Trabeculectomy bleb needling and antimetabolite administration practices in the UK: a glaucoma specialist national survey

Mercieca, Karl; Drury, Brett; Bhargava, Archana; Fenerty, Cecilia

doi:10.1136/bjophthalmol-2017-310812

Cited by 17 publications

(21 citation statements)

References 19 publications

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“…17 Mercieca K et al performed a cross-sectional online survey distributed to glaucoma specialists in United Kingdom, they reported bleb needling was performed in the operating room by 56 % of responders. 25 In our study, although we performed this procedure at the slit lamp in all cases, there were no major visual threatening complications found. Needling revision is a safe and simple method which can rescue failing blebs.…”

Section: Discussionmentioning

confidence: 55%

Bleb needling revision with 5-fluorouracil in filtering blebs with chronic failure for over 6 months post-trabeculectomy: a 12-month prospective study

Yodmuang¹

2019

EyeSEA

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Purpose: To evaluate the results of bleb needling revision with adjunctive 5-fluorouracil (5-FU) in chronic filtering bleb failure over 6 months post-trabeculectomy. Method: A prospective study of failed trabeculectomies in a glaucoma clinic between November 2017 and April 2019 were treated with bleb needling revision with 5-FU injection by the same glaucoma specialist and technique. A 27 gauge needle was used to achieve multiple punctures of subconjunctival fibrosis or encystment to attempted elevation of the scleral flap. In all cases, 0.1 ml of 50 mg/ml of 5-FU was then injected subconjunctivally superior to the reformed bleb, and topical prednisolone acetate and moxifloxacin were prescribed. Success was defined as target IOP achieved and maintained less than 21 mmHg without anti-glaucoma medication at 12 months after first needling. Patients were followed up and re-needled as required. Results: Needling was attempted on 51 eyes (30 eyes of POAG, 18 eyes of PACG and 3 eyes of secondary glaucoma). The mean number of needling procedures was 1.88 (range 1-10). Needling was successful in 41 (80.4 %) eyes. The average pre-needling IOP was 24.8 ± 12.6 mmHg and the average post needling IOP was 13.5 ± 7.4 mmHg (P < 0.001) at 12 months after first needling. The mean number of medications pre-needling was 2.6 ± 1.4 and post-needing was 0.3 ± 0.5 (P < 0.001). The mean time post trabeculectomy was 68 months (range 6-120 months). Prognostic factors for failure of needling revision was pre-needling IOP > 25 mmHg (HR = 3.1, P = 0.0003), needling revision ≥ 3 times (HR = 2.6, P = 0.0012) and history of repeated filtration surgery before performed this procedure (HR = 1.8, P = 0.011). Ten eyes (19.6 %) did not respond to needling; 6 eyes of POAG, 3 eyes of PACG and and 1 eye of secondary glaucoma which required revised trabeculectomy, glaucoma drainage device implantation and anti-glaucoma medication. Three eyes had complications; 2 hyphema and 1 hypotony and no other procedures were required. Conclusion: Late bleb needling revision with 5-FU injection is still an effective and lasting treatment for the majority of failed trabeculectomy and avoid further surgery included Thai patients. More than one needling is frequently necessary to achieve target IOP. The procedure is relatively safe, with a short operating time and is minimally invasive with less complications.

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Section: Discussionmentioning

confidence: 55%

Bleb needling revision with 5-fluorouracil in filtering blebs with chronic failure for over 6 months post-trabeculectomy: a 12-month prospective study

Yodmuang¹

2019

EyeSEA

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“…Different studies have used MMC at doses ranging from 0.004 mg (Mardelli et al, 1996) to 0.04 mg (Shetty et al, 2005). 5‐FU is mostly used at doses of 5 mg but doses up to 25 mg have been reported (Mercieca et al, 2018). Preoperative risk assessment has been recommended to serve as a guide to the approximate dose necessary to achieve surgical success but can be adjusted according to the clinical response (Lama & Fechtner, 2003).…”

Section: Discussionmentioning

confidence: 99%

“…Studies have shown that 20%–25% of patients with failed filtering blebs after trabeculectomy required needling with MMC and 5‐FU, respectively (Gutierrez‐Ortiz et al, 2006; King et al, 2007). In a survey completed by 60 glaucoma specialists, 72% preferred 5‐FU and 22% preferred MMC in needling with 12% using either of the two drugs interchangeably (Mercieca et al, 2018). The decision includes the previous needling experience of the glaucoma surgeon, presence of risk factors for failure, the level of intraocular pressure, an assessment of bleb morphology and behaviour of the bleb following trabeculectomy (Labbé & Baudouin, 2014; Mercieca et al, 2018).…”

Section: Discussionmentioning

confidence: 99%

“…In a survey completed by 60 glaucoma specialists, 72% preferred 5‐FU and 22% preferred MMC in needling with 12% using either of the two drugs interchangeably (Mercieca et al, 2018). The decision includes the previous needling experience of the glaucoma surgeon, presence of risk factors for failure, the level of intraocular pressure, an assessment of bleb morphology and behaviour of the bleb following trabeculectomy (Labbé & Baudouin, 2014; Mercieca et al, 2018). In three of the included studies, choice of anti‐metabolite was assigned to the experience and preference of the treating surgeon (Fagerli et al, 2003; Palejwala et al, 2010; Kim et al, 2019).…”

