Aims: To prospectively study the evolution of possible high risk features of conjunctival filtration blebs like avascularity, transconjunctival oozing (TCO), and leaks after mitomycin C (MMC) enhanced glaucoma surgery. Methods: Single observer, 2 year prospective study on bleb characteristics of 125 eyes of 125 consecutive patients who had MMC augmented glaucoma surgery with initially successful filtration. MMC (0.2 mg/ml for 2 minutes in most cases) was applied on the area of the scleral flap before dissection. Glaucoma surgeries included were trabeculectomy, deep sclerectomy, and combined procedures. A dry fluorescein strip was applied on the avascular part of the bleb and observed for aqueous egress with flow (point leak, PL) or without (TCO). Results: The mean time (95% CI) for observing bleb avascularity, TCO, and bleb leaks were 106 days (69 to 143), 208 days (155 to 261), and 609 days (559 to 659), respectively. Bleb leaks were observed in 17 eyes (13.6%)-15 (24.6%) in the trabeculectomy group and two (3.1%) in the deep sclerectomy group (p = 0.003). Kaplan-Meier survival analyses showed that the probability of observing bleb avascularity at sixth, 12th, and 24th month after surgery was 56%, 71%, and 73%, respectively. In eyes with avascular blebs, the probability of developing TCO and leaks was 77% and 1% at 6 months, 81% and 12% at 12 months, and 95% and 26% at 24 months, respectively. Cox's regression analyses and log rank tests showed that eyes with larger avascular blebs (.4 mm) were more likely to develop TCO (hazard ratio 3.77, p = 0.001) and delayed bleb leaks were more likely to be seen in eyes of the trabeculectomy group rather than the deep sclerectomy group (hazard ratio 0.06, p = 0.0006). Conclusions: MMC application over the area of scleral flap dissection during glaucoma surgery is associated with a high incidence of bleb avascularity, TCO, and delayed bleb leaks. Most eyes developed bleb avascularity within the first year after surgery. TCO will eventually be seen in all eyes with avascular blebs and the incidence of leaks gradually increases with time. This study shows that patients with eyes undergoing glaucoma surgery with MMC and avascular blebs should be monitored indefinitely.

Aims: To compare outcomes of phacoemulsification combined with trabeculectomy (PT) or deep sclerectomy (PDS) with intraoperative mitomycin C (MMC) application. Methods: Non-randomised, consecutive, retrospective comparative study. 97 eyes of 97 patients (59 PDS, 38 PT) undergoing combined surgery with intraoperative MMC (0.1-0.4 mg/ml for 1-3 minutes) were identified for inclusion in the study. Results: The probability of maintaining intraocular pressure (IOP) below 19 mm Hg and 15 mm Hg, with a 30% drop from preoperative IOP and without additional medication, 1 year after surgery were 77.6% (95% CI: 67 to 90) and 71.5% (60 to 85) for the PDS group and 89.5% (80 to 99) and 89.5 (80 to 99) for the PT group, respectively, and these differences were not statistically significant (p.0.05, log rank test). After excluding ocular co-morbidity no differences were observed in the improvement of visual acuity between the two groups. There were no major differences in the complication rates except that delayed bleb leaks were seen in seven eyes (18.4%) of the PT group (p = 0.004). Conclusion: In this study, no statistically significant difference was found in the IOP and visual outcomes between PDS and PT. A significantly higher frequency of late bleb leaks after PT was observed.T he decision to do sequential or combined cataract and glaucoma surgery depends on several individual patient factors including the degree of visual impairment, target intraocular pressure (IOP), stage of glaucoma, compliance, age, and life expectancy. 1-3Combined phacoemulsification and trabeculectomy (PT) is the most widely reported procedure for combined surgery. 4 Augmentation of the procedure with mitomycin C (MMC) has been shown to be beneficial when risk factors for failure are present. 2Newer surgical techniques, loosely termed as non-penetrating glaucoma surgery (NPGS), have been reported to successfully lower IOP in the long term.5 6 Compared to trabeculectomy, the IOP lowering efficacy of NPGS is the same or less depending on the publication but all randomised trials agree that the complication rates are less with NPGS. 7-11The success rates of deep sclerectomy can be improved and IOPs in the low teens achieved using by intraoperative MMC application and postoperative Nd:YAG laser goniopuncture in selected cases. 12Reports suggest that phaco-deep sclerectomy (PDS) and phaco-viscocanalostomy (PVCT) are effective in lowering IOP.13-16 MMC augmentation of PDS has not previously been reported. The aim of this study was to compare the outcomes of PT with MMC and PDS with MMC and selective Nd:YAG laser goniopuncture. METHODSConsecutive patients undergoing combined glaucoma and phacoemulsification surgery with intraoperative MMC between September 2001 and November 2003, were identified from an ongoing correlational database (Microsoft Access) of all glaucoma surgery performed by the glaucoma unit. The surgeries were done or closely supervised by one surgeon (NA). The decision to do PDS or PT was based on several factors including available ope...