Incidence of short‑term complications and associated factors after primary trabeculectomy in Chiang Mai University Hospital.

Background: To determine the incidence of early postoperative complications and associated factors after primary trabeculectomy in Thai glaucoma patients. Design: This was a retrospective observational study performed in Chiang Mai University Hospital. Participants: One hundred and eighteen glaucoma patients participated in the study. Methods: All glaucoma patients underwent primary trabeculectomy with mitomycin C (MMC) using fornix‑based conjunctival flap technique between December 2011 and May 2013. Surgical complications during the first 3 months of follow‑up were recorded, and associated risk factors were analyzed. Main Outcome Measures: The incidence of posttrabeculectomy complications was the main outcome measure. Results: One hundred and eighteen eyes of 118 patients were included. Early postoperative complications developed in 55 eyes (56.7%). Complications included hypotony (25 eyes, 27.2%), serous choroidal detachment (CD) (14 eyes, 15.6%), subconjunctival hemorrhage (12 eyes, 13.0%), hyphema (11 eyes, 12.4%), bleb leak (8 eyes, 8.8%), encapsulated bleb (2 eyes, 2.2%), aqueous misdirection (1 eyes, 1.1%), corneal epithelial defect (1 eyes, 1.1%), and overfiltration (1 eyes, 1.1%). There were no reported cases of endophthalmitis or blebitis. Hypotony was associated with serous CD (P = 0.006), and hyphema was associated with neovascular glaucoma (NVG) patients (P = 0.009). NVG was not associated with the increased rate of surgical failure (P = 0.083). Conclusions: The incidence of early complications after first‑time trabeculectomy with MMC was high (56.7%) in this Thai clinic setting, but most were transient and self‑limited conditions. The correlations between hypotony and CD as well as hyphema and NVG were compatible with the previous studies.

Outcomes of trabeculectomy in juvenile open angle glaucoma.

Purpose: This study was aimed at reporting the outcomes of trabeculectomy in primary juvenile open angle glaucoma (JOAG). Design: This study was a retrospective noncomparative case series. Materials and Methods: We included 60 eyes of 41 JOAG patients who underwent primary trabeculectomy without mitomycin-C (MMC) between 1995 and 2007. The primary outcome was success, defined as complete, if intraocular pressure (IOP) was >5 and ≤21 mmHg without medications or qualified if IOP was >5 and ≤21 mmHg with or without antiglaucoma medications. Secondary outcome measures were mean and percentage IOP reduction, complications, and risk factors for the failure of trabeculectomy. Results: The mean (±standard deviation) age at presentation was 24.1 ± 6.8 years (range, 12–35). Mean follow-up was 67 ± 41 months (range, 12–156). At 1 year, the probability of complete success was 92% (n = 56, 95% CI: 81–96%), at 3 years it was 89% (n = 47, 95% CI: 78–95%), and at the end of 5 years, it was 80% (n = 34, 95% CI: 65–89%). The probability of qualified success was 100% (n = 60) at 1 year, 98% (n = 51, 95% CI: 87–100%) at 3 years, and 96% (n = 36, 95% CI: 84–99%) at the end of 5 years. The mean IOP reduced from 35 ± 10 to 13 ± 2.5 mmHg (P < 0.001) after trabeculectomy. There was no serious postoperative complication. Young age was the only significant risk factor associated with the failure (odds ratio = 0.89, P = 0.03). Conclusion: Primary trabeculectomy without MMC has good success rates in JOAG.

Analysis of Early Failure after Trabeculectomy

PURPOSE: Among the patients with increased intraocular pressure (IOP) after primary trabeculectomy, we evaluated the factors which might influence the surgical results in early failure cases. METHOD: We retrospectively reviewed the charts of the patients who had undergone primary trabeculectomies. Surgical failures were defined as the eyes with the increased IOPs (> or =21 mmHg), and early failure cases were defined as the elevated IOP within 2 months after surgeries, and as late failures thereafter. The early failure cases were then divided into the recovery group (IOP was decreased by digital massages or releasable suture removals) and non-recovery group. RESULTS: Thirty-eight cases among 78 eyes experienced elevated IOPs during the mean follow-up period of 25.3 months, and 28 cases had experienced early failures. Among the early failure cases, 12 eyes belonged to the recovery group and 16 eyes to the non-recovery group. Sex, age, preoperative IOP, mitomycin C use, systemic diseases, types of glaucoma, triple surgeries, numbers of preoperative medications, and types of scleral flap were similar between the recovery and non-recovery groups. However, the mean failure time was shorter in the recovery group than in the non-recovery group (0.4 vs 1.0 months; p= 0.0017, t-test). CONCLUSIONS: Our results suggest that there is greater probability in recovery of increased IOP with earlier digital pressures or releasable suture removals for the early postoperative increased IOP than with the managements of the later postoperative increased IOP.

