Our results of large area mitomycin C application trabeculectomy in cases with advanced glaucoma

Öz

Objective: To evaluate large area Mitomycin-C (MMC) applied trabeculectomy results in advanced glaucoma patients in which targeted intraocular pressure (IOP) can not be achieved with maximum medical therapy. Methods: 41 eyes of 35 advanced glaucoma patients that can not be controlled with medical treatment were included to the study. Large area MMC application was applied for 2 minutes in 0.2 mg/ml concentration. The mean follow-up period was 28 months (24-36). All of the cases were advanced glaucoma patients and 21mmHg IOP level could not be achieved in spite of maximum treatment with three drugs. Results: Of the 35 patients that were included to study, 19 were male and 16 were female and the mean age was 52.5±1.8 years (range, 45-73). Twenty-seven of eyes were primary open angle glaucoma, 11 was pseudoexfoliative glaucoma, 3 were angle closure glaucoma. In 5 eyes (12.1%) there were early hypotonia. Additional suturation was made in 2 eyes with hypotonia. Two eyes were treated with tight patching. Suture addition was made in 1 eye with choroid effusion. Cataract was developed in 4 eyes. There were 3 cystic bleb (7.3%) and they were treated with needle application. Thin avascular bleb was developed in 10 eyes (24.4%). In other eyes (68.3%) there were thin diffuse bleb formations. When targeted IOP was considered as 15 mmHg, targeted IOP was achieved in 36 (87.8%) eyes. Conclusion: We suggest that trabeculectomy with large area MMC application is an effective choice in advanced glaucoma patients in which targeted IOP can not be achieved with maximum medical treatment.

Anahtar Kelimeler

• Mitomycin-C, trabeculectomy, bleb

İleri evre glokomlu olgularda geniş alan mitomisin C uygulamalı trabekülektomi sonuçlarımız

Öz

Amaç: Maksimum tıbbi tedavi ile hedef göziçi basıncı (GİB) sağlanamayan ileri evre glokomlu hastalarda geniş alan Mitomisin-C (MMC) uygulamalı trabekülektomi sonuçlarının değerlendirilmesi amaçlandı. Yöntemler: Çalışmaya medikal tedavi ile kontrol altına alınamayan ileri evre glokomu olan 35 hastanın 41 gözü dahil edilmiştir. Geniş alan MMC uygulaması 0,2 mg/ml konsantrasyonda 2 dk süre ile uygulanmıştır. Ortalama izlem süresi 28 aydır (24-36). Olguların hepsi maksimum 3\'lü tedaviye rağmen GİB 21 mmHg altına düşmeyen ileri derecede glokomu olan hastalardır. Bulgular: Çalışmaya dahil edilen 35 hastanın 19\'u erkek 16\'sı kadın idi ve yaş ortalaması 52,5±1,8 yıl (45-73) olarak bulundu. Opere edilen gözlerin 27\'si primer açık açılı glokom, 11\'i psödoeksfolyatif glokom, 3\'ü açı kapanması glokomu idi. 5 (%12,1) gözde erken dönem hipotoni gelişmiştir. Hipotoni gelişen 2 göze ek sütür konulmuştur. İki göz sıkı bandaj kapama ile tedavi edilmiştir. Koroid effüzyonu gelişen 1 göze ek operasyonla sütür eklenmiştir. Dört gözde katarakt gelişmiştir. 3 gözde kistik bleb (%7,3) görülmüş iğneleme ile tedavi edilmiştir. On gözde (%24,4) ince avasküler bleb gelişmiştir. Diğer gözlerde (%68,3) ince diffüz ve fonksiyonel bleb izlenmiştir. Hedeflenen GİB 15mmHg olarak değerlendirildiğinde gözlerin 36\'sında (%87,8) hedeflenen GİB değerine ulaşılmıştır Sonuç: Maksimum tıbbi tedavi ile hedef GİB sağlanamayan ileri evre glokomlu hastalarda, geniş alan MMC uygulamalı trabekülektomi yönteminin etkili bir seçenek olabileceği düşünüldü.

