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Editors Selection IGR 12-4
Surgery: Ologen impant vs MMC Trab
Comment by Tony Wells on:
26578 Capsule excision and Ologen(trademark) implantation for revision after glaucoma drainage device surgery, Rosentreter A; Mellein AC; Konen WW et al., Graefe's Archive for Clinical and Experimental Ophthalmology, 2010; 248: 1319-1324
Despite serial improvements over the guarded filtration surgery (GFS) initially described by Cairns and Watson circa 1970 that has evolved into modern trabeculectomy, GFS still lacks the efficiency, high success rates, and long term stability that we have come to expect from cataract surgery. Incremental gains are being made, in particular the perioperative period has become dramatically safer for GFS patients in the last decade thanks to refinements and the use of releasable or adjustable sutures. An aspect that remains troublesome is the matter of how to best modulate wound healing and maintain a good bleb and IOP after surgery. Although Mitomycin C (MMC) improves post-trabeculectomy IOP control significantly, it also has an unpleasant habit of amplifying any imperfections in surgical technique, increasing the risks of complications such as bleb leaks, bleb-related endophthalmitis, and long-term hypotony with secondary consequences. Nowadays it is common lay the blame with MMC for these complications, although they were also common after full-thickness surgical procedures that predated antimetabolite use, and may be significantly minimised with changes in surgical technique.
In a thoroughly well-designed and carried out surgical study by Rosen treter et al. (1414), trabeculectomy with the Ologen biodegradable implant was compared to low-dose MMC trabeculectomy.
Although Mitomycin C improves post-trabeculectomy IOP control significantly, it also has an unpleasant habit of amplifying any imperfections in surgical technique
The study reports results for only twenty patients, ten in each group, although the study was designed with twenty in each group, because a significant difference in success rates (absolute success rates 100% in MMC group vs. 50% in Ologen group at one year) were noted at a monitoring committee review and the study was terminated.
Despite some very promising animal work the Ologen implant, instead of MMC, isn't part of the answer we are looking for
Unfortunately the perioperative safety may also have been compromised: there were twice as many patients with hypotony (six vs. three, not statistically significant, but there were only ten patients in each group) in the Ologen group as in the MMC group. This was likely a result of the Ologen surgery depending on the implant to compress the scleral flap rather than the lysable tight-fitting nylon suture in the MMC group. The quest for the ideal glaucoma surgical procedure continues, with modern MMC trabeculectomy still the frontrunner. Although it seems from this study that despite some very promising animal work the Ologen implant, instead of MMC, isn't part of the answer we are looking for, it would be interesting to know how it works as an enhancement or adjunct to other techniques.
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