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Trabeculectomy MMC Audit

Aim. To assess success and complication rates of trabeculectomies augmented with mitomycin CTo compare results to the National Trabeculectomy SurveyTo define the characteristics of patients undergoing trabeculectomy with MMC. Methods. Prospective database of consecutive patients undergoing trabe

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Trabeculectomy MMC Audit

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    1. Trabeculectomy + MMC Audit Mark Chiang, Clinical Research Fellow Mr. Peter Shah, Consultant Ophthalmic Surgeon Good Hope Hospital

    2. Aim To assess success and complication rates of trabeculectomies augmented with mitomycin C To compare results to the National Trabeculectomy Survey To define the characteristics of patients undergoing trabeculectomy with MMC

    3. Methods Prospective database of consecutive patients undergoing trabeculectomy + MMC under care of Mr. Peter Shah Data collected Demographics Pre-operative, operative and follow-up data

    4. Results Total number of eyes = 123 Note retrieval 100% 2004 Data update 99%

    5. Gender

    6. Age at surgery

    7. Ethnicity

    8. Glaucoma type

    9. Pre-op medications

    10. Surgeons

    11. Intraocular pressures (pre-operative)

    12. Intraocular pressures (post-operative)

    13. IOP distribution (1 year)

    14. Overall success (latest follow-up mean 613 days)

    15. Success by ethnicity (1 year)

    16. Success by previous surgery (1 year)

    17. Bleb morphology (1 year) Excellent bleb morphology 75.0%

    18. Bleb morphology (1 year) Satisfactory morphology 21.4%

    19. Bleb morphology (1 year) Poor morphology 3.6%

    20. Bleb Needling Revision 13.8% of patients (17/123) 64.7% males Mean pre-op highest IOP 40.7 mmHg 47.1% on Diamox pre-operatively 47.1% had previous intraocular surgery 41.2% required topical drops at latest follow-up 35.3% African-Caribbean

    21. Post-op management

    22. Complications

    23. Clinically Significant Early Hypotony (CSEH) 4.9% of patients Required intervention Viscoelastic to AC Conjunctival / scleral flap suturing Analysis of CSEH reveals: 33.3% AFC 66.7% < 45 years of age

    24. Follow-up failures (DNA) DNA in 6 patients during follow-up 4 African-Caribbean 2 Caucasian 1 alcoholic / 1 psychiatric 5 males Mean age 45.7 years old Age < 45 Male African-Caribbean ethnicity

    25. Surgery technique Fornix based conjunctival flap Wide sub-Tenons treatment with MMC (0.1 0.2 mg/ml for 1 3 mins) Pre-placed, buried, releasable adjustable scleral flap sutures Intra-op IOP titration Buried purse-string & mattress closure of conjunctiva and Tenons

    26. Conclusion High success rates for this series Low complication rates for this series Results exceed National Trabeculectomy Survey Complications are more common in African-Caribbean patients and in young patients

    27. Summary Success 97.2% Sight threatening complications 0.8% 0 Wipe-out 0 Endophthalmitis 0 Suprachoroidal haemorrhage 1 Late hypotony Clinically Significant Early Hypotony (requiring intervention) 4.9%

    28. National Trabeculectomy Survey Success, IOP < 21 92% Complications Hypotony 24.3% Hypotony maculopathy 0.2% Endophthalmitis 0.3% Wipe-out 0.4% of total cohort, 5% in advanced glaucoma Cataract needing extraction 2.5%

    29. Other series Success 80 90% Complications Hypotony 4.8 47% Hypotony maculopathy 4 12% Blebitis 2 5.7% Endophthalmitis 0.8 8% Wipe-out 25% in one series Cataract needing operation during follow-up 12 55%

    31. Its only possible with Good pre-operative, peri-operative and intensive post-operative care Good success with lower doses of MMC but 34% post-op 5-FU and 14% bleb needling revision

    32. Trabeculectomy with MMC is a complex operation requiring high degree of manual dexterity and extensive glaucoma experience Suggest Fellowship training for all surgeons performing this operation With close Consultant supervision, high success rates for Fellows in training Discussion points

    33. Actions Continue long-term analysis of series Target African-Caribbean and JOAG patients for intensive intervention Improve patient information Consider glaucoma support nurse help These results only possible with continued Fellow support

    34. Pearls Identify thin tissues pre-op Small peritomy Stromal hydration Careful closure ? No MMC Thin Tissues + Leak = Early Failure

    35. In AFC / thick tissues need early (<10 days) high flow into sub-Tenon space May need to remove both releasables Pearls

    36. Thin conj and Tenons need thick scleral flap to control aqueous outflow Pearls

    37. JOAGs get hypotony Need early surgical intervention Beware of the young! Pearls

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