Comparative Results of Trabeculectomy with Mitomycin C in Uveitic Glaucoma versus Primary Open-Angle Glaucoma

Yeon Ho Lee; Hyun Ju Oh; Soon Cheol Cha

doi:10.3341/jkos.2015.56.9.1408

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Lee, Oh, and Cha: Comparative Results of Trabeculectomy with Mitomycin C in Uveitic Glaucoma versus Primary Open-Angle Glaucoma

Original Article

J Korean Ophthalmol Soc 2015;56(9):1408-1415.

Published online: 29 August 2015

DOI: https://doi.org/10.3341/jkos.2015.56.9.1408

Comparative Results of Trabeculectomy with Mitomycin C in Uveitic Glaucoma versus Primary Open-Angle Glaucoma

Yeon Ho Lee, M.D., Hyun Ju Oh, M.D., Soon Cheol Cha, M.D., PhD

Department of Ophthalmology, Yeungnam University College of Medicine, Daegu, Korea

Address reprint requests to Soon Cheol Cha, MD, PhD Department of Ophthalmology, Yeungnam University Medical Center, #170 Hyeonchung-ro, Nam-gu, Daegu 42415, Korea Tel: 82-53-620-3442, Fax: 82-53-626-5936 E-mail: sccha@yumail.ac.kr

∗ This study was presented as an e-poster at the 111th Annual Meeting of the Korean Ophthalmological Society 2014.

Received 3 April 201515 May 2015 Accepted 21 July 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

In this study we evaluated the long-term outcomes and prognostic factors of trabeculectomy with mitomycin C (MMC) in eyes with uveitic glaucoma (UG) compared with primary open-angle glaucoma (POAG).

Methods

We performed a retrospective chart review of 60 eyes with UG and 402 eyes with POAG that were followed up for at least 1 year after trabeculectomy with MMC between June 2000 and December 2012. The review included intraocular pressure (IOP), number of anti-glaucoma medications, and postoperative complications. Surgical success was analyzed using the Kaplan-Meier life-table method based on 2 definitions of successful IOP control with topical anti-glaucoma medications: Definition A (IOP ≤ 15 mm Hg) and Definition B (IOP ≤ 18 mm Hg). Risk factors for surgical failure of trabeculectomy were ana-lyzed using the Cox proportional hazards model.

Results

Success rate at 5 years after trabeculectomy was lower in UG than in POAG (65.8% vs. 76.4%, Definition B), but with-out significant difference. However, UG had a significantly lower cumulative probability of success than POAG based on Kaplan-Meier survival curves ( p = 0.049 and 0.044, respectively). Postoperative hypotony and hypotony maculopathy was more frequent in UG ( p = 0.044 and 0.044, respectively). In UG, the Cox proportional hazards model showed postoperative shallow anterior chamber was associated with surgical failure in both Definition A and B.

Conclusions

Long-term results of trabeculectomy with MMC in eyes with UG showed successful IOP control similar to POAG. Trabeculectomy with MMC is a reasonable surgical option for the management of UG.

Keywords: Primary open angle glaucoma, Trabeculectomy, Uveitic glaucoma

References

1. Papadaki TG, Zacharopoulos IP, Pasquale LR. . Long-term re-sults of Ahmed glaucoma valve implantation for uveitic glaucoma. Am J Ophthalmol. 2007; 144:62–9.

2. Kok H, Barton K. Uveitic glaucoma. Ophthalmol Clin North Am. 2002; 15:375–87. viii.

3. Levene RZ. Glaucoma filtering surgery: factors that determine pressure control. Ophthalmic Surg. 1984; 15:475–83.

4. Skuta GL, Parrish RK. 2nd. Wound healing in glaucoma filtering surgery. Surv Ophthalmol. 1987; 32:149–70.

5. Cheung JC, Wright MM, Murali S, Pederson JE. Intermediate-term outcome of variable dose mitomycin C filtering surgery. Ophthalmology. 1997; 104:143–9.

