D.r Nishant Nawani, MS Dr. Surinder Singh Pandav, MD Dr. Amit Gupta, MD Dr. Sushmita Kaushik, MD Advanced Eye Centre PGIMER, Chandigarh The authors have.

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D.r Nishant Nawani, MS Dr. Surinder Singh Pandav, MD Dr. Amit Gupta, MD Dr. Sushmita Kaushik, MD Advanced Eye Centre PGIMER, Chandigarh The authors have no financial interest in the subject matter of this poster.

Outcome of glaucoma filtering surgery improved by the use of antifibroblastic drugs such as Mitomycin- C (MMC) MMC has potential corneal toxic effects Clinically corneal endothelial cell toxicity can manifest as change in the endothelial cell morphology i.e., pleomorphism and polymegethism and a reduction in the endothelial cell density Endothelial cell changes are reported to stabilize 3 months after intraocular surgery Arch Ophthalmol 1986;104: Endothelial morphology after application of MMC have been studied; using electron microscopy Arch Ophthalmol 1994;112:533 non contact specular microscopy J Glaucoma 2008;17: Cornea 2002;21: Endothelial mosaic better visualized in edematous or scarred corneas by confocal microscopy Techniques in Ophthalmology 2005:3:19-26

To study the change in corneal endothelial cell characteristics by confocal microscopy following trabeculectomy with 0.04% MMC

DESIGN Prospective, non-randomized, interventional case series which included 30 patients TWO GROUPS Group 1: Those undergoing trabeculectomy with 0.04% MMC applied for two minutes (n=15) Group 2: Those undergoing trabeculectomy without MMC as adjunct (n=15) INCLUSION CRITERIA Age more than 18 years Primary or secondary open angle glaucoma Primary or Secondary angle closure glaucoma Uncontrolled intraocular pressure, not responding to maximal medical therapy EXCLUSION CRITERIA Previous intraocular surgery, scleral buckling Corneal degenerations and dystrophies Corneal scarring after infective diseases Dry eye patients

Baseline examination Comprehensive ophthalmic examination including gonioscopy and, confocal microscopy (NIDEK CONFOSCAN II, Nidek Technologies, Japan) to study corneal endothelium Surgical Procedure Standard trabeculectomy, limbus based conjunctival flap Half thickness, triangular scleral flap 4mm x 4mm, base at limbus MMC o.04% applied with surgical sponge between scleral flap and Tenons capsule for 2 minutes Irrigated with 10 ml of BSS over 1-2 minutes Scleral flap closed with two releaseable, and one fixed sutures Tenon’s and conjunctiva closed in two layers Follow Up Patients were followed up on at days 1,2,7,14,30,60,90 post surgery Confocal microscopy was done at 1 and 3 months post surgery

FeatureGroup I (n=15)Group II (n=15)Total Age in years + SD (range) (23-58) (23-66) Gender (Males:Females)13:211:424:6 Diagnosis Primary open angle glaucoma Primary closed angle glaucoma Secondary open angle glaucoma Secondary closed angle glaucoma Patient Characteristics

Group I (MMC) IOP + SD (mmHg) Medications + SD Group II IOP +SD (mmHg) Medications + SD Pre-op (n=15) month (n=12) (p=0.002) (p=0.002) (p=0.018) (p=0.003) 3 months (n=9) (p=0.013) (p=0.007) (p=0.018) (p=0.016)

Group I (MMC) CCT + SD (microns) Group II CCT + SD (microns) Pre-op (n=15) month (p=0.025, n=12) (p=0.562, n=11) 3 months (p=0.038, n=9) (p=0.108,n=7)

Endothelial Characteristic Group I (MMC)Group II Pre-op (n=15) 1 month (n=12) 3 months (n=9) Pre-op (n=15) 1month (n=11) 3months (n=7) CCEC [mean + SD] (cells/mm 2 ) (p=0.239) (p=0.374) (p=.131) (p=1.00) Mean cell area – (MCA) [mean + SD] (  m 2 ) (p=0.091) (p=0.314) (p=0.477) (p=1.00) Pleomorphism [mean + SD] (%) (p=0.937) (p=0.953) (p=0.625) (p=0.866) Polymegethism [mean + SD] (%) (p=0.195) (p=0.107) (p=0.790) (p=0.889)

Reduction in cell count from baseline (%) Group I (MMC) Group II 1 month5.85%6.48% 3 months5.46%2.28%

Endothelial cell changes Effacement of intercellular junctions with cellular swelling and transcellular vacuole formation using electron microscopy (Mcdermott et al., 1994) In trabeculectomies where MMC has been used, endothelial cell loss at 3months; 11% by Pastor et al. (1993) 14.5% by Sihota et al.(1998) 9.5% by Storr-Paulsen et al. (2008) 5.46% (current study) Summary IOP reduction is significant in both groups Decrease in CCT was significant in the MMC group Endothelial cell counts decreased at one month post op with slightly better recovery of counts in non MMC group at three months Mean cell area increased at one month post op, parallel to decrease in endothelial counts with trend to recovery at three months

MMC 0.04% when applied for two minutes, shows no significant toxic effects on the corneal endothelium at 3 months following trabeculectomy