Purpose: To evaluate the long-term outcome of trabeculectomy with intra- and postoperative 5-fluorouracil (5-FU) application in glaucoma. Methods: Eighty-six patients with glaucoma planned for primary trabeculectomy with 5-FU and a minimum follow-up of 3 years were retrospectively analyzed. Success rates, postsurgical 5-FU injections, needling procedures, and complications were analyzed. Results: Mean intraocular pressure (IOP) decreased from 27.2 ± 6.7 to 13.2 ± 4.2 mm Hg at 1 year and 13.8 ± 3.7 mm Hg at the 3-year follow-up. The complete success rates (no IOP-lowering medication) were 83, 79, 73, and 45% at 1 year for IOP ≤21, ≤18, ≤16, and ≤12 mm Hg, respectively, and 64, 59, 56, and 20% for these criteria at 3 years. The average number of medications decreased from preoperatively 2.9 ± 1.4 to 0.2 ± 0.5 at 1 year and 0.7 ± 1.1 at 3 years. During the first 6 months, subconjunctival 5-FU injections were performed in 49 cases. Eleven patients underwent bleb needling during the first 6 months and 13 patients underwent the procedure between the 6th month and the 3rd year. Malignant glaucoma and bleb-related endophthalmitis occurred in 1 patient each. Conclusions: Trabeculectomy with 5-FU is an efficient surgical procedure for glaucoma treatment when combined with intensified postsurgical care.

Keywords:
Trabeculectomy, 5-Fluorouracil, Long-term results, Antifibrotics
1.
Cairns JE: Trabeculectomy. Preliminary report of a new method. Am J Ophthalmol 1968;66:673-679.
2.
Chen CW, Huang HT, Bair JS, Lee CC: Trabeculectomy with simultaneous topical application of mitomycin-C in refractory glaucoma. J Ocul Pharmacol 1990;6:175-182.
3.
Heuer DK, Parrish RK, Gressel MG, Hodapp E, Palmberg PF, Anderson DR: 5-fluorouracil and glaucoma filtering surgery. II. A pilot study. Ophthalmology 1984;91:384-394.
4.
Reibaldi A, Uva MG, Longo A: Nine-year follow-up of trabeculectomy with or without low-dosage mitomycin-c in primary open-angle glaucoma. Br J Ophthalmol 2008;92:1666-1670.
5.
The Fluorouracil Filtering Surgery Study Group: Five-year follow-up of the Fluorouracil Filtering Surgery Study. Am J Ophthalmol 1996;121:349-366.
6.
Smith S, D'Amore PA, Dreyer EB: Comparative toxicity of mitomycin C and 5-fluorouracil in vitro. Am J Ophthalmol 1994;118:332-337.
7.
Khaw PT, Sherwood MB, Doyle JW, Smith MF, Grierson I, McGorray S, et al: Intraoperative and post operative treatment with 5-fluorouracil and mitomycin-c: long term effects in vivo on subconjunctival and scleral fibroblasts. Int Ophthalmol 1992;16:381-385.
8.
Khaw PT, Doyle JW, Sherwood MB, Grierson I, Schultz G, McGorray S: Prolonged localized tissue effects from 5-min exposures to fluorouracil and mitomycin C. Arch Ophthalmol 1993;111:263-267.
9.
Koutsonas A, Remky A, Plange N: Long-term results after trabeculectomy with 5-fluorouracil (in German). Ophthalmologe 2014;111:749-756.
10.
Picht G, Grehn F: Classification of filtering blebs in trabeculectomy: biomicroscopy and functionality. Curr Opin Ophthalmol 1998;9:2-8.
11.
Picht G, Grehn F: Development of the filtering bleb after trabeculectomy. Classification, histopathology, wound healing process (in German). Ophthalmologe 1998;95:W380-W387.
12.
Edmunds B, Thompson JR, Salmon JF, Wormald RP: The National Survey of Trabeculectomy. II. Variations in operative technique and outcome. Eye (Lond) 2001;15:441-448.
13.
Siriwardena D, Edmunds B, Wormald RPL, Khaw PT: National survey of antimetabolite use in glaucoma surgery in the United Kingdom. Br J Ophthalmol 2004;88:873-876.
14.
Chen PP, Yamamoto T, Sawada A, Parrish RK, Kitazawa Y: Use of antifibrosis agents and glaucoma drainage devices in the American and Japanese Glaucoma Societies. J Glaucoma 1997;6:192-196.
15.
Joshi AB, Parrish RK, Feuer WF: 2002 survey of the American Glaucoma Society: practice preferences for glaucoma surgery and antifibrotic use. J Glaucoma 2005;14:172-174.
16.
Kirwan JF, Lockwood AJ, Shah P, Macleod A, Broadway DC, King AJ, et al: Trabeculectomy in the 21st century: a multicenter analysis. Ophthalmology 2013;120:2532-2539.
17.
Singh K, Mehta K, Shaikh NM, Tsai JC, Moster MR, Budenz DL, et al: Trabeculectomy with intraoperative mitomycin C versus 5-fluorouracil. Prospective randomized clinical trial. Ophthalmology 2000;107:2305-2309.
18.
Smith MF, Doyle JW, Nguyen QH, Sherwood MB: Results of intraoperative 5-fluorouracil or lower dose mitomycin-C administration on initial trabeculectomy surgery. J Glaucoma 1997;6:104-110.