6. Kitazawa Y, Kawase K, Matsushita H, Minobe M. Trabeculectomy with mitomycin. A comparative study with fluorouracil. Arch Ophthalmol. 1991; 109:1693–8.

7. Perkins TW, Gangnon R, Ladd W. . Trabeculectomy with mito-mycin C: intermediate-term results. J Glaucoma. 1998; 7:230–6.

8. Liebmann JM, Ritch R. Complications of glaucoma filtering surgery. Ritch R, Shields MB, Krupin T, editors. The Glaucomasglaucoma therapy. 2nd. St Louis: Mosby;1996. v. 3. chap. 84.

9. Noble J, Derzko-Dzulynsky L, Rabinovitch T, Birt C. Outcome of trabeculectomy with intraoperative mitomycin C for uveitic glaucoma. Can J Ophthalmol. 2007; 42:89–94.

10. Novak-Laus K, Mandić Z, Iveković R. . Trabeculectomy with mitomycin C in glaucoma associated with uveitis. Coll Antropol. 2005; 29:Suppl 1. 17–20.

11. Prata JA Jr, Neves RA, Minckler DS. . Trabeculectomy with mitomycin C in glaucoma associated with uveitis. Ophthalmic Surg. 1994; 25:616–20.

12. Watson PG. Surgery of the glaucomas. Br J Ophthalmol. 1972; 56:299–306.

13. Palmer SS. Mitomycin as adjunct chemotherapy with trabeculectomy. Ophthalmology. 1991; 98:317–21.

14. Wright MM, McGehee RF, Pederson JE. Intraoperative mitomy-cin-C for glaucoma associated with ocular inflammation. Ophthalmic Surg Lasers. 1997; 28:370–6.

15. Iwao K, Inatani M, Seto T. . Long-term outcomes and prog-nostic factors for trabeculectomy with mitomycin C in eyes with uveitic glaucoma: a retrospective cohort study. J Glaucoma. 2014; 23:88–94.

16. Kaburaki T, Koshino T, Kawashima H. . Initial trabeculectomy with mitomycin C in eyes with uveitic glaucoma with inactive uveitis. Eye (Lond). 2009; 23:1509–17.

17. Hamanaka T, Takei A, Takemura T, Oritsu M. Pathological study of cases with secondary open-angle glaucoma due to sarcoidosis. Am J Ophthalmol. 2002; 134:17–26.

18. Ono T, Yuki K, Shiba D. . Postoperative flat anterior chamber: incidence, risk factors, and effect on the long-term success of trabeculectomy. Jpn J Ophthalmol. 2013; 57:520–8.

19. Bindlish R, Condon GP, Schlosser JD. . Efficacy and safety of mitomycin-C in primary trabeculectomy: five-year follow-up. Ophthalmology. 2002; 109:1336–41. discussion 1341-2.

20. Greenfield DS, Suñer IJ, Miller MP. . Endophthalmitis after fil-tering surgery with mitomycin. Arch Ophthalmol. 1996; 114:943–9.

21. Jacobi PC, Dietlein TS, Krieglstein GK. Adjunctive mitomycin C in primary trabeculectomy in young adults: a long-term study of case-matched young patients. Graefes Arch Clin Exp Ophthalmol. 1998; 236:652–7.

22. Shields MB, Scroggs MW, Sloop CM, Simmons RB. Clinical and histopathologic observations concerning hypotony after trabecu-lectomy with adjunctive mitomycin C. Am J Ophthalmol. 1993; 116:673–83.

23. Waheed S, Liebmann JM, Greenfield DS. . Recurrent bleb infections. Br J Ophthalmol. 1998; 82:926–9.

24. Toris CB, Pederson JE. Aqueous humor dynamics in experimental iridocyclitis. Invest Ophthalmol Vis Sci. 1987; 28:477–81.

25. de Smet MD, Gunning F, Feenstra R. The surgical management of chronic hypotony due to uveitis. Eye (Lond). 2005; 19:60–4.

26. Jampel HD, Pasquale LR, Dibernardo C. Hypotony maculopathy following trabeculectomy with mitomycin C. Arch Ophthalmol. 1992; 110:1049–50.

