Scolaris Content Display Scolaris Content Display

Study flow diagram
Figures and Tables -
Figure 1

Study flow diagram

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
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Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
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Figure 3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Comparison 1 MMC versus 5‐FU, Outcome 1 Failure of functioning trabeculectomy at one year.
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Analysis 1.1

Comparison 1 MMC versus 5‐FU, Outcome 1 Failure of functioning trabeculectomy at one year.

Comparison 1 MMC versus 5‐FU, Outcome 2 Failure of functioning trabeculectomy at one year in descending order of MMC exposure (dose x duration).
Figures and Tables -
Analysis 1.2

Comparison 1 MMC versus 5‐FU, Outcome 2 Failure of functioning trabeculectomy at one year in descending order of MMC exposure (dose x duration).

Comparison 1 MMC versus 5‐FU, Outcome 3 Failure of functioning trabeculectomy at one year depending on 5‐FU administration technique.
Figures and Tables -
Analysis 1.3

Comparison 1 MMC versus 5‐FU, Outcome 3 Failure of functioning trabeculectomy at one year depending on 5‐FU administration technique.

Comparison 1 MMC versus 5‐FU, Outcome 4 Intraocular pressure at one year.
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Analysis 1.4

Comparison 1 MMC versus 5‐FU, Outcome 4 Intraocular pressure at one year.

Comparison 1 MMC versus 5‐FU, Outcome 5 Use of postoperative anti‐glaucoma medications at final follow up.
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Analysis 1.5

Comparison 1 MMC versus 5‐FU, Outcome 5 Use of postoperative anti‐glaucoma medications at final follow up.

Comparison 1 MMC versus 5‐FU, Outcome 6 Mean number of postoperative anti‐glaucoma medications.
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Analysis 1.6

Comparison 1 MMC versus 5‐FU, Outcome 6 Mean number of postoperative anti‐glaucoma medications.

Comparison 1 MMC versus 5‐FU, Outcome 7 Loss of 2 or more lines of Snellen visual acuity postoperatively.
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Analysis 1.7

Comparison 1 MMC versus 5‐FU, Outcome 7 Loss of 2 or more lines of Snellen visual acuity postoperatively.

Comparison 1 MMC versus 5‐FU, Outcome 8 Postoperative Complications.
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Analysis 1.8

Comparison 1 MMC versus 5‐FU, Outcome 8 Postoperative Complications.

Summary of findings for the main comparison. MMC compared to 5‐FU for wound healing in glaucoma surgery

MMC compared to 5‐FU for wound healing in glaucoma surgery

Patient or population: wound healing in glaucoma surgery
Settings:
Intervention: MMC
Comparison: 5‐FU

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants/eyes
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

5‐FU

MMC

Failure of functioning trabeculectomy at 1 year

Study population

Low‐risk population RR 0.65 (95% CI 0.19 to 2.20)

High‐risk population RR 0.49 (95% CI 0.22 to 1.08)

634
(11 RCTs: 6 including low‐risk population and 5 including high‐risk population)

⊕⊕⊝⊝
LOW 1,2

Low‐risk population: 74 per 1000

High‐risk population: 272 per 1000

Low‐risk population: 50 per 1000

High‐risk population: 137 per 1000

Intraocular pressure at 1 year

The mean intraocular pressure at 1 year ranged across 5‐FU groups.

Low‐risk population: 10.9 to 14.3 mmHg

High‐risk population: 14.8 to 16.3 mmHg

The mean intraocular pressure at 1 year in the MMC groups had a range of values.

Low‐risk population: 9.9 to 11.6 mmHg

High‐risk population: 8.6 to 13.7 mmHg

386
(7 RCTs: 3 including low‐risk population and 4 including high‐risk population)

⊕⊕⊝⊝
LOW 1,3

Loss of 2 or more lines of Snellen visual acuity at 1 year

Study population

Low‐risk population RR 2.00 (95% CI 0.53 to 7.59)

High‐risk population RR 0.81 (95% CI 0.36 to 1.80)

328
(5 RCTs: 2 including low‐risk population and 3 including high‐risk population)

⊕⊕⊝⊝
LOW 2,4

Low‐risk population: 47 per 1000

High‐risk population: 115 per 1000

Low‐risk population: 94 per 1000

High‐risk population: 96 per 1000

Postoperative complications: late hypotony

Study population

RR 1.37 (95% CI 0.41 to 4.63)

