The Efficacy of Adjunctive Mitomycin C And/or Anti-VEGF Agents on Glaucoma Tube Shunt Drainage Device Surgeries: a Systematic Review

Overview

Journal Graefes Arch Clin Exp Ophthalmol

Specialty Ophthalmology

Date 2024 Apr 24

PMID 38656422

Authors

Raquel Figueiredo

Joao Barbosa-Breda

Affiliations

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Abstract

Purpose: The effectiveness of mitomycin C (MMC) in trabeculectomy has long been established. The aim of this review is to evaluate the efficacy and safety of adjunctive agents in tube shunt drainage device surgery for glaucoma or ocular hypertension, since controversy still exists regarding their benefit.

Methods: We searched CENTRAL, PubMed, Embase, Web of Science, Scopus, and BASE for RCTs, which have used adjuvant antimetabolites-either MMC or 5-Fluorouracil (5-FU)-and/or anti-vascular endothelial growth factors (anti-VEGF) agents. The main outcome was IOP reduction at 12 months.

Results: Ten studies met our inclusion criteria. Nine used the Ahmed Glaucoma Valve (AGV) implant, while the double-plate Molteno implant was used in one study. Four studies used MMC. The remaining six studies used an anti-VEGF drug - either bevacizumab, ranibizumab or conbercept. Only one MMC-study reported a significant difference in the IOP reduction between groups at 12 months, favouring the MMC group (55% and 51%; p < 0.01). A significant difference was also reported by two out of five bevacizumab-studies, both favouring the bevacizumab group (55% and 51%, p < 0.05; 58% and 27%, p < 0.05), with the highest benefit seen in neovascular glaucoma cases, especially when panretinal photocoagulation (PRP) was also used. Neither ranibizumab nor conbercept were found to produce significant differences between groups regarding IOP reduction.

Conclusion: There is no high-quality evidence to support the use of MMC in tube shunt surgery. As for anti-VEGF agents, specifically bevacizumab, significant benefit seems to exist in neovascular glaucoma patients, especially if combined with PRP.

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References

Slabaugh M, Salim S . Use of Anti-VEGF Agents in Glaucoma Surgery. J Ophthalmol. 2017; 2017:1645269. PMC: 5549503. DOI: 10.1155/2017/1645269. View

Inatani M, Kohama I, Chu A . iStent Trabecular Micro-bypass Stent Implantation Combined with Phacoemulsification for Open-Angle Glaucoma: A 2-Year Post-marketing Surveillance Study in Japan. Adv Ther. 2022; 39(9):4076-4093. PMC: 9402767. DOI: 10.1007/s12325-022-02207-0. View

Foo V, Htoon H, Welsbie D, Perera S . Aqueous shunts with mitomycin C versus aqueous shunts alone for glaucoma. Cochrane Database Syst Rev. 2019; 4:CD011875. PMC: 6472957. DOI: 10.1002/14651858.CD011875.pub2. View

Al-Mobarak F, Khan A . Two-year survival of Ahmed valve implantation in the first 2 years of life with and without intraoperative mitomycin-C. Ophthalmology. 2009; 116(10):1862-5. DOI: 10.1016/j.ophtha.2009.03.030. View

Kwon J, Sung K . Effect of Preoperative Intravitreal Bevacizumab on the Surgical Outcome of Neovascular Glaucoma at Different Stages. J Ophthalmol. 2017; 2017:7672485. PMC: 5496122. DOI: 10.1155/2017/7672485. View

Arcieri E, Paula J, Jorge R, Barella K, Arcieri R, Secches D . Efficacy and safety of intravitreal bevacizumab in eyes with neovascular glaucoma undergoing Ahmed glaucoma valve implantation: 2-year follow-up. Acta Ophthalmol. 2014; 93(1):e1-6. DOI: 10.1111/aos.12493. View

