Trabeculectomy survival with and without intra-operative 5-fluorouracil application in an Asian population

The Outcomes of XEN Gel Stent Implantation: A Systematic Review and Meta-Analysis

Purpose

XEN gel stents are used for the treatment of open-angle glaucoma (OAG), including primary and secondary glaucoma that are uncontrolled by previous medical therapy and cases with previous failed surgery. Our aim was to systematically review of the clinical data of currently published ab-interno XEN gel stents with an emphasis on intraocular pressure (IOP), antiglaucoma medication outcomes, and safety profiles.

Methods

We analyzed all of the publications (MEDLINE, EMBASE, Cochrane Library) on the ab-interno XEN gel stent to evaluate the reduction in IOP and antiglaucoma medications following the procedure. The primary outcomes measured for the meta-analysis were reduction in IOP and anti-glaucoma medications. The secondary outcome were adverse events. For each study, we used a random effects analysis model to calculate the mean difference and 95% confidence intervals for the continuous results (reduction in IOP and antiglaucoma medications) using the inverse variance statistical method.

Results

Five hundred twenty-seven articles were checked and 56 studies were found to be relevant with a total of 4,410 eyes. There was a significant reduction in IOP as well as in the number of medications required in patients treated with ab-interno XEN implant either alone or combined with cataract surgery. This new treatment for various types of glaucoma reduced the IOP by 35% to a final average close to 15 mmHg. This reduction was accompanied by a decrease in the number of antiglaucoma medications in all the studies, approximately 2 classes of medication at the price of more needlings. The overall complete success rate was 21.0–70.8% after 2 years using strict criteria originally designed to record success rate in filtration surgery. The incidence of complications vision-threatening was low at <1%.

Conclusions

XEN gel stent was effective and safe for primary and secondary OAG. Further studies should be performed to investigate the impact of ethnicity on the success and failure rate after XEN implantation.

Outcomes of surgical bleb revision at a tertiary Singapore eye hospital

PURPOSE

To describe the outcomes of surgical bleb revisions from a tertiary glaucoma service in Singapore.

METHODS

One hundred and thirty-one eyes of 129 patients who underwent surgical bleb revisions at the Singapore National Eye Centre between 2007 and 2014 were included in the study. The indications for bleb revision were: bleb-related infection (BRI), early and late bleb leak, early and late overfiltration, and bleb dysesthesia. Regression analysis was applied to elucidate risk factors.

RESULTS

The mean age of the patients was 66 years, 62.6% were male, and 88.5% were Chinese. The majority of the eyes had primary glaucoma (79.4%). The mean interval from the initial trabeculectomy or phaco-trabeculectomy to the bleb revision was 58.8 months. The overall success rate was 69.5%. By Kaplan-Meier survival analysis, the overall cumulative success range fell from 78.6% to 49.1% over 10 years. Eyes with early bleb leak had lower surgical success compared to eyes with late bleb leak, early overfiltration and late overfiltration (P = 0.026, log-rank test). The IOP improved significantly post-operatively for eyes with BRI, early bleb leak, late bleb leak, early overfiltration and overfiltration (P < 0.05). Vision improved significantly in eyes with early overfiltration, but deteriorated in eyes with BRI (P < 0.05).

CONCLUSION

The overall success rate for surgical bleb revisions was good with complete resolution of the primary problem in the majority of cases. However, eyes with early bleb leak were less likely to have successful outcomes and should be monitored more closely post-operatively.

Comparison of Efficacy and Safety of XEN45 Implant Versus Trabeculectomy in Asian Eyes

PRCIS

Combined phacoemulsification and trabeculectomy is able to achieve greater reduction in intraocular pressure (IOP), higher rates of complete surgical success and fewer postoperative manipulations and visits compared with combined phacoemulsification and Xen implantation in glaucomatous eyes.

PURPOSE

Our study aims to compare and understand the differences between the efficacy and safety of XEN45 implantation and trabeculectomy in Asian eyes with glaucoma.

MATERIALS AND METHODS

This was a retrospective, single-center, comparative study of consecutive patients who underwent combined phacoemulsification and trabeculectomy (Phaco-Trab) from January 2013 to June 2014 and combined phacoemulsification and XEN45 implantation (Phaco-Xen) from May 2017 to September 2018 in a tertiary Ophthalmology center in Singapore. Outcome measures included IOP, number of anti-glaucoma eyedrops, success rate, factors leading to success/failure, number of postoperative interventions and visits required, and surgical complications.

