A Prospective Randomized Clinical Trial Comparing Three Delivery Methods of Mitomycin-C for Trabeculectomy Surgery: Preoperative Subconjunctival Injection, Intraoperative Subconjunctival Injection, and Topical Application (Conventional Use) During Trabeculectomy Surgery
Phase: PHASE4
Conditions: Glaucoma Open-Angle Primary, Glaucoma, Open Angle Glaucoma, Glaucoma, Open-Angle
Sponsor: University of California, Los Angeles

Official Title: A Prospective Randomized Clinical Trial Comparing Three Delivery Methods of Mitomycin-
C for Trabeculectomy Surgery: Preoperative Subconjunctival Injection, Intraoperative Subconjunctival 
Injection, and Topical Application (Conventional Use) During Trabeculectomy Surgery   
NCT Number: 03875911 
Date of Document: 01-19-2018 
 

Mitomycin-C Injection for Trabeculectomy: Pilot study 
 
Title 
Comparison of three delivery methods of Mitomycin C for trabeculectomy surgery: Preoperative 
subconjunctival injection, intraoperative subconjunctival injection and topical application during 
trabeculectomy surgery: A pilot study 
 
Purpose:   
To obtain estimates of the effect on intraocular pressure and side effects of three delivery methods of 
Mitomycin C (MMC) compared among each other: preoperative subconjunctival injection of 0.1 mL MMC 
0.002%, subconjunctival injection of 0.1 mL MMC 0.01% intraoperatively and conventional sponge 
applied MMC (0.02%) during trabeculectomy surgery in patients with Primary Open Angle Glaucoma who 
did not have any filtering surgeries before. 
 
Objective:  
To obtain estimates for intraocular pressure reduction among three delivery methods of MMC compared 
among each other: preoperative subconjunctival injection, intraoperative subconjunctival injection and 
intraoperative topical use during trabeculectomy surgery and to report any associated adverse effects. 
 
Null hypothesis: 
There is no use of hypothesis testing in this pilot study 
 
Alternative hypothesis: 
There is no use of hypothesis testing in this pilot study 
 
BRIEF SUMMARY 
 
In this Pilot explorative study, we are going to estimate and compare the outcomes of three different 
delivery methods of MMC for Trabeculectomy: a subconjunctival injection of MMC 0.002% at the site of 
future Trabeculectomy two to four weeks before the surgery, a subconjunctival injection of MMC 0.01% 
intraoperatively and topical sponge applied MMC 0.02% intraoperatively (typical use) in patients with 
Primary Open Angle Glaucoma who did not have any filtering surgeries before. 
 
After obtaining informed consent from the patients, the patients are randomly divided into three 
groups via a block randomization method: Group A receives 0.1 mL MMC 0.002 % (0.1mL MMC 
0.02mg/mL) subconjunctival injection preoperatively in superior conjunctiva at the site of future 
Trabeculectomy surgery. Group B receives 0.1mL MMC 0.01% subconjunctival injection intraoperatively 
at the site of Trabeculectomy and Group C receives conventional sponge delivery of MMC 0.02% 
intraoperatively. To avoid observer bias during postoperative evaluation of results, IOP staff obtaining 
measurements of IOP will be masked to the randomization allocation. 
 
All groups undergo conventional Trabeculectomy surgery (fornix-based) as scheduled, and the same 
routine follow up and post-op regimen will be scheduled for all three groups. Patients are routinely visited 
in the clinic at first day postoperatively, one week (+/-2 days), one month (+/-1 week), three months (+/-
2 weeks), six months (+/-3 weeks) and finally at one year (+/-(4 weeks)). In each of these visits we will be 
assessing: Visual acuity, intraocular pressure, number and type of glaucoma medication, slit lamp 
examination of the anterior segment and fundus examination.  

