Comparison of Methods to Deliver Mitomycin C in Trabeculectomy Surgery: a Systematic Review and Meta-analysis

Purpose: Compare different methods to deliver Mitomycin C (MMC) in trabeculectomy surgery.

Clinical relevance: Knowing the best way to apply MMC may provide guidance to glaucoma surgeons and improve outcomes.

Methods: Systematic review and meta-analysis (PROSPERO CRD42023394371) for studies comparing ≥2 methods to apply MMC in trabeculectomy published until February 22, 2023, from Medline, EMBASE, and CENTRAL. Randomized clinical trials (RCTs), quasi-randomized, and prospective non-randomized controlled studies published in English and conducted on human subjects were included. The primary outcome was surgical failure at one year. Secondary outcomes included intraocular pressure (IOP), number of glaucoma medications, postoperative complications, and interventions. Risk of bias was assessed with ROB2.0 and ROBINS-I tools. A random-effects meta-analysis was conducted for ≥3 studies, while a fixed-effect model was used for two studies. The certainty of evidence was assessed with GRADE score.

Results: From 7,899 records, eight articles from seven RCTs compared intraoperative sub-Tenon MMC injection (315 participants) and intraoperative MMC-soaked sponges (327 participants). One RCT and one quasi-randomized study compared postoperative (60 participants) and intraoperative (60 participants) MMC-soaked sponges application. In the injection vs sponges comparison, no significant difference in surgical failure (relative risk [RR]: 0.78, 95% confidence interval [CI]: 0.48, 1.28; p=0.33, GRADE score moderate) or IOP (mean difference [MD]: -0.85 mmHg, 95%CI: -2.19, 0.49; p=0.21, GRADE score moderate) was found at one year. Sub-Tenon injection resulted in fewer postoperative medications (MD: -0.40, 95%CI: -0.63, -0.18; p<0.001; GRADE score moderate) and better bleb morphology (GRADE score high) in terms of height (MD: -0.39, 95%CI: -0.61, -0.18; p<0.001), extension (MD: 0.28, 95%CI: 0.11, 0.45; p=0.001), and vascularity (MD: -0.52, 95%CI: -0.72, -0.31; p<0.001) than sponges. Serious complication and reintervention rates were low and comparable between groups. We did not perform a meta-analysis comparing postoperative and intraoperative sponge application due to heterogeneity in the study designs of the included studies.

Conclusions: Intraoperative sub-Tenon MMC injection is non-inferior to intraoperative MMC-soaked sponges in trabeculectomy surgery in terms of surgical failure and IOP control, with reduced number of medications, improved bleb morphology, and similar safety profile. Further research with long-term follow-up is necessary to confirm their long-term equivalence.

*Author(s): ALESSANDRO GHIRARDI, SIQI FAN, KARL MERCIECA, GIANNI VIRGILI , STEFANO DE CILLA' , ALESSANDRO RABIOLO.

Doi: 10.1016/j.ogla.2025.04.004

Link: https://www.sciencedirect.com/science/article/abs/pii/S2589419625000729

Clinical Paper of the Month manager: Rafael Correia Barão

Editors in Chief: Francesco Oddone, Manuele Michelessi