Transcript 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
• To define the characteristics of patients
undergoing trabeculectomy with MMC
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
Results
• Total number of eyes = 123
• Note retrieval 100%
• 2004 Data update 99%
Gender
Age at surgery
• Mean age = 55.6 years
Ethnicity
Glaucoma type
Pre-op medications
• Average no. of drops = 2.65 (36.6% on Diamox)
Surgeons
Intraocular pressures
(pre-operative)
HTG (108 eyes) NTG (15 eyes)
Mean pre-op 38.0 mmHg
highest IOP
18.5 mmHg
Mean pre-op 24.1 mmHg
IOP
15.7 mmHg
Intraocular pressures
(post-operative)
Mean IOP
(1 year)
% IOP drop
(1 year)
Mean IOP
(latest follow-up)
% IOP drop
(latest follow-up)
HTG
NTG
12.9 mmHg
11.3 mmHg
46.5%
28.0%
13.0 mmHg
10.6 mmHg
46.1%
32.5%
IOP distribution (1 year)
Overall success
(latest follow-up – mean 613 days)
HTG (106 eyes) NTG (14 eyes)
IOP ≤ 21
97.2%
IOP ≤ 17
87.7%
100%
IOP ≤ 14
70.8%
100%
IOP reduction 71.7%
> 30%
57.1%
Success by ethnicity
(1 year)
IOP ≤ 21
AFC (23)
Caucasian (59)
91.3% (78.3%) 98.3%
IOP ≤ 17
82.6% (78.3%) 94.9%
IOP ≤ 14
60.9%
86.4%
IOP
reduction >
30%
65.2%
78.0%
Success by previous
surgery (1 year)
None (58)
Intraocular (24)
IOP ≤ 21
98.3% (96.6%)
91.7% (90.9%)
IOP ≤ 17
98.3% (96.6%)
75%
IOP ≤ 14 89.7%
IOP
75.9%
reduction
> 30%
54.2%
70.8%
Bleb morphology (1 year)
• Excellent bleb
morphology 75.0%
Bleb morphology (1 year)
• Satisfactory
morphology 21.4%
Bleb morphology (1 year)
• Poor morphology
3.6%
Bleb Needling Revision
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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
Post-op management
Complications
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
Follow-up failures (DNA)
• DNA in 6 patients during follow-up
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4 African-Caribbean
2 Caucasian – 1 alcoholic / 1 psychiatric
5 males
Mean age 45.7 years old
• Age < 45
• Male
• African-Caribbean ethnicity
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
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
Summary
• Success 97.2%
• Sight threatening complications 0.8%
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0 Wipe-out
0 Endophthalmitis
0 Suprachoroidal haemorrhage
1 Late hypotony
• Clinically Significant Early Hypotony
(requiring intervention) 4.9%
National Trabeculectomy
Survey
• Success, IOP < 21 – 92%
• Complications
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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%
Other series
• Success – 80 – 90%
• Complications
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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%
BUT!!
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
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
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
Pearls
• Identify thin tissues pre-op
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Small peritomy
Stromal hydration
Careful closure
? No MMC
• Thin Tissues + Leak = Early Failure
Pearls
• In AFC / thick tissues need early
(<10 days) high flow into sub-Tenon
space
• May need to remove both releasables
Pearls
• Thin conj and Tenons – need thick
scleral flap to control aqueous
outflow
Pearls
• JOAGs get hypotony
• Need early surgical intervention
• Beware of the young!