Trabeculectomy MMC Audit

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Trabeculectomy MMCAudit

• Mark Chiang, Clinical Research Fellow
• Mr. Peter Shah, Consultant Ophthalmic Surgeon
• Good Hope Hospital

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Aim

• To assess success and complication rates of
  trabeculectomies augmented with mitomycin C
• To compare results to the National Trabeculectomy
  Survey
• To define the characteristics of patients
  undergoing trabeculectomy with MMC

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Methods

• Prospective database of consecutive patients
  undergoing trabeculectomy MMC under care of Mr.
  Peter Shah
• Data collected
• Demographics
• Pre-operative, operative and follow-up data

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Results

• Total number of eyes 123
• Note retrieval 100
• 2004 Data update 99

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Gender
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Age at surgery

• Mean age 55.6 years

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Ethnicity
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Glaucoma type
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Pre-op medications

• Average no. of drops 2.65 (36.6 on Diamox)

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Surgeons
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Intraocular pressures(pre-operative)
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Intraocular pressures(post-operative)
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IOP distribution (1 year)
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Overall success(latest follow-up mean 613 days)
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Success by ethnicity(1 year)
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Success by previous surgery (1 year)
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Bleb morphology (1 year)

• Excellent bleb morphology 75.0

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Bleb morphology (1 year)

• Satisfactory morphology 21.4

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Bleb morphology (1 year)

• Poor morphology 3.6

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Bleb Needling Revision

• 13.8 of patients (17/123)
• 64.7 males
• Mean pre-op highest IOP 40.7 mmHg
• 47.1 on Diamox pre-operatively
• 47.1 had previous intraocular surgery
• 41.2 required topical drops at latest follow-up
• 35.3 African-Caribbean

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Post-op management
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Complications
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Clinically Significant Early Hypotony (CSEH)

• 4.9 of patients
• Required intervention
• Viscoelastic to AC
• Conjunctival / scleral flap suturing
• Analysis of CSEH reveals
• 33.3 AFC
• 66.7 lt 45 years of age

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Follow-up failures (DNA)

• DNA in 6 patients during follow-up
• 4 African-Caribbean
• 2 Caucasian 1 alcoholic / 1 psychiatric
• 5 males
• Mean age 45.7 years old
• Age lt 45
• Male
• African-Caribbean ethnicity

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Surgery technique

• Fornix based conjunctival flap
• Wide sub-Tenons treatment with MMC (0.1 0.2
  mg/ml for 1 3 mins)
• Pre-placed, buried, releasable adjustable
  scleral flap sutures
• Intra-op IOP titration
• Buried purse-string mattress closure of
  conjunctiva and Tenons

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Conclusion

• High success rates for this series
• Low complication rates for this series
• Results exceed National Trabeculectomy Survey
• Complications are more common in
  African-Caribbean patients and in young patients

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Summary

• Success 97.2
• Sight threatening complications 0.8
• 0 Wipe-out
• 0 Endophthalmitis
• 0 Suprachoroidal haemorrhage
• 1 Late hypotony
• Clinically Significant Early Hypotony
• (requiring intervention) 4.9

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National Trabeculectomy Survey

• Success, IOP lt 21 92
• Complications
• Hypotony 24.3
• Hypotony maculopathy 0.2
• Endophthalmitis 0.3
• Wipe-out 0.4 of total cohort, 5 in advanced
  glaucoma
• Cataract needing extraction 2.5

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Other series

• Success 80 90
• Complications
• Hypotony 4.8 47
• Hypotony maculopathy 4 12
• Blebitis 2 5.7
• Endophthalmitis 0.8 8
• Wipe-out 25 in one series
• Cataract needing operation during follow-up 12
  55

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BUT!!
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• Its only possible with
• Good pre-operative, peri-operative and intensive
  post-operative care
• Good success with lower doses of MMC but 34
  post-op 5-FU and 14 bleb needling revision

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Discussion points

• Trabeculectomy with MMC is a complex operation
  requiring high degree of manual dexterity and
  extensive glaucoma experience
• Suggest Fellowship training for all surgeons
  performing this operation
• With close Consultant supervision, high success
  rates for Fellows in training

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Actions

• Continue long-term analysis of series
• Target African-Caribbean and JOAG patients for
  intensive intervention
• Improve patient information
• Consider glaucoma support nurse help
• These results only possible with continued Fellow
  support

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Pearls

• Identify thin tissues pre-op
• Small peritomy
• Stromal hydration
• Careful closure
• ? No MMC
• Thin Tissues Leak Early Failure

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Pearls

• In AFC / thick tissues need early
• (lt10 days) high flow into sub-Tenon space
• May need to remove both releasables

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Pearls

• Thin conj and Tenons need thick scleral flap to
  control aqueous outflow

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Pearls

• JOAGs get hypotony
• Need early surgical intervention
• Beware of the young!

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