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

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Presentation on theme: "Trabeculectomy + MMC Audit Mark Chiang, Clinical Research Fellow Mr. Peter Shah, Consultant Ophthalmic Surgeon Good Hope Hospital."— Presentation transcript:

1 Trabeculectomy + MMC Audit 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 = 123Total number of eyes = 123 Note retrieval 100%Note retrieval 100% 2004 Data update 99%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) HTG (108 eyes)NTG (15 eyes) Mean pre-op highest IOP 38.0 mmHg18.5 mmHg Mean pre-op IOP 24.1 mmHg15.7 mmHg

12 Intraocular pressures (post-operative) HTGNTG Mean IOP (1 year) 12.9 mmHg11.3 mmHg % IOP drop (1 year) 46.5%28.0% Mean IOP (latest follow-up) 13.0 mmHg10.6 mmHg % IOP drop (latest follow-up) 46.1%32.5%

13 IOP distribution (1 year)

14 Overall success (latest follow-up – mean 613 days) HTG (106 eyes)NTG (14 eyes) IOP ≤ % IOP ≤ %100% IOP ≤ %100% IOP reduction > 30% 71.7%57.1%

15 Success by ethnicity (1 year) AFC (23)Caucasian (59) IOP ≤ % (78.3%)98.3% IOP ≤ % (78.3%)94.9% IOP ≤ %86.4% IOP reduction > 30% 65.2%78.0%

16 Success by previous surgery (1 year) None (58)Intraocular (24) IOP ≤ % (96.6%)91.7% (90.9%) IOP ≤ % (96.6%)75% IOP ≤ %54.2% IOP reduction > 30% 75.9%70.8%

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 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 Discussion points

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

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

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

38


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