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Filter with antimetabolite more predictable than glaucoma tubes, surgeon says

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MIAMI — Filtering surgery with adjunctive antimetabolite leads to more predictably controlled intraocular pressure and better visual field outcomes than drainage devices in difficult glaucomas, according to a presentation here.

Paul F. Palmberg, MD, PhD, said drainage tubes may be preferable for certain uncommon glaucomas, such as epithelial downgrowth, active neovascular glaucoma and pediatric glaucoma. However, he noted that only trabeculectomy has been shown to halt glaucomatous damage, as highlighted in results of the Advanced Glaucoma Intervention Study (AGIS).

Dr. Palmberg spoke about the two surgical modalities here at Bascom Palmer Eye Institute’s Controversies in Glaucoma Management Battle on the Beach.

He noted that in the AGIS, patients with advanced glaucoma who had their IOPs lowered to 18 mm Hg or less had no net progression in their disease after 8 years.

“I have not yet seen any such evidence for tubes — that they can halt glaucomatous damage,” he said. “Maybe they could, but they would have to be used in primary cases in order to be compared.”

Dr. Palmberg also reviewed preliminary results of a prospective study he and colleagues are conducting. The study compares the results of primary trabeculectomy with either 5-fluorouracil or mitomycin-C (MMC) with a planned 10 year follow-up. Dr. Palmberg discussed 5-year results, which are available for 50% of the participants.

According to Dr. Palmberg, initial results in the Bascom Palmer study are similar to the results of the AGIS. Both the IOPs and the visual fields of patients have stabilized, and pattern deviation has not changed.

Dr. Palmberg acknowledged there are risks associated with antimetabolite use, but close scrutiny by the surgeon can markedly reduce the risk.

“Hypotony maculopathy, for example, can be reduced greatly by careful adjustment of the scleral flap resistance at the time of surgery,” he said. “You can’t do that with tubes. You have to take whatever that capsule gives you.”

Dr. Palmberg said the addition of MMC or 5-FU also helps increase the predictability of pressure outcomes after surgery.