D.r Nishant Nawani, MS

1
Change In Corneal Endothelial cell Morphology
Following Trabeculectomy With Mitomycin-C

• D.r Nishant Nawani, MS
• Dr. Surinder Singh Pandav, MD
• Dr. Amit Gupta, MD
• Dr. Sushmita Kaushik, MD
• Advanced Eye Centre
• PGIMER, Chandigarh

The authors have no financial interest in the
subject matter of this poster.
2
Introduction

• Outcome of glaucoma filtering surgery improved by
  the use of antifibroblastic drugs such as
  Mitomycin- C (MMC)
• MMC has potential corneal toxic effects
• Clinically corneal endothelial cell toxicity can
  manifest as change in the endothelial cell
  morphology i.e., pleomorphism and polymegethism
  and a reduction in the endothelial cell density
• Endothelial cell changes are reported to
  stabilize 3 months after intraocular surgery
• 
  Arch Ophthalmol
  19861041164-1169
• Endothelial morphology after application of MMC
  have been studied
• using electron microscopy Arch
  Ophthalmol 1994112533
• non contact specular microscopy J
  Glaucoma 200817654-657
• 
  Cornea 200221
  300-304
• Endothelial mosaic better visualized in
  edematous or scarred corneas by confocal
  microscopy
• 
  Techniques in Ophthalmology 2005319-26

3
Aim and Objectives

• To study the change in corneal endothelial cell
  characteristics by confocal microscopy following
  trabeculectomy with 0.04 MMC

4
Materials and Methods

• DESIGN
• Prospective, non-randomized, interventional case
  series which included 30 patients
• TWO GROUPS
• Group 1 Those undergoing trabeculectomy with
  0.04 MMC applied for two minutes (n15)
• Group 2 Those undergoing trabeculectomy without
  MMC as adjunct (n15)
• INCLUSION CRITERIA
• Age more than 18 years
• Primary or secondary open angle glaucoma
• Primary or Secondary angle closure glaucoma
• Uncontrolled intraocular pressure, not responding
  to maximal medical therapy
• EXCLUSION CRITERIA
• Previous intraocular surgery, scleral buckling
• Corneal degenerations and dystrophies
• Corneal scarring after infective diseases
• Dry eye patients

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• Baseline examination
• Comprehensive ophthalmic examination including
  gonioscopy and, confocal microscopy (NIDEK
  CONFOSCAN II, Nidek Technologies, Japan) to study
  corneal endothelium
• Surgical Procedure
• Standard trabeculectomy , limbus based
  conjunctival flap
• Half thickness, triangular scleral flap 4mm x
  4mm, base at limbus
• MMC o.04 applied with surgical sponge between
  scleral flap and Tenons capsule for 2 minutes
• Irrigated with 10 ml of BSS over 1-2 minutes
• Scleral flap closed with two releaseable, and one
  fixed sutures
• Tenons and conjunctiva closed in two layers
• Follow Up
• Patients were followed up on at days
  1,2,7,14,30,60,90 post surgery
• Confocal microscopy was done at 1 and 3 months
  post surgery

