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Editors Selection IGR 12-1

Filtering Blebs: MMC versus 5FU for bleb needling

Comment by Nils Loewen on:

24512 Long-term outcomes of needle revision of trabeculectomy blebs with mitomycin C and 5-fluorouracil: a comparative safety and efficacy report, Anand N; Khan A, Journal of Glaucoma, 2009; 18: 513-520

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USA Anand et al. (1305) have to be commended for conducting the first study directly comparing mitomycin C (MMC) and 5-fluoruracil (5-FU) for slit-lamp bleb needling. The authors conclude that MMC is more effective in reestablishing and maintaining bleb function yet is not associated with more complications. While at two years 61% of MMC eyes had IOPs lower than 16 mmHg off drops, this was the case in only 30% of 5-FU eyes. Serious complications occurred in 2.2% of MMC and up to 17% in 5-FU eyes but the number was too low to make a statement about significance.

MMC is more effective with slit -lamp bleb needling in reestablishing and maintaining bleb function yet is not associated with more complications

The authors are candid about the shortcomings of their study, a retrospective analysis spanning five years, likely influenced by the surgeon's learning curve and variable (or not mentioned) inclusion criteria. For instance, it is not known whether there were differences of trabeculectomy technique. In 34% eyes 5-FU revisions were done within three months of trabeculectomy, but only in 15.6% with MMC, suggesting that different stages of wound healing were present at the time of needling. This detail is even more concerning as eyes that failed early after needle revision were twice more likely to be within three months of trabeculectomy (p = 0.002). This study should be interpreted as representing the authors' own best practice pattern that has evolved over time. The value lies in the fact that their new substance of choice with better needling outcomes has become MMC, a potent pan-inhibitor of cell cycle stages with almost 100-fold fibroblast inhibitory potency compared to 5-FU and historically more serious complications. Hopefully, these findings will encourage a prospective, randomized, double-blinded trial with an even longer follow-up.

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