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M. Banitt, V. Chopra, M.S. Juzych, B.A. Hughes, C. Kim; Long-term Efficacy of Early vs. Late Scleral Flap Suture Release after Phaco-trabeculectomy with and without Adjunctive Mitomycin C . Invest. Ophthalmol. Vis. Sci. 2003;44(13):3300.
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Purpose: To investigate the timing of suture release (early vs. late) and use of adjunctive mitomycin C (MMC) on the long-term success of phaco-trabeculectomy. Methods: Retrospective chart review of 211 consecutive patients (264 eyes) who underwent primary phaco-trabeculectomy with subsequent manual or laser suture release with a minimum follow-up of 12 months. All procedures included a fornix-based conjunctival flap with 2 releasable scleral flap sutures, and phacoemulsification with posterior chamber intraocular lens implantation. Adjunctive intraoperative, subconjunctival mitomycin C was used in 163 eyes for a duration of 1-5 minutes. One hundred forty eyes underwent early suture release (in the first 3 postop weeks) and 124 eyes had late suture release (after the 3rd postop week). Long-term qualified success criterion was defined as IOP less than 18 mmHg without additional surgery. Pure success criterion was the same as qualified criterion without any glaucoma medications. Results: Mean follow-up time was 46.0±7.3 months with 83% patient retention. Adjunctive MMC improved the long-term success rate in African-American patients (p=0.01), but did not affect the outcome in the Caucasian group (p=0.56). Patients with MMC use had significantly higher immediate (<1 hour) IOP reduction with suture release in both groups (early p=0.004; late p=0.02). Median time to suture release in the early group was 8 days, in the late group 39 days. The immediate percent IOP reductions from suture release during the first week, from 1 to 3 weeks, from 3 to 6 weeks, and after 6 weeks were 53%, 45%, 30%, and 26% respectively. Late suture release had a significantly higher long-term success rate than early suture release at 4 years (qualified p=0.001, 81% success late vs. 63% early group; pure p=0.0002, 29% success late vs. 16% early group). There was no significant difference in method of suture release in long-term success rate (p=0.80). Of the 13 cases of hypotony which received MMC, 6 required air/healon injection to reform the anterior chamber and 2 required surgical drainage of choroidal detachments. Eleven of 13 cases were in the early group. Conclusions: Four-year success rate was greater in patients who underwent late scleral flap suture release. MMC increased the amount of immediate reduction of IOP after suture release. There was higher risk of postop complications with early suture release and use of MMC. Increasing the time interval between surgery and suture release resulted in better long-term success and decreases the risk of complications.
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