The efficacy of adjunctive mitomycin C and/or anti-VEGF agents on glaucoma tube shunt drainage device surgeries: a systematic review

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.

Keywords: Anti-vascular endothelial growth factor; Antimetabolites; Glaucoma; Glaucoma drainage implants; Mitomycin.

Fig. 1

PRISMA flowchart diagram for study identification and selection. This flowchart visually summarises the studies identification and selection process

Fig. 2

Methodological quality summary (Cochrane risk of bias assessment tool for randomized trials): review authors’ judgements about each methodological quality item for each included study. Only Arcieri et al. (2014) [36], Yazdani et al. (2016) [37] and Miraftabi et al. (2018) [38] explicitly reported the randomization method. In the study performed by Costa et al. (2004) [11], 28/60 (47%) participants did not complete one year of follow-up. Only Yazdani et al. (2016) and Zarei et al. (2021) [12] published a protocol or a trial registry record to compare outcomes with an official source