27. Stamper RL, McMenemy MG, Lieberman MF. Hypotonous mac-ulopathy after trabeculectomy with subconjunctival 5-fluorouracil. Am J Ophthalmol. 1992; 114:544–53.

28. Daugeliene L, Yamamoto T, Kitazawa Y. Cataract development af-ter trabeculectomy with mitomycin C: a 1-year study. Jpn J Ophthalmol. 2000; 44:52–7.

29. Husain R, Aung T, Gazzard G. . Effect of trabeculectomy on lens opacities in an East Asian population. Arch Ophthalmol. 2006; 124:787–92.

30. AGIS (Advanced Glaucoma Intervention Study) Investigators The Advanced Glaucoma Intervention Study: 8. Risk of cataract formation after trabeculectomy. Arch Ophthalmol. 2001; 119:1771–9.

31. Lazaro C, Benitez-del-Castillo JM, Castillo A. . Lens fluo-rophotometry after trabeculectomy in primary open-angle glaucoma. Ophthalmology. 2002; 109:76–9.

32. Popovic V, Sjöstrand J. Course of exfoliation and simplex glauco-ma after primary trabeculectomy. Br J Ophthalmol. 1999; 83:305–10.

33. Belfort R Jr, Nussenblatt RB. Surgical approaches to uveitis. Int Ophthalmol Clin. 1990; 30:314–7.

34. Foster CS, Fong LP, Singh G. Cataract surgery and intraocular lens implantation in patients with uveitis. Ophthalmology. 1989; 96:281–8.

35. Jampel HD, Jabs DA, Quigley HA. Trabeculectomy with 5-fluo-rouracil for adult inflammatory glaucoma. Am J Ophthalmol. 1990; 109:168–73.

36. Ophir A, Ticho U. Remission of anterior uveitis by subconjunctival fluorouracil. Arch Ophthalmol. 1991; 109:12–3.

37. Weinreb RN. Adjusting the dose of 5-fluorouracil after filtration surgery to minimize side effects. Ophthalmology. 1987; 94:564–70.

Figure 1.

Kaplan-Meier curves for successful intraocular pres-sure (IOP) control by trabeculectomy with mitomycin C in pa-tients with uveitic glaucoma (UG, solid line) and primary open angle glaucoma (POAG, broken line). Definition of success of IOP control was IOP ≤ 15 mm Hg with medication (Definition A). Cumulative probability of success at 5 years was 52.4 ±0.1% in UG and 56.7 ± 0.1% in POAG ( p = 0.049, log-rank test).

Figure 2.

Kaplan-Meier curves for successful intraocular pres-sure (IOP) control by trabeculectomy with mitomycin C in pa-tients with uveitic glaucoma (UG, solid line) and primary open angle glaucoma (POAG, broken line). Definition of success of IOP control was IOP ≤ 18 mm Hg with medication (Definition B). Cumulative probability of success at 5 years was 65.8 ±0.8% in UG and 76.4 ± 0.3% in POAG ( p = 0.044, log-rank test).

Table 1.

Demographic characteristics according to types of glaucoma

Characteristics	UG (n = 60)	POAG (n = 402)	p-value
Age (years, range)	41.5 ± 11.4 (19-67)	54.3 ± 15.3 (14-82)	0.001^*
Gender			0.305^†
Male (n, %)	38 (63.3)	281 (69.9)
Female (n, %)	22 (36.7)	121 (30.1)
Eye laterality			0.888^†
Right/left	34/26	231/171
Preoperative BCVA	0.53 ± 0.57	0.46 ± 0.56	0.560^*
BCVA at final follow-up	0.64 ± 0.63	0.51 ± 0.57	0.308^*
Corneal endothelial cell density (cells/mm²)	2,211 ± 419	2,454 ± 515	0.029^∗
Diabetes mellitus (n, %)	8 (13.3)	71 (17.7)	0.592^†
Hypertension (n, %)	6 (10)	60 (14.9)	0.232^†

Values are presented as mean ± SD unless otherwise indicated. UG = uveitic glaucoma; POAG = primary open angle glaucoma; BCVA = best-corrected visual acuity.