19.
WuDunn D, Cantor LB, Palanca-Capistrano AM, Hoop J, Alvi NP, Finley C, et al: A prospective randomized trial comparing intraoperative 5-fluorouracil vs mitomycin C in primary trabeculectomy. Am J Ophthalmol 2002;134:521-528.
20.
Palanca-Capistrano AM, Hall J, Cantor LB, Morgan L, Hoop J, WuDunn D: Long-term outcomes of intraoperative 5-fluorouracil versus intraoperative mitomycin C in primary trabeculectomy surgery. Ophthalmology 2009;116:185-190.
21.
Rothman RF, Liebmann JM, Ritch R: Low-dose 5-fluorouracil trabeculectomy as initial surgery in uncomplicated glaucoma: long-term followup. Ophthalmology 2000;107:1184-1190.
22.
Katz GJ, Higginbotham EJ, Lichter PR, Skuta GL, Musch DC, Bergstrom TJ, et al: Mitomycin C versus 5-fluorouracil in high-risk glaucoma filtering surgery. Extended follow-up. Ophthalmology 1995;102:1263-1269.
23.
Kim HY, Egbert PR, Singh K: Long-term comparison of primary trabeculectomy with 5-fluorouracil versus mitomycin C in West Africa. J Glaucoma 2008;17:578-583.
24.
Lamping KA, Belkin JK: 5-Fluorouracil and mitomycin C in pseudophakic patients. Ophthalmology 1995;102:70-75.
25.
Kitazawa Y, Kawase K, Matsushita H, Minobe M: Trabeculectomy with mitomycin. A comparative study with fluorouracil. Arch Ophthalmol 1991;109:1693-1698.
26.
Anand N, Dawda VK: A comparative study of mitomycin C and 5-Fluorouracil trabeculectomy in West Africa. Middle East Afr J Ophthalmol 2012;19:147-152.
27.
Jampel HD, Solus JF, Tracey PA, Gilbert DL, Loyd TL, Jefferys JL, et al: Outcomes and bleb-related complications of trabeculectomy. Ophthalmology 2012;119:712-722.
28.
Ehrnrooth P, Lehto I, Puska P, Laatikainen L: Long-term outcome of trabeculectomy in terms of intraocular pressure. Acta Ophthalmol Scand 2002;80:267-271.
29.
Molteno AC, Bosma NJ, Kittelson JM: Otago glaucoma surgery outcome study: long-term results of trabeculectomy - 1976 to 1995. Ophthalmology 1999;106:1742-1750.
30.
Tsai JC, Feuer WJ, Parrish RK, Grajewski AL: 5-Fluorouracil filtering surgery and neovascular glaucoma. Long-term follow-up of the original pilot study. Ophthalmology 1995;102:887-892; discussion 892-893.
31.
Gedde SJ, Schiffman JC, Feuer WJ, Herndon LW, Brandt JD, Budenz DL; Tube Versus Trabeculectomy Study Group: Treatment outcomes in the Tube Versus Trabeculectomy (TVT) study after five years of follow-up. Am J Ophthalmol 2012;153:789-803.e2.
32.
Seah SK, Prata JA, Minckler DS, Baerveldt G, Lee PP, Heuer DK: Hypotony following trabeculectomy. J Glaucoma 1995;4:73-79.
33.
Greenfield DS, Liebmann JM, Jee J, Ritch R: Late-onset bleb leaks after glaucoma filtering surgery. Arch Ophthalmol 1998;116:443-447.
34.
Lama PJ, Fechtner RD: Antifibrotics and wound healing in glaucoma surgery. Surv Ophthalmol 2003;48:314-346.
35.
Wallin Ö, Al-ahramy AM, Lundström M, Montan P: Endophthalmitis and severe blebitis following trabeculectomy. Epidemiology and risk factors; a single-centre retrospective study. Acta Ophthalmol 2014;92:426-431.
36.
Yamamoto T, Sawada A, Mayama C, Araie M, Ohkubo S, Sugiyama K, et al: The 5-year incidence of bleb-related infection and its risk factors after filtering surgeries with adjunctive mitomycin C: collaborative bleb-related infection incidence and treatment study 2. Ophthalmology 2014;121:1001-1006.
37.
Zahid S, Musch DC, Niziol LM, Lichter PR; Collaborative Initial Glaucoma Treatment Study Group: Risk of endophthalmitis and other long-term complications of trabeculectomy in the Collaborative Initial Glaucoma Treatment Study (CIGTS). Am J Ophthalmol 2013;155:674-680, 680.e1.
38.
Vaziri K, Kishor K, Schwartz SG, Maharaj AS, Moshfeghi DM, Moshfeghi AA, et al: Incidence of bleb-associated endophthalmitis in the United States. Clin Ophthalmol 2015;9:317-322.
39.
The Fluorouracil Filtering Surgery Study Group: Fluorouracil Filtering Surgery Study one-year follow-up. Am J Ophthalmol 1989;108:625-635.
40.
Traverso CE, Facino M, Murialdo U, Corazza M, Gandolfo E, Calabria G: Decreased corneal complications after no-reflux, low-dose 5 fluorouracil subconjunctival injection following trabeculectomy. Int Ophthalmol 1994;18:247-250.
© 2017 S. Karger AG, Basel
2017
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.