Deep sclerectomy augmented with mitomycin C.
ABSTRACT To investigate the comparative efficacy and safety of deep sclerectomy with and without intraoperative mitomycin C (MMC) application for lowering the intraocular pressure (IOP).
A total of 71 eyes of 71 consecutive patients who had routine deep sclerectomy (DS), nonaugmented (DS-noMMC) or with mitomycin C (DS-MMC) augmentation (0.2 mg/ml for 2 min) and follow-up of 4 months or more were identified from an ongoing prospective database on glaucoma surgery. Indications for MMC use were the presence of risk factors for subconjunctival scarring and low target IOPs. MMC 0.2 mg/ml was applied in the sub-Tenons space for 2 min.
There were 19 eyes in the DS-noMMC group and 52 eyes in the DS-MMC group. In 11 eyes (15.5%), the procedure was complicated by intraoperative perforation of the trabeculo-Descemet's window. Eyes in the DS-MMC group had significantly lower IOPs (MANOVA, P = 0.04). Kaplan-Meier survival curve analysis showed that the probability of maintaining IOP below target IOP level, below 18 mmHg and below 14 mmHg at 1 year was 51, 67, and 35% for the DS-noMMC group and 80, 86, and 74% for the DS-MMC group. The survival rates of the DS-MMC group were not statistically significant (P = 0.06) when the success criterion was maintaining an IOP less than 18 mmHg but were significant for the other criteria, namely IOP less than target levels (P = 0.03) and less than 14 mmHg (P = 0.03). Nd:YAG goniopuncture to lower IOP to target levels was done more frequently in the DS-noMMC group (13 eyes, 81%) than the DS-MMC group (20 eyes, 45%) and this difference was significant (P = 0.03). The prevalence of avascular areas within filtration blebs and transconjunctival oozing of aqueous was significantly higher in the DS-MMC group (P < 0.01).
The use of intraoperative MMC during deep sclerectomy has a significant effect on the postoperative IOP and increases the probability of achieving target IOPs. However, our current technique of MMC application is associated with a higher incidence of avascular blebs and transconjunctival oozing.
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ABSTRACT: To evaluate the safety and efficacy of deep sclerectomy with implant and mitomycin C in uveitic glaucoma. Design Prospective, noncomparative case study. Nine patients (13 eyes) with uncontrolled uveitic glaucoma underwent deep sclerectomy with implant from 2002 to 2006. All patients had their uveitis controlled before and after surgery with anti-inflammatory therapy. Main outcome measures Control of intraocular pressure. A secondary outcome measure was the number of antiglaucoma medications required to achieve the desired intraocular pressure. Visual acuity and complication associated with the surgery were monitored. Mean follow-up was 21 months (range 12-54 months). Intraocular pressure (IOP) was reduced from a mean preoperative value of 28.7 mmHg to a mean postoperative value of 13.85 mmHg (Wilcoxon signed rank test P = 0.005). At the most recent visit, complete success was obtained in 84.6%, qualified success was obtained in 7.7%, and complete failure in 7.7%. Mean number of antiglaucoma medications was reduced from 3.07 to 0.2 (Wilcoxon signed rank test P = 0.001). Neodymium:YAG goniopuncture was performed in two eyes. Postoperative complications included transient hypotony with maculopathy in one eye, shallow choroidal effusions in two eyes, and progression of cataract in four eyes. Deep sclerectomy with implant in uveitic glaucoma appeared to be effective in controlling the IOP at short-term follow-up with no serious postoperative side-effects.International Ophthalmology 07/2008; 29(5):367-72.
Article: The changing conceptual basis of trabeculectomy: a review of past and current surgical techniques.[show abstract] [hide abstract]
ABSTRACT: The original intent of glaucoma surgery was to allow aqueous humor to exit more easily either through the sclera or into the suprachoroidal space. The former came to be called, generically, a glaucoma filtering procedure. As this surgery evolved, some explored the concept of lowering pressure without producing a hole in the sclera, with its resultant "filtering bleb." For example, Cairns hoped that cutting open the edges of Schlemm's canal would allow aqueous to leave without producing a filtering bleb; however, it became apparent that Cairns's "trabeculectomy" only worked when a filtering bleb developed. The goal of today's trabeculectomy is the creation of a longlasting transscleral fistula. In fact, trabeculectomy is a misnomer as excision of trabecular meshwork is unimportant. Frequently, the tissue excised to create a trans-scleral fistula is sclera, cornea, or both. The current trabeculectomy is really a guarded sclerokeratectomy. Newer techniques hope to increase aqueous outflow through Schlemm's canal to avoid complications associated with subconjunctival filtering blebs. Non-penetrating glaucoma surgeries (deep sclerectomy, viscocanalostomy) and ab interno trabecular surgery attempt to lower intraocular pressure with bleb-less procedures. We describe the recent evolution of glaucoma surgery, particularly the idea that intraocular pressure may be lowered satisfactorily without creating a filtering bleb.Survey of Ophthalmology 01/2012; 57(1):1-25. · 2.35 Impact Factor
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ABSTRACT: To study the efficacy and safety of deep sclerectomy (DS) augmented with intraoperative low dose mitomycin C (MMC) in a west African population. Prospective, randomised, controlled trial. Trial participants were Nigerian patients with medically uncontrolled primary open angle glaucoma undergoing primary surgery at Maja Hospital, Lagos, Nigeria. 39 eyes of 39 patients undergoing DS were randomised into receiving intraoperative MMC 0.25 mg/ml for 2 minutes at the end of procedure (DS-MMC) and a control group (DS-noMMC). There were 21 patients in the DS-noMMC and 18 in the DS-MMC group with no difference in the preoperative characteristics of the groups. Mean follow up was 16.4 (SD 11.3) months. The probability of maintaining an intraocular pressure less than 18 mm Hg with or without additional medications (95% confidence intervals) at 1 year was 70% (47-92%, 95%) and 79% (57-100%), and at 18 months was 35% (8-62%) and 38% (7-69%) for the DS-noMMC and DS-MMC groups, respectively, with no difference in success rates (p = 0.6). An IOP of less than 18 mm Hg without additional medication was maintained in 65% (41-89%) and 73% (49-96%) at 1 year and 24% (8-48%) and 13% (13-46%) at 18 months for the DS-noMMC and DS-MMC groups, respectively (p = 0.5). There were no serious complications related to the procedure. The success rates of DS in black west African glaucoma patients, as performed in this study, were low. The study did not achieve sufficient power to detect whether low dose intraoperative MMC application can increase success rates of DS.British Journal of Ophthalmology 04/2006; 90(3):310-3. · 2.90 Impact Factor