 
BACKGROUND INFORMATION 
 
The effect and safety of MMC subconjunctival injection either preoperatively or intraoperatively has been 
previously investigated in Pterygium surgery (Khakshoor H, Razavi ME, Daneshvar R, Shakeri MT, Ghate 
MF, Ghooshkhanehi H. Am J Ophthalmol. 2010 Aug;150(2):193-8. Preoperative subpterygeal injection vs 
intraoperative mitomycin C for pterygium removal: comparison of results and complications).  
 
Previous studies comparing effectiveness of subconjunctival injection of MMC vs sponge-applied MMC 
have shown inconsistent results. In one retrospective study, Mitomycin-C applied by injection resulted in 
significantly lower IOP, and the need for fewer glaucoma medications, however description of methods 
is incomplete. (Lim MC. A comparison of trabeculectomy surgery outcomes with mitomycin-C applied by 
intra-Tenon injection versus sponge method. American Glaucoma Society 23rd Annual Meeting; 2013, 
San Francisco, CA). One retrospective study showed similar efficacy and safety of intraoperative MMC 
injection compare to sponge application in trabeculectomy surgery with overall lower IOP in the injection 
group and main advantages being a large surface area of exposure and a predictable dose of deliver when 
the injection was performed. No difference in postoperative complications between groups was 
observed. A small sample size (30) in each group might prevent finding statistical significant results. 
(Khouri AS, Huang G, Huang LY. Intraoperative Injection vs Sponge-applied Mitomycin C during 
Trabeculectomy: One-year Study. J Curr Glaucoma Pract 2017;11(3):101-106). A previous case report on 
preoperative administration of MMC for Trabeculectomy showed reduction of IOP with short follow-up 
(6 months) Hung PT, Lin LL, Hsieh JW, Wang TH. Preoperative mitomycin-C subconjunctival injection and 
glaucoma filtering surgery. J Ocul Pharmacol Ther. 1995;11(3):233-241. 
One RCT with a follow-up of 3 years compared outcomes of intraoperative injection versus sponge-
applied MMC and no significant difference in IOP was found however a more favorable bleb 
morphology was found in the injection group which is correlated with better function and long-term 
success of Trabeculectomy ( Esfandiari, Hamed et al. Treatment Outcomes of Mitomycin C-Augmented 
Trabeculectomy, Sub-Tenon Injection versus Soaked Sponges, after 3 Years of Follow-up 
(Ophthalmology Glaucoma , Volume 1 , Issue 1 , 66 – 74) 
 
In this study the comparison will be the timing and route of delivery of MMC in all three groups, having 
found inconsistent reports in the literature and very scarce data on the effect of preoperative 
subconjunctival MMC we like to further explore in this pilot study the effect of subconjunctival injection 
on IOP reduction for trabeculectomy at preoperative and intraoperative phases. Since there is no group 
receiving placebo, the inclusion of a sham injection will not affect the outcomes compared to GROUP C 
and could increase preoperative risks to patients. The same methodology has been applied in two 
previous randomized controlled trials. (Pakravan M, Esfandiari H, Yazdani S, et al. Mitomycin C-
augmented trabeculectomy: subtenon injection versus soaked sponges: a randomized clinical trial Br J 
Ophthalmol 2017;101:1275–1280 and Khan F, Niazi S, Awais M et all. Effectiveness of Preoperative 
Subconjunctival Injection of Mitomycin-C in Primary Pterygium Surgery Journal of the College of 
Physicians and Surgeons Pakistan 2017, Vol. 27 (2): 88-91) 
 
Glaucoma patients who need glaucoma surgery, such as trabeculectomy, have ongoing damages that 
cannot be managed only with medication such as drops, and pressure reduction is absolutely crucial in 
preserving visual function in these patients, hence any possible action that can add to this reduction is 
valuable. 

