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Trabeculectomy + MMC Audit

Trabeculectomy + MMC Audit. Mark Chiang, Clinical Research Fellow Mr. Peter Shah, Consultant Ophthalmic Surgeon Good Hope Hospital. Aim. To assess success and complication rates of trabeculectomies augmented with mitomycin C To compare results to the National Trabeculectomy Survey

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Trabeculectomy + MMC Audit

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  1. Trabeculectomy + MMCAudit Mark Chiang, Clinical Research Fellow Mr. Peter Shah, Consultant Ophthalmic Surgeon Good Hope Hospital

  2. 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

  3. 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

  4. Results • Total number of eyes = 123 • Note retrieval 100% • 2004 Data update 99%

  5. Gender

  6. Age at surgery • Mean age = 55.6 years

  7. Ethnicity

  8. Glaucoma type

  9. Pre-op medications • Average no. of drops = 2.65 (36.6% on Diamox)

  10. Surgeons

  11. Intraocular pressures(pre-operative)

  12. Intraocular pressures(post-operative)

  13. IOP distribution (1 year)

  14. Overall success(latest follow-up – mean 613 days)

  15. Success by ethnicity(1 year)

  16. Success by previous surgery (1 year)

  17. Bleb morphology (1 year) • Excellent bleb morphology 75.0%

  18. Bleb morphology (1 year) • Satisfactory morphology 21.4%

  19. Bleb morphology (1 year) • Poor morphology 3.6%

  20. 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

  21. Post-op management

  22. Complications

  23. 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% < 45 years of age

  24. 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 < 45 • Male • African-Caribbean ethnicity

  25. 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

  26. 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

  27. 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%

  28. National Trabeculectomy Survey • Success, IOP < 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%

  29. 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%

  30. BUT!!

  31. It’s 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

  32. 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

  33. 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

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

  35. Pearls • In AFC / thick tissues need early (<10 days) high flow into sub-Tenon space • May need to remove both releasables

  36. Pearls • Thin conj and Tenons – need thick scleral flap to control aqueous outflow

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

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