Comparison of efficacy and safety of Mitomycin and Aflibercept used to support primary trabeculectomy - a prospective, randomized trial in patients with open-angle glaucoma undergoing surgery.

Glaucoma is a neurodegenerative disease characterized by progressive dying of retinal ganglion cells, axonal loss and damage to the optic nerve. This leads to a gradual loss of the visual field, and in the final stage to blindness. High intraocular pressure is considered to be the main risk factor for glaucomatous neuropathy. In the treatment we use pharmacological therapies and surgical treatment. The trabeculectomy has been the golden standard for the treatment of glaucoma for many years. This procedure consisting in the creation of a filtering bleb, which allows drainage of aqueous humor from within the eye to underneath the conjunctiva where it is absorbed. in addition to the surgery, anti-proliferative substances play a significant role in suppressing the physiological healing process. Bleb insufficiency observed in the postoperative period results to a large extent from progressive scarring of the follicle, which is responsible for excessive fibroblast proliferation and subconjunctival fibrosis.

Mitomycin is an antineoplastic antibiotic produced by Streptomyces caespitosus. It is one of the bi- or tri-functional alkylating agents causing cross-linking of DNA and inhibition of DNA synthesis. Its properties cause that mitomycin is now a popular medicine used to support trabeculectomy, with proven effectiveness of inhibiting the unwanted healing process of the fistula, and thus extend its period of its proper functioning.

Aflibercept is an inhibitor of vascular endothelial growth factor (VEGF). Its properties cause inhibition of the pathological process of formation of new vessels and their excessive permeability, as well as reduction of leukocyte infiltration and inflammation.

The aim of the research:

Comparison of the effectiveness of primary trabeculectomy in patients with open angle glaucoma supported with Eylea (Aflibercept) compared to the group of patients treated with mitomycin.

Materials and methods:

The research conducted at the Department of Glaucoma Diagnostics and Microsurgery in Medical University of Lublin will include patients treated with antiproliferative substances and trabeculectomy. Two groups of patients will participate in the study:

Group I - patients qualified for mitomycin trabeculectomy Group II - patients qualified for Eylea assisted trabeculectomy (Aflibercept) Mitomycin will be administered in the first group of patients during an operation at a dose of 0.3mg / ml for 3 minutes on a soaked sponge. Aflibercept will be applied intraoperatively in a dose of of 0.05 ml (40 mg / ml) subconjunctival and one week after surgery in the same dose.

Criteria for inclusion:

1. Open angle glaucoma or capsular glaucoma.

2. Patient's age> 40 years

3. Local treatment ineffective due to:

   1. intraocular pressure more than 21mmHg with maximum pharmacological therapy (using B-blocker + carbonic anhydrase + prostaglandins) or
   2. intolerance to topical treatment or
   3. progression in the visual field examination (assessed on the basis of MD, PSD).

4. Lack of previous ophthalmological surgical interventions.

5. No previous laser gonioplasty.

6. No previous laser trabeculoplasty or laser trabeculoplasty performed for more than a year.

Exclusion criteria:

1. Patient with angle-closure glaucoma or secondary glaucoma (except for glaucoma in the course of pseudoexfoliation syndrome).
2. One-eye patient.
3. A patient with pseudophakia or aphakia.
4. Patient after previous ophthalmic procedures (phacoemulsification with intraocular lens implantation, traditional pars plana vitrectomy, keratoplasty).
5. A patient diagnosed or suspected of having uveitis or intraocular inflammation.
6. Any corneal abnormalities or other conditions that make it impossible to reliably test with an applanation tonometer in the treated eye, including earlier refractive surgery of the eye

The efficacy of surgery in both groups will be assessed at subsequent postoperative controls based on the following diagnostic tests:

• Visual acuity examination;
• Intraocular pressure examination;
• Evaluation of the filtering bleb in the slit lamp;
• A photo of the filtering bleb;
• Optical coherence tomography of the filtration bleb;
• Visual field;
• Study of corneal endothelial cell density.

Inclusion Criteria:

1. Primary open-angle glaucoma or capsular glaucoma.

2. Patient's age: over 40 years, no sex preference;

3. Local treatment ineffective due to:

   1. Intraocular pressure above 21mmHg at maximum pharmacological therapy (using β-blocker + carbonic anhydrase inhibitor + prostaglandins) or
   2. Intolerance to topical treatment or
   3. Progression in visual field examination

4. Lack of previous ophthalmological surgical interventions.

5. Lack of previously performed laser gonioplasty.

6. No laser trabeculoplasty or laser trabeculoplasty performed for more than a year.

Exclusion Criteria:

1. Patient with primary closed-angle glaucoma or secondary glaucoma (except for glaucoma in the course of pseudoexfoliation syndrome).
2. One-eye patient.
3. Patient with aphakia.
4. Patient after previous ophthalmic procedures (cataract removal by phacoemulsification with an implant of an intraocular lens, vitrectomy by pars plana, keratoplasty).
5. A patient diagnosed or suspected of having uveitis or intraocular inflammation.
6. Any corneal abnormalities or other conditions that prevent reliable testing with an applanation device in the treated eye, including earlier refractive surgery of the eye.