoma phenotypes. Despite its accessibility, several challenges persist. Limited availability of surgical gonioscopes and viscoelastic devices in smaller centers, lack of reimbursement frameworks, and inadequate exposure to angle-based surgery during residency all impede wider dissemination. Furthermore, the absence of standardized surgical certification or case-logging systems for MIGS/Phaco-MIGS in India contributes to variability in technique and outcomes. Addressing these barriers through regional training hubs and hands-on workshops can accelerate skill acquisition and ensure quality assurance as GATT becomes mainstream. As glaucoma care moves toward precision, sustainability, and equity, GATT and Phaco-GATT symbolize the convergence of elegance, efficacy, and economy in surgical innovation. By leveraging existing surgical skills and affordable tools, it offers a realistic pathway to safe, physiologic IOP control for India’s diverse and resource-stratified population. The challenge ahead lies not in proving that GATT works—but in ensuring that it works consistently, accessibly, and equitably across all levels of care. “In the end, true progress in glaucoma care is not just lowering pressure—it is raising the standard of access.”
Parul Ichhpujani (Wed,) studied this question.