Section: Discussionmentioning

confidence: 99%

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Needling after trabeculectomy ‐ does augmentation by anti‐metabolites provide better outcomes and is Mitomycin C better than 5‐Fluoruracil? A systematic review with network meta‐analyses

Halili

Kessel

Subhi

et al. 2020

Acta Ophthalmologica

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Purpose. Favourable outcome after glaucoma surgery depends on proper control of the inflammatory response. Failing filtration bleb and consequently increased intraocular pressure is an important cause of continuous visual field deterioration after uncomplicated glaucoma surgery. The present systematic review and metaanalysis aimed to compare the effects of employing either Mitomycin C (MMC), 5-Fluoruracil (5-FU) or no anti-metabolite in needling revision of trabeculectomies. Methods. We performed a systematic literature search in PubMed, Cochrane and EMBASE to identify randomized and non-randomized trials published between year 2000 and March 2019 comparing the efficacy of needling filtering blebs when using no anti-fibrotic agent, MMC or 5-FU in patients with glaucoma. Efficacy was defined as intraocular pressure at 12 months or latest follow-up, rate of complications, rates of success and the number of re-needling cases. Comparisons were made using network meta-analyses. Results. We identified one randomized trial and five retrospective trials. Twelve months after needling revision of trabeculectomy, no significant difference was observed when comparing the effect of the use of MMC with 5-FU or without any use of anti-metabolite on intraocular pressure, complication rates, qualified success, complete success or number of re-needling cases. Conclusion. We found no significant difference in the efficacy of using either MMC, 5-FU or no anti-metabolite in needling revision of trabeculectomies. The number of studies meeting our inclusion criteria was limited. Considering the design of studies, only one was randomized leading to an overall low quality of evidence on the subject matter. Further research is warranted.

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“…Tai et al 26 evaluated the shortterm outcomes of NR in a cohort of 58 patients randomized to MMC alone or in association with bevacizumab and found no difference regarding success rates and IOP control, despite a better bleb morphology in the association group. 9,10,17,22 In this study, we retrospectively reviewed the long-term efficacy and safety of office-based NR augmented with 5-FU or betamethasone for impending bleb failure in a large cohort of patients who had previously undergone trabeculectomy or phacotrabeculectomy. In our cohort of patients, NR had a favorable profile in terms of efficacy and safety.…”

Section: Discussionmentioning

confidence: 99%

Needle revision outcomes after glaucoma filtering surgery: survival analysis and predictive factors

Rabiolo

Marchese

Bettin

et al. 2019

European Journal of Ophthalmology

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Purpose: To evaluate the efficacy and safety of needle revision and examine factors predictive of failure. Methods: In total, 157 eyes of 131 patients that underwent needle revision augmented with either 5-fluorouracil or betamethasone for trabeculectomy failure were included in this retrospective study. Complete failure was defined as additional glaucoma surgery, ciliodestructive procedures, loss of light perception, sight-threatening complications, hypotony maculopathy, and surgical bleb revision. Success was defined as intraocular pressure ⩽ 18 (criterion A), ⩽15 (criterion B), and ⩽12 mmHg (criterion C) reached with (qualified) or without (complete) medications, and absence of any criteria of complete failure. Results: The median (interquartile range) follow-up was 25.0 (41.0) months. Complete failure rates were 19%, 26%, and 31% at 1, 2, and 3 years, respectively. For criterion A, qualified and complete success rates were, respectively, 77% and 69% at 1 year, 66% and 51% at 2 years, and 60% and 47% at 3 years. For criterion B, qualified and complete success rates were, respectively, 67% and 61% at 1 year, 48% and 42% at 2 years, and 44% and 39% at 3 years. For criterion C, qualified and complete success rates were, respectively, 43% and 41% at 1 year, 27% and 25% at 2 years, and 24% and 23% at 3 years. High baseline intraocular pressure and primary surgery were associated with higher and lower risks of complete failure, respectively. Conclusion: Needle revision is an effective and safe procedure to rescue failing trabeculectomy postponing or avoiding further glaucoma surgery. Eyes with low target intraocular pressure may have poor long-term outcomes.

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Trabeculectomy bleb needling and antimetabolite administration practices in the UK: a glaucoma specialist national survey

Cited by 17 publications

References 19 publications

Bleb needling revision with 5-fluorouracil in filtering blebs with chronic failure for over 6 months post-trabeculectomy: a 12-month prospective study

Bleb needling revision with 5-fluorouracil in filtering blebs with chronic failure for over 6 months post-trabeculectomy: a 12-month prospective study

Needling after trabeculectomy ‐ does augmentation by anti‐metabolites provide better outcomes and is Mitomycin C better than 5‐Fluoruracil? A systematic review with network meta‐analyses

Needle revision outcomes after glaucoma filtering surgery: survival analysis and predictive factors

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