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Antimetabolite can enhance needling after nonpenetrating glaucoma surgery
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MUNICH, Germany — Use of an antimetabolite before needling of a fibrotic filtering bleb can improve the chances of success of the intervention, according to a surgeon speaking here.
Ike Ahmed, MD, discussed the role of goniopuncture needling after nonpenetrating glaucoma surgery at a clinical research symposium at the European Society of Cataract and Refractive Surgeons meeting.
He said episcleral fibrosis is a frequent cause of bleb failure after nonpenetrating glaucoma surgery. Bleb encapsulation can be managed either medically or surgically via needling, he noted. The addition of an antimetabolite to the needling procedure can induce remission of fibroblast proliferation, he said.
Dr. Ahmed described a retrospective, consecutive case series in which he used bleb needling in 21 eyes of 19 patients who had undergone deep sclerectomy with collagen implant. Eight patients were treated with adjunctive 5-FU and 13 with adjunctive mitomycin. All patients underwent an initial Nd:YAG goniopuncture. Follow-up averaged 13.3 months.
In the needling procedure, 5-fluorouracil (5-FU) or mitomycin is injected into the bleb site approximately 7 mm posterior to the filtration site while the patient is under topical anesthesia. To allow absorption of antimetabolite in the bleb and prevent its penetration into the eye through the filtration site, the surgeon waits 15 to 30 minutes before the needling is performed.
The needle is inserted posteriorly through the bleb. Once the needle enters the area under the flap, a rise in the bleb can be detected, indicating that flow of aqueous has been restored.
Dr. Ahmed said needling the bleb will usually suffice, but it is sometimes necessary to enter the anterior chamber to restore filtration.
Dr. Ahmed said he prefers mitomycin because it is more potent than 5-FU. Studies have shown it can reduce the need for additional revisions due to postoperative elevated intraocular pressure, he said.
In his study, patients who received mitomycin required statistically significantly fewer subsequent needlings than patients treated with 5-FU. Mitomycin patients required 1.1 ± 0.3 reinterventions compared to 2.8 ± 0.8 in the 5-FU group.
Also, 77% of patients treated with mitomycin had IOPs lower than 18 mm Hg, compared to 50% of the 5-FU group, a difference that was also statistically significant, he said.