RESULTS

A total of 137 eyes (91 Phaco-Trab, 46 Phaco-Xen) were included. Phaco-Trab group had greater mean IOP reduction at all time points beyond postoperative month (POM) 1 (mean difference 2.9 to 3.8 mm Hg; P<0.05), and greater reduction in mean number of antiglaucoma eyedrops beyond POM3, thought this was not statistically significant. At POM12, complete success was achieved in 83.5% in Phaco-Trab and 52.2% of Phaco-Xen group, respectively (P<0.001). There was no significant factor associated with surgical failure, other than the difference in surgical procedure. Phaco-Trab group required fewer number of postoperative interventions (P=0.009), with only a mean of 0.1 bleb interventions required per patient, versus 1.5 in Phaco-Xen group (P<0.001). Safety profiles in both groups were comparable, with no statistically significant difference in intraoperative/postoperative complications.

CONCLUSION

Phaco-Trab has significantly higher reduction in both IOP and number of antiglaucoma medications compared with Phaco-Xen group, with greater surgical success and fewer postoperative manipulations and visits. Safety profiles were comparable.

Learning from the past: Mitomycin C use in trabeculectomy and its application in bleb-forming minimally invasive glaucoma surgery

Trabeculectomy has been performed since the mid-1960s and remains the gold standard for glaucoma surgery. Newer surgical options have evolved, collectively referred to as minimally invasive glaucoma surgeries. Despite producing large intraocular pressure decreases, full-thickness procedures into the subconjunctival space may be limited by fibrosis. Mitomycin C (MMC) and 5-fluorouracil have been in use with trabeculectomy with good evidence of significantly increased success at the cost, however, of an increased risk of complications. Off-label MMC application can be found in almost all clinical trials, including in combination with minimally invasive glaucoma surgeries. We explore current evidence for MMC use in trabeculectomy and how this may differ for minimally invasive glaucoma surgery devices and analyze the range of agents and doses that are used. Although we found that most studies could not show any correlation between MMC dosage and the surgical outcome, the success rates with the Xen® microshunt seemed to be higher when using 20 mcg of MMC than when using 10 mcg. Certain important methodological considerations make this hard to confirm definitively, and other factors such as placement of the device may play a more substantial role. For the PreserFlo® microshunt, preliminary data suggest higher success rates with higher MMC dosage at the cost of higher device-related adverse events and reoperations. Although the ideal dose still needs to be established, it seems very likely that MMC provides significant improvement in outcomes in bleb-forming minimally invasive glaucoma procedures.

Two-year results of a multicenter study of the ab interno gelatin implant in medically uncontrolled primary open-angle glaucoma

PURPOSE

To evaluate the effectiveness of an ab interno subconjunctival gelatin implant as primary surgical intervention in reducing intraocular pressure (IOP) and IOP-lowering medication count in medically uncontrolled moderate primary open-angle glaucoma (POAG).

METHODS

In this prospective, non-randomized, open-label, multicenter, 2-year study, eyes with medicated baseline IOP 18-33 mmHg on 1-4 topical medications were implanted with (phaco + implant) or without (implant alone) phacoemulsification. Changes in mean IOP and medication count at months 12 (primary outcomes) and 24, clinical success rate (eyes [%] achieving ≥ 20% IOP reduction from baseline on the same or fewer medications without glaucoma-related secondary surgical intervention), intraoperative complications, and postoperative adverse events were assessed.

RESULTS

The modified intent-to-treat population included 202 eyes (of 218 implanted). Changes (standard deviation) in mean IOP and medication count from baseline were - 6.5 (5.3) mmHg and - 1.7 (1.3) at month 12 and - 6.2 (4.9) mmHg and - 1.5 (1.4) at month 24, respectively (all P < 0.001). Mean medicated baseline IOP was reduced from 21.4 (3.6) to 14.9 (4.5) mmHg at 12 months and 15.2 (4.2) mmHg at 24 months, with similar results in both treatment groups. The clinical success rate was 67.6% at 12 months and 65.8% at 24 months. Overall, 51.1 (12 months) and 44.7% (24 months) of eyes were medication-free. The implant safety profile compared favorably with that published for trabeculectomy and tube shunts.

CONCLUSIONS

The gelatin implant effectively reduced IOP and medication needs over 2 years in POAG uncontrolled medically, with an acceptable safety profile. ClinicalTrials.gov registration number: NCT02006693 (registered in the USA).