Costa V, Azuara-Blanco A, Netland P, Lesk M, Arcieri E . Efficacy and safety of adjunctive mitomycin C during Ahmed Glaucoma Valve implantation: a prospective randomized clinical trial. Ophthalmology. 2004; 111(6):1071-6. DOI: 10.1016/j.ophtha.2003.09.037. View

Sterne J, Savovic J, Page M, Elbers R, Blencowe N, Boutron I . RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019; 366:l4898. DOI: 10.1136/bmj.l4898. View

Addicks E, Quigley H, Green W, Robin A . Histologic characteristics of filtering blebs in glaucomatous eyes. Arch Ophthalmol. 1983; 101(5):795-8. DOI: 10.1001/archopht.1983.01040010795021. View

10.

Mahdy R, Nada W, Fawzy K, Alnashar H, Almosalamy S . Efficacy of intravitreal bevacizumab with panretinal photocoagulation followed by Ahmed valve implantation in neovascular glaucoma. J Glaucoma. 2012; 22(9):768-72. DOI: 10.1097/IJG.0b013e318259aec4. View

11.

Yazdani S, Mahboobipour H, Pakravan M, Doozandeh A, Ghahari E . Adjunctive Mitomycin C or Amniotic Membrane Transplantation for Ahmed Glaucoma Valve Implantation: A Randomized Clinical Trial. J Glaucoma. 2015; 25(5):415-21. DOI: 10.1097/IJG.0000000000000256. View

12.

Ayyala R, Duarte J, Sahiner N . Glaucoma drainage devices: state of the art. Expert Rev Med Devices. 2006; 3(4):509-21. DOI: 10.1586/17434440.3.4.509. View

13.

Pereira I, van de Wijdeven R, Wyss H, Beckers H, den Toonder J . Conventional glaucoma implants and the new MIGS devices: a comprehensive review of current options and future directions. Eye (Lond). 2021; 35(12):3202-3221. PMC: 8602385. DOI: 10.1038/s41433-021-01595-x. View

14.

Zhang X, Du S, Fan Q, Peng S, Yu M, Ge J . Long-term surgical outcomes of primary congenital glaucoma in China. Clinics (Sao Paulo). 2009; 64(6):543-51. PMC: 2705148. DOI: 10.1590/s1807-59322009000600009. View

15.

Tan M, Choy H, Koh Teck Chang V, Aquino M, Sng C, Lim D . Two-Year Outcomes of the Paul Glaucoma Implant for Treatment of Glaucoma. J Glaucoma. 2022; 31(6):449-455. PMC: 9148669. DOI: 10.1097/IJG.0000000000001998. View

16.

Miraftabi A, Nilforushan N, Darghahi M, Alemzadeh S, Parsamanesh M, Yadgari M . Effect of subconjunctival Bevacizumab injection on the outcome of Ahmed glaucoma valve implantation: a randomized control trial. Clin Exp Ophthalmol. 2018; 46(7):750-756. DOI: 10.1111/ceo.13191. View

17.

Gedde S, Feuer W, Lim K, Barton K, Goyal S, Ahmed I . Treatment Outcomes in the Primary Tube Versus Trabeculectomy Study after 3 Years of Follow-up. Ophthalmology. 2019; 127(3):333-345. DOI: 10.1016/j.ophtha.2019.10.002. View

18.

Cantor L, Burgoyne J, Sanders S, Bhavnani V, Hoop J, Brizendine E . The effect of mitomycin C on Molteno implant surgery: a 1-year randomized, masked, prospective study. J Glaucoma. 1998; 7(4):240-6. View

19.

Mahdy R . Adjunctive use of bevacizumab versus mitomycin C with Ahmed valve implantation in treatment of pediatric glaucoma. J Glaucoma. 2010; 20(7):458-63. DOI: 10.1097/IJG.0b013e3181efbea5. View

20.

Bailey A, Sarkisian Jr S . Complications of tube implants and their management. Curr Opin Ophthalmol. 2014; 25(2):148-53. DOI: 10.1097/ICU.0000000000000034. View