|Year : 1993 | Volume
| Issue : 2 | Page : 78-80
Intraoperative Mytomycin C in complicated glaucomas
Gurdeep Singh, Jagmeet Kaur, Ajay Dogra
Dept. of Ophthalmology, Gandhi Medical College, Bhopal, India
E-1/100, Arera Colony, Bhopal - 462 016
Source of Support: None, Conflict of Interest: None
Filtering surgery has been found to be less successful in certain types of glaucoma. These include young patients, those with pigmentary glaucoma, secondary glaucoma, angle recession glaucoma, aphakic or pseudophakic glaucoma, and patients requiring reoperation. This study describes the authors' attempt to evaluate the effectiveness of conventional trabeculectomy with intraoperative application of mitomycin C in such patients. Ten eyes of 8 patients were evaluated in this study. Of these cases 4 eyes (2 bilateral cases) were from the primary juvenile open angle group; 2 eyes each had pseudophakic glaucoma and previous anti-glaucoma surgery which had failed; one eye had aphakic glaucoma and the last suffered from angle recession glaucoma. The intraocular pressure was successfully controlled in all the ten eyes. The preoperative IOP ranged from 28 to 50 mm Hg and the postoperative IOP ranged from 7 to 16 mm Hg. The postoperative complications were minimal
Keywords: Glaucoma, complicated, trabeculectomy, Mitomycin C filtering procedures
|How to cite this article:|
Singh G, Kaur J, Dogra A. Intraoperative Mytomycin C in complicated glaucomas. Indian J Ophthalmol 1993;41:78-80
|How to cite this URL:|
Singh G, Kaur J, Dogra A. Intraoperative Mytomycin C in complicated glaucomas. Indian J Ophthalmol [serial online] 1993 [cited 2020 Nov 23];41:78-80. Available from: https://www.ijo.in/text.asp?1993/41/2/78/25618
Since 1982 subconjunctival 5-Fluorouracil (5-FU), an antimetabolite that inhibits fibroblastic proliferation has been advocated in patients with a high risk of failure of glaucoma filtration surgery. ,, Although the beneficial effects of 5-FU have been well documented, certain complications accompany its use. The most common of these include recurrent corneal epithelial defects, corneal abrasions, late bleb infections and perforations . In the present study the authors clinically evaluated the efficacy of a single application of mitomycin C (MMC), an antineoplastic antibiotic used intraoperatively in complicated types of glaucoma cases.
MMC is generally used topically in the treatment of recurrent pterygium.  Bergstrom and co-workers  have demonstrated the efficacy of MMC in a rabbit model of filtering surgery. Palmer  has also reported the beneficial effect of a single intraoperative application of MMC on the filtration site. Gregory et a1  have compared the results of MMC with 5-FU in a group of high-risk patients and demonstrated the advantages of MMC over 5-FU.
| Materials and methods|| |
In this study 10 eyes of 8 randomly selected patients were included with possible risk of failure of filtering surgery. The possible causes of high risks include primary juvenile open angle glaucoma (4 eyes), failed previous antiglaucoma operations (2 eyes), pseudophakic glaucoma (2 eyes), aphakic glaucoma (1 eye) and angle recession glaucoma (1 eye).
Preoperative base line information was obtained for each patient. This data included age, sex, diagnosis, previous ocular surgeries, visual acuity, intraocular pressure and ocular medications [Table - 1].
Surgery was performed using a standardised technique. Limbal based conjunctival flap was made approximately 8 to 10 mm. posterior to the limbus.
A medium thickness rectangular scleral flap of 5 x 4 mm. was dissected. A cellulose sponge soaked in a 0.5 mg/ml solution of MMC was placed between the conjunctivo - Tenon capsule and episcleral tissue for 3 minutes. Care was taken to protect the conjunctival edge from contact with the MMC sponge in order to prevent prolonged wound leakages later on. The tissues were then gently rinsed with balanced salt solution (BSS), after which an internal section of trabecular meshwork with clear cornea measuring 2 x 1 mm. was removed. A peripheral iridectomy was done and the scleral flap was resutured with 3 interrupted 10-0 nylon sutures while the conjunctivo-Tenon layer was sutured using 7-0 vicryl sutures. The anterior chamber was reformed using BSS from a temporal paracentesis. The eye was dressed with local steroidantibiotic drops and 1 % cyclopentolate eye drops.
Postoperative treatment included the use of steroidantibiotic drops four times a day with tapering doses for 4 to 6 weeks with cyclopentolate 1 % eye drops once a day for the first 4 postoperative days.
Results were evaluated in relation to postoperative visual acuity, control of intraocular pressure and type of filtering bleb. Postoperative data was collected at 1 week, 2 weeks, 4 weeks, 2 months and 6 months after surgery.
'Appropriate' surgical success was defined as intraocular pressure less than 17 mm Hg without the use of any anti-glaucoma medication. 'Qualified' surgical success was defined as some form of local anti-glaucoma medication being required to bring the intraocular pressure to 17 mm Hg and 'failure' was defined as an intraocular pressure greater than 17 mm Hg with maximal medications.
| Results|| |
The study included a total of 10 eyes of 8 patients who underwent MMC trabeculectomy. Five were males and 3 females. Of these, 2 cases were bilateral, both involving patients below 40 years, with juvenile primary open angle glaucoma.