Time Heals All Wounds: Obstacles in Glaucoma Surgery from an Asian Perspective

Glaucoma is the leading cause of irreversible blindness worldwide and is a particular burden on the Asian population. Glaucoma surgeries such as trabeculectomy and glaucoma drainage implants are routinely performed to lower intraocular pressure (IOP) to prevent disease progression. However, scarring of the filtering bleb limits their long-term success and Asian eyes are more at risk. Although this is so, many existing studies have been done on Caucasian patients, but few have focused solely on Asian patients. Intraoperative anti-metabolites such as Mitomycin-C (MMC) and 5-Fluorouracil (5-FU) are the current mainstay of adjunctive treatments to reduce scarring, and in this review, we evaluate the evolution, benefits and side effects of these agents. Recently, newer methods of wound modulation including anti-vascular endothelial growth factor (VEGF) agents and collagen implants are also being investigated as part of a multi-pronged approach to tackle this problem. Some opportunities exist to limit scarring post-operatively, but it is an ongoing battle.

Complications and outcomes of primary phacotrabeculectomy with mitomycin C in a multi-ethnic asian population

PURPOSE

To determine the occurrence of intraoperative and postoperative complications up to three years after primary phacotrabeculectomy with intraoperative use of Mitomycin C (MMC) in primary open angle (POAG) and primary angle closure glaucoma (PACG) patients, and the effect of postoperative complications on surgical outcome.

METHODS

Retrospective review of 160 consecutive patients with POAG (n = 105) and PACG (n = 55), who underwent primary phacotrabeculectomy with MMC at the National University Hospital, Singapore, from January 1, 2008 to December 31, 2010. Data was collected using a standardized form that included patient demographic information, ocular characteristics and postoperative complications, including hypotony (defined as intraocular pressure < 6 mmHg), shallow anterior chamber (AC) and hyphema.

RESULTS

The mean age ± standard deviation (SD) of patients was 68.2 ± 8.2 years. No patient lost light perception during duration of follow-up. 77% of the postoperative complications occurred within the first month only. The commonest complications were hypotony (n = 41, 25.6%), hyphema (n = 16, 10.0%) and shallow AC (n = 16, 10.0%). Five patients (3.1%) required reoperation for their complications. Early hypotony (defined as hypotony < 30 days postoperatively) was an independent risk factor for surgical failure (hazard ratio [HR], 5.1; 95% CI, 1.6-16.2; p = 0.01). Hypotony with another complication was also a risk factor for surgical failure (p < 0.02).

CONCLUSIONS

Hypotony, hyphema and shallow AC were the commonest postoperative complications in POAG and PACG patients after phacotrabeculectomy with MMC. Most complications were transient and self-limiting. Early hypotony within the first month was a significant risk factor for surgical failure.

Efficacy and safety of collagen matrix implants in phacotrabeculectomy and comparison with mitomycin C augmented phacotrabeculectomy at 1 year

BACKGROUND

To assess the efficacy and safety of collagen matrix implant (Ologen) in phacotrabeculectomy.

DESIGN

Prospective, non-randomized, comparative study.

PARTICIPANTS

Sixty-six Asian patients.

METHODS

Thirty three consecutive patients underwent phacotrabeculectomy with Ologen implant and intraocular lens implantation, and 33 subjects recruited as controls underwent surgery with mitomycin C augmentation.

MAIN OUTCOME MEASURES

The primary outcome measure was postoperative intraocular pressure at month 12. Additional postoperative treatments, such as bleb needling, and adverse events were secondary outcomes.

RESULTS

The overall percentage reduction in intraocular pressure was 13% (95% confidence interval 6.7-19.2) in the Ologen group and 26% (95% confidence interval 14.8-37.9) in the mitomycin C group (P = 0.05). At 1 year after surgery (after adjusting for baseline differences), intraocular pressure decreased by 4.2 mmHg (95% confidence interval 2.8-5.6 mmHg) and 5.6 mmHg (95% confidence interval 4.2-7.0 mmHg), respectively (P = 0.16). Needling with 5-fluorouracil was required more often in the Ologen group (39% vs. 6%; P = 0.003). There was similar frequency (<10%) of adverse events in both groups, and there were no complications directly related to the Ologen implant. The blebs in the mitomycin C group had greater central area (P = 0.005), maximal area (P = 0.01) and height (P = 0.005), and were less vascular (P = 0.023) than the Ologen blebs.

CONCLUSIONS

At 1 year, the overall performance of Ologen in combined phacotrabeculectomy was suboptimal compared with combined surgery with mitomycin C. Eyes in the Ologen group required more frequent bleb needling procedures.