Comparison of Long-term Results of Primary Trabeculectomy with Mitomycin C in Juvenile-onset and Adult-onset Primary Open Angle Glaucoma

PURPOSE: Young age is controversial risk factor for filtration failure following trabeculectomy with adjunctive mitomycin C (MMC). This study aimed at investigating whether juvenile-onset primary open angle glaucoma (JPOAG) patients have worse long-term outcome than adult-onset primary open angle glaucom (APOAG) patients following primary trabeculectomy with adjunctive MMC. METHODS: Medical records of 162 eyes of 113 primary open angle glaucoma patients who had undergone primary trabeculectomy with MMC and minimum follow up of 12 months were retrospectively reviewed. All the patients were free of other known risk factors except young age for surgical failure following trabeculectomy. The patients were divided into two groups; juvenile group (68 eyes of 42 patients, 10~35 years of age) and adult group (51 eyes of 41 patients, age 50 years or older). Forty-three eyes of 30 patients, aged 36~49 years, were excluded from the analysis for the study purpose. Demographic, preoperative and postoperative data were collected for up to 96 months. Kaplan-Meier survival analysis was used for probability of cumulative success estimations according to success criterion (defined as postoperative intraocular pressure of 20 mmHg or less without glaucoma medications). RESULTS: Cumulative life-table success rates of juvenile group were 98.5% at 12 months, 84.6% at 48 months, and 71.2% at 96 months. Those of adult group were 98.0%, 77.0%, and 68.5% respectively. There was no statistically significant difference in overall filtration success rates between juvenile and adult groups (p=0.52). Using a Cox proportional hazard regression analysis of potential risk factors, young age was not found to significantly affect the surgical failure (p=0.97). CONCLUSIONS: Young age itself was not associated with the poor surgical outcome following primary trabeculectomy with adjunctive MMC in this study. The present results suggest that the success rate of the JPOAG compares favorably with that of the APOAG. Primary trabeculectomy with MMC in juvenile glaucoma without other concomitant risk factors may have a favorable long-term clinical outcome as adult glaucoma.

Mitomycin C Trabeculectomy for Uncomplicated Glaucoma: A Comparison between 0.25 and 0.5mg/ml of Mitomycin C

The purpose of this study is to compare the efficacy and safety of 0.25 and 0.5mg/ml of mitomycin C(MMC) on the outcome of glaucoma filtration surgery in eyes undergoing primary trabeculectomy. Twenty-eight eyes of 20 patients with primary open-angle glaucoma or primary angle-closure glaucoma, who underwent primary trabeculectomy with 0.25mg/ml MMC for 3 minutes were compared with a demographically similar group of 31 eyes of 22 patients with primary open-angle glaucoma or primary angle-closure glaucoma, who had undergone primary trabeculectomy with 0.5mg/ml MMC for 3 minutes. MMC was applied between the sclera and Tenon's capsule during trabeculectomy, and scleral flap was closed with tight releasable sutures. The mean preoperative intraocular pressure was 35.2 +/- 9.3mmHg in the 0.25mg group and 32.1 +/- 9.2mmHg in the 0.5mg group(p=0.21, Student's unpaired t-test). The mean number of preoperative medications was 2.7 +/- 0.9 and 2.7 +/- 0.8(p=0.92, Mann Whitney U test), respectively. No statistically significant differences were found in mean intraocular pressures between the two groups at the three. six, and nine months postoperative periods. The mean follow-up was 9.2 months in the 0.25mg group and 9.0 months in the 0.5mg group(p=0.82, Student's unpaired t-test). At the last postoperative visit. 89%(25 eyes) in the 0.25mg group and 97%(30 eyes) in the 0.5mg group had an intraocular pressure less than 21mmHg with or without glaucoma medication(p=0.50, Fisher exact test). The mean intraocular pressures were 16.0 +/- 6.9mmHg and 13.6 +/- 3.6mmHg, respectively (p=0.10, Student's unpaired t-test). The 0.25mg group received an average of 0.5 medications for IOP control, and the 0.5mg group received an average of 0.2 medications(p=0.32, Mann Whitney U test). The postoperative visual outcome of the two groups did not differ significantly(p=0.27, Fisher exact test). There was no significant difference in complications between the two groups. Hypotony developed in one eye in the 0.5mg group. These results suggest that using 0.25 and 0.5mg/ml MMC for 3 minutes in primary trabeculectomy yields similar results in terms of efficacy and safety.