On the other hand, there are several risks associated with the topical applied MMC usage at the time of 
surgery mainly due to the inability to precisely quantify the amount of MMC delivered by the sponge 
application which was shown to be far less with the injection of MMC by delivering a predicted volume 
either at surgery or before the surgery which are mentioned in the first two paper references. 
The selected concentrations for the MMC injection are based on pharmacological studies performed on 
ocular tissue in which the concentration achieved after subconjunctival injection was established 
 
STUDY DESIGN 
This is a multicenter randomized controlled pilot study with a main objective of obtaining estimates of 
differences in IOP reduction among three methods of delivery of mitomycin C for use in trabeculectomy 
surgery. 
The injectors and patients are unmasked in this study while the evaluators are masked. 
 
Inclusion Criteria  
1. 
Age: 20-85 years 
2. 
Willingness to participate in the study by signing informed consent 
3. 
Primary open angle glaucoma (including pigmentary glaucoma and pseudoexfoliation glaucoma) 
indicated with open angles upon previous gonioscopy and demonstrative optic nerve and visual field 
damage 
4. 
Trabeculectomy needed as treatment as determined by the care provider 
 
Exclusion criteria  
1. Patient unwilling or unable to give informed consent, unwilling to accept randomization, or unable to 
return for scheduled study visits throughout the duration of the study (1 year) 
2. Any secondary cause of glaucoma, or angle closure shown on gonioscopy 
3. Any ocular or neurological problems with optic nerve or visual field defect (ie. retinal disease, post 
trauma, corneal scar) that may confound the interpretation of glaucoma such as visual field or optic nerve 
interpretation 
4. Pregnant women, nursing women, and/or anyone with a history of allergy to MMC 
5. Previous glaucoma surgery or ocular surgery that included manipulation of the conjunctiva. 
 
METHODS 
 
Patients who met inclusion criteria and had signed an informed consent will then be randomized into 
three groups as follows: 
 
 
Group A: Patients will receive a subconjunctival injection of 0.1mL MMC 0.02mg/mL which 
corresponds to 0.002% (a tenth of the concentration of conventional topical MMC use) at the 
site of future trabeculectomy surgery two to four weeks in advance. A follow-up phone call 1 
week after the MMC injection will assess any side effects of the procedure. If side effects are 
reported by the patient an appointment will be schedule for a follow up in-office visit and 
appropriate treatment will be delivered. On the day of conventional trabeculectomy no MMC 
will be injected. Follow-up will be scheduled for one year. 
 
 
Group B: On the day of conventional trabeculectomy patients will receive a subconjunctival 
injection intraoperatively of 0.1 mL MMC 0.1mg/mL which corresponds to 0.01% (half the 

concentration of conventional topical MMC use) at the site of trabeculectomy.  Surgeon will 
irrigate the surface of the eye after MMC injection to remove any MMC that might have leaked 
out. Follow-up will be scheduled for one year. 
 
 
Group C: On the day of conventional trabeculectomy patients will receive MMC by applying a 
sponge soaked in 1mL of MMC 0.2 mg/mL (0.02%) for 1 minute to the site of trabeculectomy 
surgery followed by irrigation.  MMC is standard of care for trabeculectomy surgery at UCLA. This 
differs from the proposed research because the MMC will be administered as an injection either 
two to four weeks before the surgery in Group A or intraoperatively in Group B rather than the 
usual topical administration on the day of surgery (Group C). Follow-up will be scheduled for one 
year. 
 
The concentration of MMC in each group were chosen according to the delivery method and the timing 
of exposition of the tissue to the MMC in order to prevent complications from overdose. Based on 
experimental studies on ocular tissues that evaluated the final amount of MMC delivered to scleral tissue 
and finding a similar result when using subconjunctival injection of 0.02% with immediate irrigation and  
0.002% without irrigation, we chose the latter for group A. Few studies evaluated MMC subconjunctival 
injection one month before pterygium surgery using 0.02% and 0.015% with a follow-up of 3 years 
establishing safety of this approach. For group B we chose a similar methodology of a previous RCT 
comparing subconjunctival injection versus topical administration of MMC for trabeculectomy that used 
a reduced concentration of 0.01%. 
 