The singapore 5-Fluorouracil trabeculectomy study: effects on intraocular pressure control and disease progression at 3 years

PURPOSE

To report 3-year results of a randomized, controlled trial comparing the use of a single application of 5-fluorouracil (5-FU) with placebo in trabeculectomy surgery.

DESIGN

Prospective, randomized, double-blinded treatment trial.

PARTICIPANTS

Two hundred forty-three Asian patients with primary open-angle or primary angle-closure glaucoma undergoing primary trabeculectomy.

METHODS

One eye of each patient was randomized to receive either intraoperative 5-FU or normal saline (placebo) during trabeculectomy.

MAIN OUTCOME MEASURES

Primary outcome measure was the level of intraocular pressure (IOP). Secondary outcomes were progression of visual field loss, rates of adverse events, and interventions after surgery.

RESULTS

Of the 288 eligible patients, 243 were enrolled and 228 completed 3 years follow-up; 120 patients received 5-FU and 123 received placebo. Trial failure, according to predefined IOP criteria, was lower in the 5-FU group compared with the placebo group, although the difference was only significant with a failure criterion of IOP >17 mmHg (P = 0.0154). There was no significant difference in progression of optic disc and/or visual field loss over 36 months between 5-FU and placebo (relative risk [RR], 0.67; 95% confidence interval [CI], 0.34-1.31; P = 0.239). Uveitis occurred more often in the 5-FU-treated group (14/115 [12%] vs 5/120 [4%]; P = 0.032).

CONCLUSIONS

This is the first masked, prospective, randomized trial reporting the effect of adjunctive 5-FU in trabeculectomy surgery in an East Asian population. The trial shows that an increased success rate can be achieved for several years after a single intraoperative treatment with 5-FU. We conclude that 5-FU is relatively safe and can be routinely used in low-risk East Asian patients.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

Intermediate-term comparison of trabeculectomy with intraoperative mitomycin-C between Asian American and Caucasian glaucoma patients: a case-controlled comparison

PURPOSE

Compare the efficacy and survival of trabeculectomy with intraoperative mitomycin-C (MMC) between Asian American and Caucasian patients in the same clinical setting.

METHODS

In total, 29 Asian American patients (29 eyes) with trabeculectomies were matched case to case with 29 Caucasian patients (29 eyes) retrospectively. Matching criteria included age, glaucoma subtype, and preoperative intraocular pressure (IOP), gender, surgeon, ocular history, and glaucoma medications. Criteria of success included: (1) Final IOP>5 and <22 mmHg, (2) IOP reduction>or=20%, or final IOP<or=10 mmHg, and (3) without additional glaucoma surgery, loss of light perception, or complication.

RESULTS

Mean follow-up durations of Asian American and Caucasian group were 40.11+/-22.5 months and 38.8+/-17.7 months, respectively (P=0.81). At the final visits, IOP decreased from 18.7+/-6.1 to 10.9+/-4.0 mmHg (P<0.0001) in the Asian American group, and from 19.0+/-5.5 to 11.0+/-3.8 mmHg (P<0.0001) in the Caucasian group. There were no significant differences between the two groups in IOP levels at 6 months, 1 year, and final visits. The probabilities of trabeculectomy survival (continuing to meet definition of success criteria) at 12 and 48 months were 75.9 and 56.6% in the Asian American group and 82.8 and 66.6% in the Caucasian group, respectively. (P=0.46) There were no significant differences for rates of surgical success, failure, complication, vision decrease, hypotony, and cataract development. Patients who had episodes of hypotony had a higher rate of diagnosis of low-tension glaucoma subtype (P=0.02).

CONCLUSIONS

In a case-controlled comparison of an intermediate-term follow-up of trabeculectomy with intraoperative MMC, Asian American patients have a similar efficacy and survival probability as Caucasian patients.

What is the direct cost of treatment of acute primary angle closure glaucoma? The Singapore model

AIM

To estimate the cost of management of acute primary angle closure glaucoma in Singapore.

METHODS

In this cost analysis using retrospective data, the authors performed a MEDLINE search of published papers on acute primary angle closure glaucoma (APACG) in Singapore. Using information from published data, clinical management pathways were constructed and clinical outcomes identified. For each management path, costs of medical treatment, hospitalization, clinic charges, investigations, laser treatment and surgery were identified and accounted over a 5-year treatment period, using year 2002 rates.

