Antimetabolite-Augmented Trabeculectomy Combined with Cataract Extraction for the Treatment of Cataract and Glaucoma

Glaucoma filtration surgery, or trabeculectomy, was first described in 1968 by Cairns, and the most common cause for failure was postoperative scarring. A number of modifications to the surgical technique have been developed including the use of antifibrotic agents. The most commonly used antifibrotic agents are the antimetabolites, 5-fluorouracil (5-FU), and mitomycin C (MMC). This chapter reviews the use of antimetabolites in patients undergoing combined cataract extraction and glaucoma surgery that creates subconjunctival filtration. The indications for surgery and risk stratification for the use of antifibrotic agents is discussed as per the Moorfields Eye Hospital More Flow regimen. The instrumentation and operative technique in cases of combined trabeculectomy and cataract surgery is also discussed. The postoperative care following the use of antifibrotic agents is discussed, and the reported outcomes in the literature of antimetabolite augmented trabeculectomy combined with cataract extraction is reviewed. The chapter concludes with a summary of potential complications following combined surgery augmented with antimetabolites and our recommendations for prevention of these complications based on the Moorfields Safer Surgery System.