Trabeculotome Tunneling Trabeculoplasty (3T): A Step-by-step Surgical Protocol for Primary Open-angle Glaucoma

Primary open-angle glaucoma (POAG) requires sustained intraocular pressure (IOP) reduction to delay disease progression. Traditional filtering surgeries, while effective, are associated with significant tissue trauma, postoperative complications, and long-term scarring. Minimally invasive glaucoma surgery (MIGS) offers a safer alternative but may be limited by incomplete IOP reduction or long-term structural instability of Schlemm's canal (SC). Trabeculotome tunneling trabeculoplasty (3T) is a novel MIGS technique designed to restore physiological aqueous outflow while preserving trabecular meshwork (TM) structure. The procedure consists of three key steps: trabecular fenestration using a trabeculotome, viscoelastic-mediated dilation of SC, and placement of a tension suture to maintain long-term canal patency. This article provides a step-by-step surgical protocol and accompanying training video for the 3T procedure. Representative outcomes from a single-center, non-comparative case series demonstrate that 3T is associated with significant IOP reduction, decreased dependence on antiglaucoma medications, and a low complication rate. This protocol aims to facilitate standardized clinical implementation of 3T and provide a practical educational resource for surgeons performing minimally invasive glaucoma procedures.