RESULTS

Given that, in Singapore, APACG affects 12.2 per 100,000 per year (95% confidence interval [CI], 10.5-13.9) in those aged 30 and older, each annual cohort would need to pay 261,741.78 US dollars (95%CI: US$225 310.90-298 265.10) or 287,560.26 US dollars (95%CI: 247,274.04-330,624.84 US dollars), if inclusive of cataract surgery, over 5 years after the episode of APACG. In this period, individuals would have to commit between 879.45 US dollars and 2576.39 US dollars, depending on the complexity of disease and accompanying cataract surgery.

CONCLUSION

Acute primary angle closure glaucoma produces a substantial financial burden on society as well as on the individuals.

A review of trabeculectomy in East Asian people—the influence of race

Glaucoma is the leading cause of irreversible blindness worldwide. East Asians account for approximately half of all glaucoma sufferers. It is likely that trabeculectomy will be needed for many of these people as the intraocular pressure is to be maintained at a satisfactorily low level. The eyes of East Asian people differ in some aspects from those of other races. This review describes the natural history of the eye after trabeculectomy in East Asians.

Intermediate-term outcome of Baerveldt glaucoma implants in Asian eyes

PURPOSE

To determine the intermediate-term efficacy and safety of Baerveldt glaucoma implants in Asian eyes with complicated glaucoma.

DESIGN

Retrospective, nonrandomized, comparative trial.

PARTICIPANTS

One hundred twenty-four Asian patients (124 eyes) with complicated glaucoma.

INTERVENTION

Implantation of 54 250-mm(2) and 70 350-mm(2) Baerveldt glaucoma drainage implants at Singapore National Eye Center from 1994 through 1999.

MAIN OUTCOME MEASURES

Intraocular pressure, number of glaucoma medications, and complications.

RESULTS

The mean follow-up period was 33.4 +/- 14.4 months (mean +/- SD; range, 12-72 months). Intraocular pressure (IOP) was reduced from a mean preoperative IOP of 36.5 +/- 10.7 mmHg (range, 21-80 mmHg) to 15.3 +/- 6.0 mmHg (range, 1-34 mmHg), and the number of glaucoma medications decreased from 2.6 +/- 0.6 (range, 1-5) before the time of surgery to 0.5 +/- 0.9 (range, 0-4) medications at last follow-up. Overall, there were 67 eyes (54%) that were classified as complete successes, 27 eyes (22%) that were qualified successes, and 30 eyes that failed (24%). Postoperative complications occurred in 43 eyes (34.7%), and 21 eyes (17%) required further surgical intervention and revision. There was no statistically significant difference between the 250-mm(2) and 350-mm(2) type of implants in terms of success rates, final IOP, number of medications, and rates of complications. After adjusting for gender, preoperative IOP, and length of follow-up, increasing age (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.01-1.09; P = 0.02) and the number of previous operations performed before implant surgery (OR, 1.57; 95% CI, 1.07-2.31; P = 0.01) were found to be correlated positively with failure.

CONCLUSIONS

In Asian eyes with complicated glaucoma, Baerveldt glaucoma implants achieve stable and satisfactory IOP reduction with low incidence of complications in the intermediate term after surgery.

Fornix-based trabeculectomy using the 'anchoring' corneal suture technique

AIM

To assess the safety and efficacy of fornix-based tra-beculectomy with the 'anchoring' corneal suture technique in Chinese patients.

METHODS

A retrospective non-comparative case series of 66 eyes of 63 Chinese patients who underwent fornix-based trabeculectomy combined with intraoperative mitomycin C (MMC) 0.4 mg/mL for 2-5 min were studied. Conjunctival wound closure of all eyes was with the anchoring corneal suture technique using a 9-0 nylon suture to prevent leakage at the corneolimbal interface. The success rate, with or without anti-glaucoma medication, the complication rate and the longevity of the drainage blebs were analyzed.

RESULTS

At a mean follow-up period of 447.36 +/- 337.98 days, the mean intraocular pressure decreased from 26.83 +/- 7.90 mmHg to 17.74 +/- 8.74 mmHg (P < 0.001). The mean glaucoma medication decreased from 2.95 +/- 0.98 preoperatively to 1.23 +/- 1.41 postoperatively (P < 0.001). Thirty-one eyes (47.0%) required no anti-glaucoma medication postoperatively. Twenty eyes (30.3%) had qualified success postoperatively. Eight eyes (12.1%) had early wound leakage that resolved with conservative treatment. Three eyes (4.5%) required surgical repair. One eye (1.5%) had hypotonous maculopathy. No other major complications were encountered.