211
(4 RCTs)

⊕⊕⊝⊝
LOW 2,4

37 per 1000

59 per 1000

Postoperative complications: choroidal detachment

Study population

RR 0.86 (95% CI 0.45 to 1.63)

494
(8 RCTs)

⊕⊕⊝⊝
LOW 1,2

68 per 1000

70 per 1000

Postoperative complications: endophthalmitis

Study population

RR 3.89 (95% CI 0.44 to 34.57)

315
(4 RCTs)

⊕⊕⊝⊝
LOW 1,2

0 per 1000

19 per 1000

Quality of life at 1 year

Not reported

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
5‐FU: 5‐Fluorouracil; CI: confidence interval; MMC: mitomycin C; RCT: randomised controlled trial; RR: risk ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1Downgraded for risk of bias: only one study at low risk of bias in all domains

2Downgraded for imprecision: wide confidence intervals

3Downgraded for inconsistency: I2 = 60%

4Downgraded for risk of bias: no study at low risk of bias in all domains

Figures and Tables -
Summary of findings for the main comparison. MMC compared to 5‐FU for wound healing in glaucoma surgery
Table 1. Interventions

Study

MMC*

5‐FU

Dose

Duration (minutes)

Location

Intraoperative or postoperative

Dose

Number of injections

Duration

Location

Katz 1995

0.5 mg/ml

5

Between the conjunctiva and the episclera

Postoperative

5 mg

10 (daily for 1 week, 3 times following week)

NA (injection)

Subconjunctival injection

Kitazawa 1991

0.4 mg/ml

5

Between the conjunctival and scleral flap

Postoperative

5 mg

10 (each day for 1 week and every other day for the following week)

NA (injection)

Subconjunctival injections, 90 to 180 degrees away from the surgical site

Lamping 1995

0.4 mg/ml

2.5

Between the conjunctival and scleral flap

Postoperative

5 mg

10 (first 10 days)

NA (injection)

Subconjunctival injection, 180 degrees from operating site

Mostafaei 2011

0.02 mg

not stated

Subconjunctival injection, 180 degrees away from operating site

Intraoperative

5 mg

NA

Not stated

Subconjunctival injection

Singh 1997

0.5 mg/ml

3.5

Between scleral flap and conjunctiva

Intraoperative

50 mg/ml

NA

5

Between scleral flap and conjunctiva

Singh 2000

0.4 mg/ml

2

Not stated

Intraoperative

50 mg/ml

NA

5

Not stated

Sisto 2007

0.2 mg/ml

2

Between the sclera and the Tenon's capsule

Postoperative

0.1 ml of 50 mg/ml

10 (starting on day 7, 2 injections per week for 2 weeks and then 1 injection per week for 6 weeks

NA (injection)

Subconjunctival injections near the bleb

Uva 1996

0.2 mg/ml

2

Between the sclera and the Tenon's capsule

Intraoperative

50 mg/ml

NA

5

Between the sclera and the Tenon's capsule

WuDunn 2002

0.2 mg/ml

2

Not stated

Intraoperative

50 mg/ml

NA

5

Not stated

Xinyu 2001

0.2 mg/ml

5

Not stated

Postoperative

5 mg

6 to 8 (alternate days, starting on day 3)

NA (injection)

Subconjunctival, 180 degrees away from the site of scleral flap

Zadok 1995

0.2 mg/ml

5

Between the conjunctiva and episclera

Postoperative

5 mg (0.5 ml of 10 mg/ml solution)

7 (once daily up to 7 times in the first week after surgery)

NA (injection)

Subconjunctival, 180 degrees from site of surgery

NA: not applicable

* All MMC only one intraoperative application

Figures and Tables -
Table 1. Interventions
Comparison 1. MMC versus 5‐FU

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Failure of functioning trabeculectomy at one year Show forest plot

11

634

Risk Ratio (M‐H, Random, 95% CI)

0.54 [0.30, 1.00]

1.1 Low risk of failure

6

370

Risk Ratio (M‐H, Random, 95% CI)

0.65 [0.19, 2.20]

1.2 High risk of failure

5

264

Risk Ratio (M‐H, Random, 95% CI)

0.49 [0.22, 1.08]

