Revision of trabeculectomy filtering blebs with mitomycin C: Long term results

Abstract

Aim:The aim of the study is to assess the outcomes of transconjunctival mitomycin C (MMC)-augmented revision in eyes with failed trabeculectomy.Materials and Methods:This is a retrospective, noncomparative case series. One hundred and twenty-one eyes of 113 consecutive glaucoma patients with previously failed trabeculectomy who underwent transconjunctival revision with at least 12 months of follow-up were initially included in the study. The success was determined on the basis of intraocular pressure (IOP) alone. The main outcome measures were IOP, best-corrected distance visual acuity, complications, bleb appearance, lens status, visual field progression, and time between primary trabeculectomy and MMC revision. The main purpose of the study was to determine the efficacy of a single MMC-augmented needle revision.Results:Mean follow-up was 2.3 years. Twelve months after revision, IOP had declined from 26.1 ± 8.4 mmHg to 14.1 ± 4.8 mmHg (P < 0.05) and remained 16.0 ± 5.6 mmHg at 24 months, 15.7 ± 5.8 mmHg at 48 months, and 15.2 ± 4.0 mmHg at 60 months. Complete success was achieved in 53% of cases, 84% achieved qualified success, and 16% were classified as failures 12 months after revision. Early complications developed in 45 of the initial 121 eyes (37.2%).Conclusions:Transconjunctival MMC-augmented revision appears to be a safe and useful tool in reducing IOP and re-establishing filtration after trabeculectomy failure. This simple procedure has a high rate of success and helps avoid other surgical interventions which are more destructive for the conjunctiva.

Safety and Efficacy of Bleb Needling with Antimetabolite after Trabeculectomy Failure in Glaucoma Patients: A Systemic Review and Meta-Analysis

“…IOP reduction levels at six months, one year, two years, and last visit after bleb needling were analyzed. Data at one year were regarded as last-visit data for the studies with loss of >50% cases at the last visit [ 12 , 15 – 17 ]. Combined analysis with a random-effect model showed a significant reduction in IOP at a different timeline ( p < 0.001).…”

“…Needling will alter the morphology of failed bleb, though data are presented in limited studies [ 13 , 17 , 29 , 35 ]. Flat blebs [ 13 , 17 , 35 ] and scared blebs [ 29 ], as the primary form of bleb characteristic in the studies, significantly shifted into diffuse blebs after needling [ 13 , 35 ]. Four studies [ 11 , 23 , 30 , 40 ] had focused on encapsulated bleb while one study [ 25 ] shed light on flat filtering bleb.…”

“…As far as the relationship between bleb morphology and surgical outcomes was concerned, only seven studies were involved [ 2 , 7 , 8 , 13 , 17 , 20 , 35 ]. Based on different descriptions for bleb characteristics, the conclusion varied among studies.…”

“…They displayed that when the bleb was injected or microcystic, bleb elevation at the time of needling correlated with longer survival time. However, IOP reduction had no significant difference in comparison of flat blebs and other types before needling [ 7 , 8 , 17 ]. While under a definition of postneedling IOP < 22 mmHg, or 30% reduction of IOP, the variation of success rate between bleb types did not reach statistical significance [ 35 ].…”

“…According to our estimation, complications that appeared after MMC injection might be slightly more than that of 5-Fu injection, especially in conjunctival haemorrhage (10.8% vs. 2.7%). Besides, some rare complications were listed as they were not suitable for aggregation (events/cases): vitreous haemorrhage (4%, 5/125) [ 25 ], cystoid macular oedema (2.4%, 4/266) [ 2 , 10 , 33 ], bullous keratopathy (1.7%, 5/290) [ 11 , 17 , 29 , 31 , 39 ], corneal endothelial decompensation (1.5%, 5/330) [ 2 , 10 , 14 , 29 ], suprachoroidal haemorrhage (1.4%, 6/422) [ 2 , 4 , 17 , 26 , 29 , 41 ], endophthalmitis (1.4%, 3/220) [ 10 , 41 ], hypotony maculopathy (1.3%, 2/157) [ 10 ], and blebitis (0.6%, 1/157) [ 10 ]. The variance of incidence among studies was probably caused by the setting of different trials.…”