CONCLUSION

Fornix-based trabeculectomy with adjunctive mitomycin C employing the anchoring corneal suture technique appears to be both safe and effective in Chinese patients.

The efficacy and safety of intraoperative and/or postoperative 5-fluorouracil in trabeculectomy and phacotrabeculectomy

PURPOSE

First, to assess the safety and efficacy of using 5-fluorouracil (5-FU) to improve trabeculectomy and phacotrabeculectomy success rates, and second, to assess the efficacy of intraoperative and reduced postoperative 5-FU following trabeculectomy compared with a more intensive course of postoperative 5-FU alone.

METHODS

In a retrospective, unmatched, non-randomized consecutive series study, 186 eyes of 186 patients who had filtration surgery were followed for 2 years in four groups: 51 patients had undergone trabeculectomy surgery with postoperative 5-FU, 51 had phacotrabeculectomy with postoperative 5-FU, 56 had trabeculectomy with both intraoperative and postoperative 5-FU, and 28 patients had trabeculectomy without antifibrotics.

RESULTS

At all times mean intraocular pressure (IOP) was reduced n all groups (P < 0.001 for each group). Success was defined as IOP < 16 mmHg and > 30% IOP reduction at the 2-year follow up. It was achieved in 71% of the trabeculectomy patients with intraoperative and postoperative 5-FU, 76% of the trabeculectomy group with only postoperative 5-FU, 55% of the phacotrabeculectomy/5-FU group, and in 29% of the trabeculectomy-only eyes (between-group differences P < 0.01). Success rates were not significantly different for the intraoperative and postoperative 5-FU trabeculectomy versus the postoperative 5-FU-only eyes, but the former had fewer postoperative 5-FU injections and corneal ulceration (P < 0.01 for both).

CONCLUSIONS

5-Fluorouracil was safe and improved trabeculectomy survival. Intraoperative 5-FU allowed fewer postoperative 5-FU injections and fewer side-effects without compromising success rates. Phacotrabeculectomy with postoperative 5-FU had a lower surgical success rate than did trabeculectomy with 5-FU and this was not statistically different from trabeculectomy without 5-FU.

Low-dose 5-fluorouracil trabeculectomy as initial surgery in uncomplicated glaucoma: long-term followup

OBJECTIVE

To compare the effectiveness of trabeculectomy with adjunctive, low-dose, subconjunctival 5-fluorouracil (5-FU) to trabeculectomy alone in patients with uncomplicated glaucoma undergoing their first incisional surgical procedure.

DESIGN

Retrospective, nonrandomized comparative trial.

PARTICIPANTS

Consecutive series of 52 patients and 74 control subjects.

INTERVENTION

Trabeculectomy was performed in all patients. Study patients received adjunctive, subconjunctival injections of 5-FU up to 14 days from the date of surgery.

MAIN OUTCOME MEASURES

Intraocular pressure, number of postoperative antiglaucoma medications, interventions, and complications were evaluated.

RESULTS

Mean followup for all patients was 58.1 +/- 44.1 months (range, 1.1-159.9 months). Mean followup for successful eyes was 55.9 +/- 47.1 months (range, 7.6-159.9 months). The cumulative 5-year success (intraocular pressure [IOP] < or = 21 mmHg) was 77.8% in the 5-FU group and 62.2% in the control group (P = 0.02, Wilcoxon test. Complete success (IOP < or = 21 mmHg without medications) at 5 years was lower in both the 5-FU group (72.3%) and the control group (51.3%). Postoperative mean IOP at 5 years for all successful patients was lower in eyes receiving 5-FU (10.7 +/- 3.6 mmHg vs. 16.0 +/- 6.1 mmHg [P = 0.02, t-test]). For those patients considered to be complete successes, there was no difference in IOP between the two groups of patients at any evaluated time interval. Patients in the 5-FU group were using 0.7 +/- 1.1 medications at final followup compared with 1.8 +/- 1.4 medications in the control group (P = < 0.0001, t test). Bleb-related ocular infection occurred in 6.3% of patients and was more common in patients receiving 5-FU than controls (6 of 52 vs 2 of 74, respectively; P = 0.05, Fischer's exact test).

CONCLUSIONS

Adjunctive, low-dose 5-FU at the time of initial surgery in uncomplicated glaucoma improves long-term IOP control and reduces the need for postoperative, antiglaucoma therapy. Eyes receiving 5-FU are at greater risk of developing late bleb-related ocular infection.