2 Failure of functioning trabeculectomy at one year in descending order of MMC exposure (dose x duration) Show forest plot

10

594

Risk Ratio (M‐H, Random, 95% CI)

0.54 [0.30, 1.00]

3 Failure of functioning trabeculectomy at one year depending on 5‐FU administration technique Show forest plot

10

594

Risk Ratio (M‐H, Random, 95% CI)

0.54 [0.30, 1.00]

3.1 5‐FU by postoperative injections

6

273

Risk Ratio (M‐H, Random, 95% CI)

0.55 [0.27, 1.15]

3.2 5‐FU by intraoperative sponge application

4

321

Risk Ratio (M‐H, Random, 95% CI)

0.52 [0.13, 2.08]

4 Intraocular pressure at one year Show forest plot

7

386

Mean Difference (IV, Random, 95% CI)

‐3.05 [‐4.60, ‐1.50]

4.1 Low risk of failure

3

162

Mean Difference (IV, Random, 95% CI)

‐1.72 [‐3.28, ‐0.16]

4.2 High risk of failure

4

224

Mean Difference (IV, Random, 95% CI)

‐4.18 [‐6.73, ‐1.64]

5 Use of postoperative anti‐glaucoma medications at final follow up Show forest plot

7

426

Risk Ratio (M‐H, Random, 95% CI)

1.03 [0.57, 1.85]

5.1 Low risk of failure

4

273

Risk Ratio (M‐H, Random, 95% CI)

1.11 [0.60, 2.07]

5.2 High risk of failure

3

153

Risk Ratio (M‐H, Random, 95% CI)

0.99 [0.26, 3.76]

6 Mean number of postoperative anti‐glaucoma medications Show forest plot

4

342

Mean Difference (IV, Random, 95% CI)

‐0.33 [‐0.70, 0.05]

6.1 Low risk of failure

2

223

Mean Difference (IV, Random, 95% CI)

‐0.08 [‐0.27, 0.11]

6.2 High risk of failure

2

119

Mean Difference (IV, Random, 95% CI)

‐0.71 [‐1.34, ‐0.09]

7 Loss of 2 or more lines of Snellen visual acuity postoperatively Show forest plot

5

328

Risk Ratio (M‐H, Fixed, 95% CI)

1.05 [0.54, 2.06]

7.1 Low risk of failure

2

128

Risk Ratio (M‐H, Fixed, 95% CI)

2.0 [0.53, 7.59]

7.2 High risk of failure

3

200

Risk Ratio (M‐H, Fixed, 95% CI)

0.81 [0.36, 1.80]

8 Postoperative Complications Show forest plot

11

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

8.1 Bleb leak

2

154

Risk Ratio (M‐H, Random, 95% CI)

1.22 [0.32, 4.68]

8.2 Wound leak

6

391

Risk Ratio (M‐H, Random, 95% CI)

1.17 [0.51, 2.71]

8.3 Late hypotony

4

211

Risk Ratio (M‐H, Random, 95% CI)

1.37 [0.41, 4.63]

8.4 Maculopathy

4

342

Risk Ratio (M‐H, Random, 95% CI)

1.71 [0.35, 8.33]

8.5 Cataract

4

275

Risk Ratio (M‐H, Random, 95% CI)

1.73 [0.65, 4.61]

8.6 Shallow anterior chamber

5

311

Risk Ratio (M‐H, Random, 95% CI)

1.22 [0.67, 2.21]

8.7 Choroidal detachment

8

494

Risk Ratio (M‐H, Random, 95% CI)

0.86 [0.45, 1.63]

8.8 Epitheliopathy

8

419

Risk Ratio (M‐H, Random, 95% CI)

0.23 [0.11, 0.47]

8.9 Tenon cyst

3

177

Risk Ratio (M‐H, Random, 95% CI)

0.94 [0.20, 4.38]

8.10 Hyphaema

4

250

Risk Ratio (M‐H, Random, 95% CI)

0.62 [0.42, 0.91]

8.11 Suprachoroidal haemorrhage

3

303

Risk Ratio (M‐H, Random, 95% CI)

0.73 [0.09, 5.66]

8.12 Endophthalmitis

4

315

Risk Ratio (M‐H, Random, 95% CI)

3.89 [0.44, 34.57]

Figures and Tables -
Comparison 1. MMC versus 5‐FU