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Editors Selection IGR 17-4

Surgical Treatment: Mitomycin

Comment by Yvonne Buys on:

61164 Evaluating the long-term efficacy of short-duration 0.1 mg/ml and 0.2 mg/ml MMC in primary trabeculectomy for primary adult glaucoma, Sihota R; Angmo D; Chandra A et al., Graefe's Archive for Clinical and Experimental Ophthalmology, 2015; 253: 1153-1159

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Success rates of trabeculectomy have improved with the introduction of mitomycin C (MMC). However, increased concentration and/or duration of MMC exposure is also related to increased complications, specifically vision threatening complications such as hypotony, bleb leaks and infection. Titrating MMC exposure to find a balance between success and complications is required. Sihota et al. report on the two-year results of a prospective randomized study of 50 subjects with primary open- or closed-angle glaucoma without a history of previous eye surgery who were randomized to trabeculectomy with one minute of 0.1 or 0.2 mg/ml MMC. They reported no difference in success or complications however the 0.2 mg/ml MMC group had larger blebs with more transparent/thin areas.

Lower concentrations and short MMC exposure may not impact efficacy but could minimize complications and underscores the importance of monitoring one's surgical results over the long term to suggest modifications to current surgical technique

Although these results suggest low-concentration, short-exposure MMC is equally effective to higher concentrations and longer exposure, the study fails to provide important details including the location of MMC application and rates of suture lysis. The definition of success changes from the study design (6-15 mmHg) to discussion (≤ 15 mmHg). Figure 1 seems to have a low outlier in the 0.1 mg/ml group which might change the complete success rate from 92% to 88% in addition the complete success rate of the 0.2 mg/ml group was reported as 88% in the results and 91.7% in the discussion. Surprising is the virtually 100% complete and qualified success rates at two years (the one failure, IOP 16 mmHg on two medications, experienced trauma on post-op day two) and zero complications. The authors acknowledge this and attribute it to the small sample size.

Surgical studies can be difficult to translate into individual practice given varying techniques. In addition filtration surgery results are significantly impacted by post-operative care. It is unlikely that a 'one-size-fits-all' approach can be applied to MMC use. However, this study highlights that lower concentrations and short MMC exposure may not impact efficacy but could minimize complications and underscores the importance of monitoring one's surgical results over the long term to suggest modifications to current surgical technique.

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