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Editors Selection IGR 8-4
Surgical Treatment: Ahmed glaucoma implant with MMC & 5 FU
Comment by Paul Palmberg on:
21747 Ahmed valve implantation with adjunctive mitomycin C and 5-fluorouracil: Long-term outcomes, Alvarado JA; Hollander DA; Juster RP et al., American Journal of Ophthalmology, 2008; 146: 276-284
See also comment(s) by Tarek Shaarawy •Alvarado et al. (1236) report impressive results they believe support the usefulness of a long (average eight minutes) application of MMC and supplemental 5-FU injections (average five) in Ahmed Glaucoma Implant (AGI) surgery. The life table estimate of success at six years was 72% for the Ahmed alone, and 84% for combined AGI-phaco procedures. However, while the results are better than the average for AGI surgery without supplemental MMC (e.g., Souza C, et al. AJO 2007; 144: 893: 49% success at five years), there is evidence from two prospective, randomized trials that the use of MMC is of no benefit with AGI surgery (Susanna R Jr, the Latin American Glaucoma Society Investigators. BJO 2003; 87: 994; and Costa VP, et al. Ophthalmology 2004; 111: 1071). Furthermore, an equally good result was reported for AGI surgery without MMC by Chen et al. (Zhonghua Yan Ke Za Zhi 2005:41:796), 87% success at four years.
It cannot be concluded with any certainty that the use of MMC and/ or 5-FU is beneficial in glaucoma drainage device surgeryThe Alvarado study had no randomized control group with which to compare the results. Given the clearly improved results that antimetabolites confer on filtering surgery, perhaps Alvarado and colleagues felt it was likely to be in their patients' best interests to use them. A further limitation to the Alvarado study is that it was a retrospective study, albeit a consecutive case study, and that it excluded any patients for whom there was not at least a six-month follow-up. Prospective studies have the benefit of enrolling only those subjects who intend to be available for follow-up. On the other hand, studies that exclude subjects with short-term follow-up, or have other losses to follow-up, may underestimate failures. Given the wide range of reported success rates, which may reflect differing case mixes, it cannot be concluded with any certainty that the use of MMC and/or 5-FU is beneficial in glaucoma drainage device surgery.
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