Intraoperative Subconjunctival Injection of Mitomycin C in Trabeculectomy

A single intraoperative application of mitomycin C(MMC) has been used to improve the surgical outcome of glaucomatous eyes. But this soaking method has a few disadvantages, including difficulty in controlling amount. The purpose of this study is to evaluate the effectiveness of intraoperative subconjunctival injection of MMC to overcome this problem. In a retrospective analysis, 29 eyes of 24 consecutive patients, who were phakic primary glaucoma, who underwent primary trabeculectomy with subconjunctival injection of MMC (0.04 mg/ml, 0.05ml) were reviewed. All patients were followed for a periods of 3 months to 1 year. Preoperative mean intraocular pressure(IOP) was 33.9 +/- 9.3mmHg. The mean IOPs after 1, 3, and 6 months were 16.4 +/- 7.0, 16.1 +/- 7.5 and 16.9 +/- 5.8 mmHg, respectively. Twenty two eyes(76%) achieved an IOP of less than 21mmHg without antiglaucoma medication. Postoperative complications were transient hyphema in 3 eyes(20%), shallow anterior chamber in 2 eyes(7%), conjunctival wound leakage in 1 eye(3%), and hypotony maculopathy in 1 eye(3%). There were 4 cases (14%) of avascular cystic bleb and 8 cases (28%) of nonfunctional fibrotic bleb. We suggested that intraoperative subconjunctival injection of MMC could control concentration and amount of MMC.

Efficacy and Safety of Mitomycin C Trabeculectomy in Patients with Uncomplicated Glaucoma Compared with Refractory Glaucoma

The efficacy and safety of mitomycin C(MMC) trabeculectomy was tested in patients with uncomplicated glaucoma(low-risk group) and the result was compared with that in patients with refractory glaucoma(high-risk group). Subjects included 37 eyes of 26 consecutive patients in low-risk group and 36 eyes of 26 patients in high-risk group. The mean preoperative IOP was 32.9 +/- 9.7 mmHg and 31.9 +/- 8.7 mmHg, respectively(p=1.45). The mean number of preoperative medications was 2.8 +/- 0.8 and 2.0 +/- 0.9, respectively(p<0.05). MMC(0.25 mg/ml or 0.5 mg/ml) was applied between Tenon's capsule and the sclera during trabeculectomy for 3 minutes in low-risk group, for 5 minutes in high-risk group. Scleral-flap was closed with tight releasable sutures. Eyes followed longer than 3 months were included(mean of 14.1 +/- 8.0 months vs 11.9 +/- 6.8 months, p=0.23). The low-risk group had better postoperative results including: a lower IOP at last follow-up(13.7 +/- 3.2 vs 17.2 +/- 8.4 mmHg, p=0.02), a better success rate(94% vs 83% with or without medications, p=0.23: 83% vs 55% without medications, p=0.02), a lower postoperative need for glaucoma medications(0.2 +/- 0.4 vs 0.6 +/- 08, p=0.005). Overall complications were similar between both groups. One of 37 eyes(3%) in the low-risk group developed a hypotony(p=0.51) and one of 36 eyes(3%) in the high-risk group developed a hypotony maculopathy(p=0.49). This study suggests that MMC trabeculectomy with tight releasable scleralflap sutures is safe and effective in controlling IOP not only in refractory glaucoma but also, more successfully, in uncomplicated glaucoma.