^∗ Independent t-test;

^† Chi-square test.

Table 2.

Preoperative and postoperative IOP and number of glaucoma medication

Factors	UG (n = 60)	POAG (n = 402)	p-value^∗
Preoperative IOP^† (mm Hg)	32.2 ± 9.5 (14-60)	22.8 ± 7.5 (9-60)	<0.001
Preoperative glaucoma medications (n)	3.8 ± 0.8 (2-5)	3.7 ± 0.7 (1-5)	0.503
Postoperative follow up period (months)	54.8 ± 38.8 (12-134)	60.7 ± 22.1 (12-169)	0.759
Postoperative IOP^‡ (mm Hg)	17.1 ± 3.0 (5-70)	12.4 ± 3.3 (5-50)	0.038
Postoperative glaucoma medications (n)	0.6 ± 1.3 (0-5)	0.4 ± 0.7 (0-4)	0.346

Values are presented as mean ± SD (range) unless otherwise indicated.

IOP = intraocular pressure; UG = uveitic glaucoma; POAG = primary open angle glaucoma.

^∗ Independent t-test;

^† Preoperative IOP was expressed as the average value during prior three visits preceding trabeculectomy;

^‡ Postoperative IOP was expressed as the value at last visit after trabeculectomy.

Table 4.

Postoperative complications according to type of glaucoma

Complications	UG (n = 60)	POAG (n = 402)	p-value
Postoperative hypotony^∗	5 (8.3)	11 (2.7)	0.044^†
Hypotony maculopathy	5 (8.3)	11 (2.7)	0.044^†
Anterior chamber bleeding (hyphema)	7 (11.7)	45 (11.2)	0.914^‡
Early postoperative wound leak	2 (3.3)	5 (1.2)	0.227^†
Bleb leak	4 (6.7)	12 (3.0)	0.141^†
Serous choroidal detachment	6 (10.0)	28 (7.0)	0.416^†
Shallow anterior chamber	4 (6.7)	20 (5.0)	0.536^†
Corneal decompensation	2 (3.3)	0 (0.0)	0.467^†
Endophthalmitis	1 (1.7)	1 (0.2)	0.243^†
Cataract progression	28 (46.6)	152 (37.8)	0.189^‡

Values are presented as n (%) unless otherwise indicated. UG = uveitic glaucoma; POAG = primary open angle glaucoma.

^∗ Postoperative hypotony (long standing ocular hypotony was defined as intraocular pressure [IOP] less than 5 mm Hg lasting more than 3 months or IOP less than 10 mm Hg associated hypotony maculopathy;

^† Fisher’s exact test;

^‡ Chi-square test.

Table 5.

Risk factors for failure of trabeculectomy with mitomycin C in uveitic glaucoma for definition A, B

Variables	Definition A			Definition B
Variables	Hazard ratio	Range (95% CI)	p-value^∗	Hazard ratio	Range (95% CI)	p-value^∗
Age at operation < 50 years	0.464	0.165-1.300	0.144	0.463	0.159-1.356	0.160
Preoperative IOP ≥ 30 mm Hg	0.755	0.257-2.212	0.608	1.502	0.476-4.740	0.488
Preoperative medications ≥ 3	6.172	0.253-6.290	0.123	1.874	0.390-9.004	0.433
Postoperative hypotony	0.482	0.115-2.026	0.319	0.997	0.254-3.913	0.997
Hyphema	0.968	0.267-3.503	0.960	0.316	0.069-1.441	0.137
Shallow anterior chamber	4.219	1.326-13.425	0.015	4.720	1.540-14.463	0.007
Postoperative uveitis relapse	1.431	0.544-3.765	0.467	1.576	0.588-4.272	0.366

Definition A is a postoperative IOP ≤ 15 mm Hg with medication and Definition B is a postoperative IOP ≤ 18 mm Hg with medication. CI = confidence interval; IOP = intraocular pressure.

^∗ Cox proportional hazards regression analysis.

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