The preoperative intraocular pressure ranged from 28 to 50 mm Hg while the postoperative pressure ranged from 7 to 16 mm Hg. The intraocular pressure was successfully controlled in all the 10 eyes and none of the cases required any form of local or systemic medication. In all cases the blebs were thin and avascular, showing good filtration.
Postoperative complications were minimal and included a reactionary transient hyperemia of conjunctiva and mild anterior uveitis for the first 3 to 4 days which cleared with the use of topical steroids. Mild shallowing of anterior chamber was observed in 3 eyes. This resolved with conventional local pressure dressing. One eye showed hypotony maculopathy with vision falling by 2 Snellen lines. Visual acuity improved by 1 to 3 lines in 3 eyes, due to clearing of the hazy media, mainly corneal oedema. No case in our series had conjunctival wound leakage or dehiscence. This was probably due to the fact that the MMC soaked sponge was not allowed to touch the lips of the conjunctival wound, proper rinsing of the area after 5 minutes and very close suturing of the conjunctivo-Tenon wound.
Since the blebs were thin and avascular in all cases, no bleb infection was seen up to the last follow up. No case of scleral thinning or perforation was seen in this series.
| Discussion|| |
Filtering surgery has been shown to be less successful in comparatively younger patients. Various authors have reported this to be related to thicker Tenon's capsule and greater fibroblastic proliferative response. ,,
Other poor prognostic cases include aphakic glaucoma with or without a lens implant, traumatic and glaucoma failed filters. , Various methods have been advocated for the management of these cases. Charles et al  have described prophylactic bleb survival in rabbits using bio-erodible polymers impregnated with mitomycin C in glaucoma filtering surgeries. Similar experimental observation and clinical trials described by Chen et al  suggest that mitomycin C may effectively inhibit fibroblast proliferation and enhance surgical success in the absence of a sustained release system in poor-risk patients of glaucoma.
The concentration and exposure time of MMC used in our study was based on the personal communication of Rentsch. Palmer  in his study used 0.2 mg/ ml. concentration for 5 minutes while Chen et al  advocated a concentration of 0.2 to 0.4 mg/ml. The actual pharmacokinetics of MMC being delivered to the sub-conjunctival tissues have not been evaluated in this study. Consequently, we feel that additional work is necessary to establish optimal concentration and exposure time.
Based on our clinical results in relation to intraocular pressure control, stable visual function, no corneal or scleral toxicity and more importantly, easy single application as compared to repeated subconjunctival injections of 5-FU, the authors believe that mitomycin C is useful in eyes with uncontrolled glaucoma, aphakic glaucoma, patients with juvenile primary open angle glaucoma and cases of previously failed filtering surgery.
| References|| |
The Flurouracil filtering surgery study group. Fluorouracil filtering study one year follow-up. Am J Ophthalmol. 108: 625-635, 1989.
Rockwood EJ, Parrish RK II, Heuer DK et al : Glaucoma filtering surgery with 5-Fluorouracil. Ophthalmology. 94: 1071-1078,1987.
Liebmann JM, Ritch R, Harmor M et al. Initial 5-FU. trabeculectomy in uncomplicated glaucoma. Ophthalmology. 98: 1036-1041, 1991.
Lee DA, Hersch P, Kersten D and Melamed S. Complications of sub-conjuctival 5-FU following glaucoma filtering surgery. Ophthalmic Surgery. 18: 187-190, 1987.
Knapp A, Hemer DK, Stern GA and Driche WT. Serious corneal complications of glaucoma filtering surgery with postoperative 5-FU. Am J Ophthalmol. 103 : 183-187, 1987.
Singh G, Wilson MR and Foster CS. Mitomycin C eye drops as treatment of pterygium. Ophthalmology 95 : 813821, 1988.
Bergstrom TJ, Wilkinson WS, Skuta GL et al. The effect of topical mitomycin C on glaucoma filtering surgery in rabbits. J Ocul Pharmacol 7: 1-8, 1991.
Palmer SS. Mitomycin as adjuvant chemotherapy with trabeculectomy. Ophthalmology 98: 317-321, 1991.
Gregory LS, Charles CB, Eric JH et al. Intra-operative mitomycin Vs postoperative 5-FU in high risk glaucoma filtering surgery. Ophthalmology, 99: 438-444, 1992.
Lamping KA, Bellow AR, Hutchinson BT and Afran SI. Long term evaluation of initial filtering surgery. Ophthalmology. 93: 91-101, 1986.
Beauchamf GR and Parks MM. Filtering surgery in children : Barriers to success. Ophthalmology. 86: 170-180, 1979.
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Charles JB, Ganthier R Jr, Wilson MR et al. Use of bioerodible polymers impregnated with mitomycin C in glaucoma filtering surgery in rabbits. Ophthalmology. 98: 503-508, 1991.
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[Table - 1]
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