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Evidence-Based Target Pressures

Evidence-Based Target Pressures. How to Achieve Low Target Pressures Safely with MMC or 5-FU. Paul Palmberg, MD, PhD Bascom Palmer Eye Institute University of Miami School of Medicine. Advanced Glaucoma Intervention Study. All < 18 mmHg 75%-99% < 18 50%-74% < 18 < 50% < 18.

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Evidence-Based Target Pressures

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  1. Evidence-Based Target Pressures How to Achieve Low Target Pressures Safely with MMC or 5-FU Paul Palmberg, MD, PhD Bascom Palmer Eye Institute University of Miami School of Medicine

  2. Advanced Glaucoma Intervention Study All < 18 mmHg 75%-99% < 18 50%-74% < 18 < 50% < 18 The AGIS Investigators. Am J Ophthalmol. 2000;130:429-440.

  3. Can MMC or 5-FU give us the low IOP we want without too many complications? • We could reduce post-op healing • What would be the cost? • How could we get a discount?

  4. How to use MMC or 5-FU Safely • The use of Mitomycin C or 5-Fluorouracil never causes hypotony. • BUT, the use of MMC or 5-FU will preserve any hypotony you create! • Antimetabolites allow one to use a new strategy: 1) set the IOP by adjusting the scleral resistance 2) use antimetabolites to prevent the formation of additional resistance in the conjunctiva-Tenons

  5. Highlights of Ophthalmology 1993

  6. Highlights of Ophthalmology 1993

  7. Highlights of Ophthalmology 1993

  8. Primary Filtering Surgery with 5-FU or Mitomycin:Intraocular Pressure Control and Visual Field Data mm Hg # (IOP) MD PSD # fields Pre-OP 26.1 212 -14.3 7.58 181 1 Year 10.7 183 -13.6 7.59 117 2 Years 10.8 161 -12.4 7.67 96 3 Years 10.8 143 -13.3 8.18 92 4 Years 10.5 125 -13.6 8.05 71 5 Years 11.8 123 -11.9 7.68 65 6 Years 10.6 99 -13.0 8.70 47 7 Years 11.0 81 -12.6 9.34 42 8 Years 11.0 63 -12.7 8.79 22 9 Years 10.4 46 -10.7 7.42 19 10 Years11.0 30 -12.1 8.71 13 Ishida K, E Escalona, J Schiffman, Palmberg P, ARVO 2003 Technique: Suner, et al, Ophthalmology 1997:104:207-214.

  9. -8 -10 6 -12 4 -14 2 -16 0 Mean±S.E. -18 -2 -20 -4 8YMD 9YMD 10YMD 1yMD 2yMD 3yMD 4yMD 5yMD 6yMD 7yMD Pre MD -6 ⊿1yMD ⊿9yMD ⊿10yMD ⊿6yMD ⊿2yMD ⊿4yMD ⊿5yMD ⊿8yMD ⊿3yMD ⊿7yMD Mean MD over time Mean change of MD over time MD(dB) ⊿MD(dB) > 0 = deterioration Mean±S.E. N=181 116 96 91 72 65 47 42 22 29 13 N=109 86 85 68 59 44 35 21 23 9 There was no statistical difference between baseline and each year’s value ( Wilcoxon signed ranks test ).

  10. Improve tissue function? Hypothesis • Growth arrested cells • Release stimulatory factors • Stimulate normal fibroblasts • Ring of scar tissue • “ring of steel” • + Anterior drainage jet • Thinned area Occleston et al Invest Ophthalmol Vis Sci 1997, Daniels et al 1999 Exp Eye Res

  11. Khaw Infusion System to prevent complications of filtration surgery (trabeculectomy)

  12. Results • Discomfort • Leakage • Hypotony • Blebitis • Endophthalmitis

  13. Results Before Change Limbus based Small Area MMC 0.4 mg/ml After change Fornix based Large Area MMC 0.5 mg/ml Bleb related problems inc leaks / blebitis / endoph 0% 20% Ophthalmology 2003 in press

  14. IOP vs 5 Yr Risk of Progression

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