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Editors Selection IGR 12-4

Surgical Therapy: Ologen 'spacer' versus MMC

Comment by Marlene Moster on:

27331 A prospective randomised trial of trabeculectomy using mitomycin C vs an ologen implant in open angle glaucoma, Rosentreter A; Schild AM; Jordan JF et al., Eye, 2010; 24: 1449-1457

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Yogi Berra once said: 'If the world was perfect, it wouldn't be.' Nonetheless, we in glaucoma surgery are constantly in search of the perfect surgery ‐ one with excellent IOP control and no complications. The use of mitomycin-C antimetabolite (MMC) in glaucoma filtration surgery has the advantage of reduced scarring, but it has also wrought thin, avascular blebs more prone to leaks and infections. As surgical techniques have improved, these adverse events occur with less frequency, but still remain a challenge for today's glaucoma surgeon. In this prospective randomized study, Rosentreter et al. (2003) explored the alternative of a biodegradable 'spacer' to eliminate contact between sclera and tenons ‐ thereby theoretically limiting adherent scar between the two. Ten patients were randomized to standard filtration surgery with MMC, and ten were randomized to surgery with an ologen implant. Though the ologen surgeries produced improved bleb morphology, they were 50% less successful in reducing intraocular pressure than surgery with MMC. This small study is an interesting early exploration of the role of 'spacers' in glaucoma filtration surgery. Though these results suggest spacers will not supplant MMC, it may simply be the design of the ologen implant used that is the failure. Rosentreter et al. used the first-generation prototype of ologen, which measures a bulky 4 x 7 mm. This is akin to placing a pebble over the scleral flap, and such flap compression may have reduced aqueous outflow. Further, this first-generation ologen implant dissolves within a month, yet dynamic healing is still occurring at this point. The newer ologen prototype is thin and covers a more diffuse area (1 x 12 mm). These dimensions may not only alleviate issues of flap compression, but also allow for a transparent implant amenable to laser suturelysis. Further, it now lasts up to three months, which will see most patients out of their post-operative scarring. This author proposes that a comparison between MMC and a better-designed ologen implant may yield different results, and certainly begs investigation.

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