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Editors Selection IGR 9-4

Surgical treatment: MMC

Comment by Paul Palmberg on:

15121 Postoperative application of mitomycin c improves the complete success rate of primary trabeculectomy: a prospective, randomized trial, Mietz H; Krieglstein GK, Graefe's Archive for Clinical and Experimental Ophthalmology, 2006; 244: 1429-1436

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Mietz and Krieglstein (1318) laudably performed a randomized trial to test their hypothesis that MMC applied topically post-operatively would improve the success of trabeculectomy. They believe that they achieved a positive result as significantly more MMC treated patients than controls achieved a 25% pressure lowering (85% vs 54%). However, the analysis of results is partially confounded by a marked imbalance of pre-operative IOP (31 vs 25 mmHg) that accounts for virtually all of the difference in outcome. The final pressures were no different, at 15.4 and 15.6 mmHg. An analysis of covariance (ANCOVA) would be a more appropriate test of the data, and likely would yield a negative result. On the other hand, they also state that a survival analysis for complete success significantly favored the MMC group, so there may be some merit to the technique. The study is unfortunately not definitive, given the confounding.

An interesting follow up study would be for them to compare the use of Intraoperative MMC (applied with thin sponges to a wide area, à la Peng Khaw, which is reported to have markedly reduced complications and is the most commonly used technique) to their technique of post-operative use, so that both the effectiveness and complications could be compared in comparable patients.

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