Data collection will be as follows: At preoperative visit, first day postoperatively, one week (+/- 2 days), 
one month (+/- 1 week), three months (+/- 2 weeks), six months (+/- 3 weeks) and one year (+/- (4 
weeks)). The data will be recorded trough the Redcap (Research Electronic Data Capture) software 
which has free access and allows for easy recording and uploading of imaging (VF, Optic nerve OCT, AS-
OCT and bleb photography) for future analysis. 
In each of these visits the following data will be collected: Visual acuity, intraocular pressure, number 
and type of glaucoma medication, slit lamp examination of the anterior segment, fundus examination 
and adverse events if present. Visual field and optic nerve OCT will also be included in the preoperative 
evaluation and at 12 months postoperatively.  
For better assessment of the bleb morphology we will include a clinical grade system, slitlamp 
photography and AS-OCT ( Anterior segment module of Spectralis OCT device (Heidelberg Engineering, 
Inc., Heidelberg, Germany) of the bleb. 
For the clinical description of the bleb and a more standardized comparison of the morphological 
changes over time we included at every postoperative visit the description of the bleb using the 
Moorfields Bleb Grading System (MBGS) which captures more morphological features and regional 
vascularity compared to other systems.  (Wells AP, Ashraff N, HalL RC et all Comparison of Two Clinical 
Bleb Grading Systems Ophthalmology 2006;113:77–83). 
The bleb photography will be included at the 3 and 12 months postoperatively and AS-OCT at 1,3,6 and 
12 months follow-ups. The inclusion of AS-OCT allows for evaluation of the internal structure of the 
bleb that has been shown to have prognostic implications for outcomes of surgery. Kokubun T, Tsuda S, 
Kunikata H et all. Anterior-Segment Optical Coherence Tomography for Predicting Postoperative 
Outcomes After Trabeculectomy, Current Eye Research, DOI: 10.1080/02713683.2018.1446535 
 
 

Block randomization: 
To ensure the balance of sample size between three treatment groups, block randomization is used for 
treatment assignment. Specifically, each block consists of 6 patients, including 2 patients in each of three 
treatment groups, and all possible permutations of a sequence of treatment assignment for these 6 
patients are generated, such as AABBCC, ABCABC, etc. A random number is then generated to select a 
block of treatment assignment for 6 patients among all possible blocks, and a sequence of such random 
blocks will form the sequence of treatment assignment for all patients after their enrollment. 
 
 
Statistical analysis 
Since the literature on the effect of preoperative subconjunctival injection and intraoperative 
subconjunctival injections for trabeculectomy shows inconsistent results and there are no estimates 
available for the IOP reduction among all three methods, the primary objective is to obtain such estimates 
in this pilot study. Hence, we want to perform pairwise comparisons among three groups and obtain the 
mean IOP estimates at each time point up to 1 year. The sample size for each randomized will be 50 
patients (total 150 patients) taking in consideration the patient flow and recruitment for trabeculectomy 
surgery at the Glaucoma Division. 
 
 
 
 
 
 
 
 
SCHEDULE 
VA IOP 
Glaucoma 
medications 
Ant. segment 
exam 
Fundus 
exam 
Bleb 
photo 
AS-
OCT 
Optic nerve 
-OCT 
Visual 
field 
Preoperative exam 
✓ 
✓ 
✓ 
✓ 
✓ 
 
 
✓ 
✓ 
Postoperative exam day 1 
✓ 
✓ 
✓ 
✓ 
 
 
 
 
 
Postoperative exam week 1 
✓ 
✓ 
✓ 
✓ 
 
 
 
 
 
Postoperative exam month 1 
✓ 
✓ 
✓ 
✓ 
 
 
✓ 
 
 
Postoperative exam month 3 
✓ 
✓ 
✓ 
✓ 
 
✓ 
✓ 
 
 
Postoperative exam month 6 
✓ 
✓ 
✓ 
✓ 
 
 
✓ 
 
✓ 
Postoperative exam month 12 
✓ 
✓ 
✓ 
✓ 
✓ 
✓ 
✓ 
✓ 
✓