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ResultsPaired nonparametric test (Wilcoxon)
was used to compare pre- and postoperative
parameters and the Mann-Whitney test was used to
compare data between the two groups .Plt 0.05 as
the criterion for statistical significance
Patient Characteristics
Feature Group I (n15) Group II (n15) Total
Age in years SD (range) 40.47 10.72 (23-58) 50.40 12.21 (23-66)
Gender (MalesFemales) 132 114 246
Diagnosis Primary open angle glaucoma Primary closed angle glaucoma Secondary open angle glaucoma Secondary closed angle glaucoma
Diagnosis Primary open angle glaucoma Primary closed angle glaucoma Secondary open angle glaucoma Secondary closed angle glaucoma 2 6 8
Diagnosis Primary open angle glaucoma Primary closed angle glaucoma Secondary open angle glaucoma Secondary closed angle glaucoma 3 6 9
Diagnosis Primary open angle glaucoma Primary closed angle glaucoma Secondary open angle glaucoma Secondary closed angle glaucoma 8 2 10
Diagnosis Primary open angle glaucoma Primary closed angle glaucoma Secondary open angle glaucoma Secondary closed angle glaucoma 2 1 3
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Comparison Of Change In IOP and no. of
Antiglaucoma Medications(Pre and Post surgery)
Group I (MMC) IOP SD (mmHg) Medications SD Group I (MMC) IOP SD (mmHg) Medications SD Group II IOP SD (mmHg) Medications SD Group II IOP SD (mmHg) Medications SD
Pre-op (n15) 29.60 11.28 3.80 0.86 30.20 8.51 3.67 .98
1 month (n12) 10.58 3.52 (p0.002) 0.17 0.38 (p0.002) 14.64 4.01 (p0.018) 0.45 0.82 (p0.003)
3 months (n9) 12.56 3.24 (p0.013) 0.22 0.44 (p0.007) 16.29 4.82 (p0.018) 0.86 1.21 (p0.016)
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Change in central corneal thickness (CCT) Pre and
Post surgery
Group I (MMC) CCT SD (microns) Group II CCT SD (microns)
Pre-op (n15) 553.33 38.18 536.36 57.48
1 month 533.50 36.84 (p0.025, n12) 548.55 37.77 (p0.562, n11)
3 months 536.56 47.56 (p0.038, n9) 552.00 38.41 (p0.108,n7)
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Endothelial Morphometry
Endothelial Characteristic Group I (MMC) Group I (MMC) Group I (MMC) Group II Group II Group II
Endothelial Characteristic Pre-op (n15) 1 month (n12) 3 months (n9) Pre-op (n15) 1month (n11) 3months (n7)
CCEC mean SD (cells/mm2) 2080.07 379.76 1958.25 367.42 (p0.239) 1967.00 380.56 (p0.374) 2116.71 316.44 1979.09 256.71 (p.131) 2068.00 364.62 (p1.00)
Mean cell area (MCA) mean SD (mm2) 496.36 91.19 528.17 102.69 (p0.091) 525.78 102.48 (p0.314) 494.66 76.14 521.07 68.25 (p0.477) 493.14 90.95 (p1.00)
Pleomorphism mean SD () 46.88 13.89 44.51 11.85 (p0.937) 48.73 5.17 (p0.953) 46.18 11.99 45.91 12.34 (p0.625) 43.07 10.69 (p0.866)
Polymegethism mean SD () 37.62 6.93 35.02 5.06 (p0.195) 35.17 7.57 (p0.107) 36.19 7.28 37.20 6.49 (p0.790) 40.00 8.54 (p0.889)
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Reduction in cell count from baseline () Reduction in cell count from baseline () Reduction in cell count from baseline ()
Group I (MMC) Group II
1 month 5.85 6.48
3 months 5.46 2.28
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Discussion

• Endothelial cell changes
• Effacement of intercellular junctions with
  cellular swelling and transcellular vacuole
  formation using electron microscopy (Mcdermott
  et al., 1994)
• In trabeculectomies where MMC has been used,
  endothelial cell loss at 3months
• 11 by Pastor et al. (1993)
• 14.5 by Sihota et al.(1998)
• 9.5 by Storr-Paulsen et al. (2008)
• 5.46 (current study)
• Summary
• IOP reduction is significant in both groups
• Decrease in CCT was significant in the MMC group
• Endothelial cell counts decreased at one month
  post op with slightly better recovery of counts
  in non MMC group at three months
• Mean cell area increased at one month post op,
  parallel to decrease in endothelial counts with
  trend to recovery at three months

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Conclusion

• MMC 0.04 when applied for two minutes, shows no
  significant toxic effects on the corneal
  endothelium at 3 months following trabeculectomy