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Editors Selection IGR 12-1

Surgical Treatment: Ahmed glaucoma implant with MMC & 5 FU

Comment by Tarek Shaarawy 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

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Alvarado et al. (1236) present a retrospective consecutive series of patients who underwent Ahmed-valve implantation, either alone or in combination with cataract surgery. All patients received a rather vigorous antimetabolite regimen, where an intraoperative application of mitomycin C (MMC), and at least one postoperative injection of 5-fluorouracil (5-FU) (median five injections) were administered. What gives true value to this study is its relatively long follow-up period (median 50.4 months) for such a large group of patients (130 eyes), and the fact that it re-kindles a debate, that was never settled, on the value of antimetabolites in conjunction with glaucoma drainage device (GDD) implantation. The authors have compared their outcomes with previously published studies in which antimetabolites were not employed. They reported that the estimated probabilities of valve success for both the second and fourth postoperative years in their study exceeded those found in all of the other compared trials. And they concluded that these results suggest that there is a potential benefit associated with the use of MMC and 5-FU in combination during the intraoperative and early postoperative period. The authors also report markedly lower rates of the hypertensive phase that occurs following GDD implantation compared to previously published reports. This takes a whole new dimension when we take in consideration the fact that the group exhibiting a hypertensive phase had a significant increase in the likelihood of valve failure. As a retrospective non-controlled trial, that compares its results with the results of other published trials, the results of this study do not provide conclusive evidence to support of the use of antimetabolites in GDD surgery. Nevertheless the more than encouraging results reported should re-ignite interest in this subject, and should be taken seriously. Finally, the authors caution that there results were obtained exclusively with the use of the S2 model (Polypropylene). However, when the same authors used the FP-7 model (entirely made of silicone) in three cases, employing the same regimen of intra- and postoperative antimetabolite application, 'the wounds failed to close and chronic leaks developed, requiring explanation.' This study does not provide conclusive evidence to support the use of antimetabolites in GDD surgery.

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