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Trabeculectomy MMC Audit

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Title: Trabeculectomy MMC Audit


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 lt 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 lt 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 lt 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
  • Its 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
  • (lt10 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!

38
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