Anahtar Kelimeler

• Mitomisin-C, trabekülektomi, bleb

Kaynakça

1. Önol M, Pehlivanlı Z, Hasanreisoğlu H. Trabekülektomide başarın arttırılması: geniş alan mitomisin C uygulaması. Glo-Kat 2006;1:7-12.
2. Lama PJ, Fechtner RD. Antifibrotics and wound healing in glaucoma surgery. Surv Ophthalmol 2003;48:314-346.
3. Maquet JA, Dios E, Aragón J, et al. Protocol for mitomy- cin C use in glaucoma surgery. Acta Ophthalmol Scand 2005;83:196-200.
4. Storr-Paulsen T, Norregaard JC, Ahmed S, Storr-Paulsen A. Corneal endothelial cell loss after mitomycin C-augmented trabeculectomy. J Glaucoma 2008;17:654-657.
5. Salmon SE, Sartorelli AC. Cancer chemotherapy, in Katsung: Basic and Clinical Pharmacology, 4th edition. Norwalk: CT Appleton and Lange,1987:680–681.
6. Jampel HD: Effect of brief exposure to mitomyin C on vi- ability and proliferation of cultured human Tenon’s capsule fibroblast. Ophthalmology 1992;99:1471-1476.
7. Zacharia PT, Deppermann SR, Schuman JS. Ocular hypoto- ny after trabeculectomy with mitomycin C. Am J Ophthal- mol 1993;116:314-326.
8. Cohen JS, Novack GD, Li ZL: The role of mitomycin C treat- ment duration and previous intraocular surgery on the suc- cess of trabeculectomy surgery. J Glaucoma 1997;6:3-9.

9. Kim YY, Sexton RM, Shin DH, et al. Outcomes of primary phakic trabeculectomies without versus with 0.5-1-min- ute versus 3-5-minute mitomycin C. Am J Ophthalmol 1998;126:755–762.
10. Flynn WJ, Carlson DW, Bifano SL. Mitomycin trabecu- lectomy: the microsurgical sponge difference. J Glaucoma 1995;4:86-90.
11. Cordeiro MF, Constable PH, Alexander RA, et al. Effect of varying the mitomycin-C treatment area in glaucoma filtration surgery in the rabbit. Invest Ophthalmol Vis Sci 1997;38:1639-1646.
12. Hu CY, Matsuo H, Tomita G, et al. Clinical characteristics and leakage of functioning blebs after trabeculectomy with mitomycin-C in primary glaucoma patients. Ophthalmol- ogy 2003;110:345-352.
13. Sari A, Onol M, Ozdek S, et al. Effect of mitomycin C on ciliary body and intraocular pressure with various applica- tion depths: an experimental study. Clin Experiment Oph- thalmol 2005;33:169-175.
14. Mietz H. The toxicology of mitomycin C on the ciliary body. Curr Opin Ophthalmol1996;7:727-729.
15. Schraermeyer U, Diestelhorst M, Bieker A, et al. Morpho- logic proof of the toxicity of mitomycin C on the ciliary body in relation to different application methods. Graefes Arch Clin Exp Ophthalmol 1999;237:593-600.
16. Greenfield DS, Liebmann JM, Jee J, Ritch R. Late-onset bleb leaks after glaucoma filtering surgery. Arch Ophthal- mol 1998;116:443-447.
17. Soltau JB, Rothman RF, Budenz DL, et al. Risk factors for glaucoma filtering bleb infections. Arch Ophthalmol 2000;118:338-342.
18. Akarsu C., Önol M., Hasanreisoğlu B. İnce tenon ve konjonktivalı olgularda primer trabekülektominin uzun dö- nem sonuçları. Turkiye Klinikleri J Ophthalmol 2003;12:1- 8.