Success and Failure Factors for Trabeculectomy in Glaucomatous Patients in Southwest China: A 325 Eyes Analysis

Success and Failure Factors for Trabeculectomy in Glaucomatous Patients in Southwest China: A 325 Eyes Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Success and Failure Factors for Trabeculectomy in Glaucomatous Patients in Southwest China: A 325 Eyes Analysis Zuoxin Qin, Xi Ying, Qing Han, Lu Wang, Lian Tan, Yufei Xu, Nan Wu, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1080435/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose To evaluate the outcomes and elucidate the success and failure factors for trabeculectomy with mitomycin C (MMC) in Southwest Chinese patients. Methods A retrospective correlational study was conducted on the glaucomatous patients who underwent initial trabeculectomy with MMC in Southwest Hospital and had been followed up for 1-3 years. A complete success for surgery is defined as a postoperative intraocular pressure (IOP) > 5 and ≤ 21 mmHg and 20% reduction of IOP compared to preoperative, without IOP-lowering medications. A qualified success for surgery is defined as the abovementioned postoperative IOP with or without IOP-lowering medications. The primary outcomes were IOP, the number of IOP-lowering medications, and cumulative success rate. The secondary outcomes included best corrected visual acuity (BCVA), mean deviation (MD) of visual field, major complications, and risk factors for surgical failure. Results A total of 325 eyes of 261 glaucomatous patients had been included in our study. Both the mean IOP and the number of IOP-lowering medications were significantly decreased from 32.9 ± 12.0 mmHg to 16.4 ± 5.7 mmHg ( P <0.0001) and 3.0 ± 0.9 to 0.9 ± 1.0 ( P <0.0001), respectively, at the last visit. The cumulative complete success rate and qualified success rate were 77.8% and 92.0% at 1-year follow-up, and 47.2% and 77.7% at 3-year follow up. There were no significant differences in surgical outcomes between primary angle-closure glaucoma (PACG) and primary open angle glaucoma (POAG). In PACG patients, the success rates of trabeculectomy were comparable with those of phacotrabeculectomy. Hypertension (HR=1.904, P =0.011), encapsulated bleb (HR=2.756, P <0.001), and more preoperative topical medications (HR=2.475, P =0.008) were risk factors for surgical failure. Conclusions The qualified success rate of trabeculectomy with MMC in glaucomatous patients in Southwest China is 92.0% at 1-year follow-up, and 77.7% at 3-year follow up. Hypertension, encapsulated bleb, and more preoperative topical medications are associated with surgical failure. Ophthalmology Glaucoma Trabeculectomy Outcomes Risk factors Figures Figure 1 Figure 2 Figure 3 Background Glaucoma is an irreversible optic neuropathy that considered to be one of the leading causes of blindness worldwide. More than 90% of patients are unaware of their vision loss and many risk factors are associated with physiopathology of glaucoma. Among them, intraocular pressure (IOP) remains the main modifiable risk factor, and surgical treatment is the standard care for glaucomatous patient aiming to lower IOP if not controlled by pharmacological agents. Nowadays, minimally invasive glaucoma surgeries are blooming[ 1 , 2 ]. Recent studies of the American Glaucoma Society have demonstrated a rise in the proportion of using tube shunts and a decline in the popularity of trabeculectomy[ 3 , 4 ]. Nevertheless, trabeculectomy still remains the most effective procedure 5 for glaucoma management in China since most patients suffer from primary angle-closure glaucoma (PACG). The success rate of trabeculectomy has been increasing along with innovation of intraoperative techniques such as wide application of antifibrotics and placement of adjustable sutures. It is believed that the postoperative interventions, for instance, removal of adjustable sutures or laser suture lysis, ocular massage, and bleb needling, have reduced complications and improved outcomes of trabeculectomy[ 6 , 7 ]. There are some studies report the efficacy and safety of trabeculectomy in Asian. The 5-year success rate was 87.3% according to the Japanese Collaborative Bleb-Related Infection Incidence and Treatment Study (CBIITS)[ 8 ]. A research in Taiwan described a cumulative qualified success rate of 67.1% in a 10-year follow-up period[ 9 ]. A retrospective study on mitomycin C (MMC)-augmented trabeculectomy revealed that the qualified success rate was 75% after a follow-up period of 21.8 months in Hong Kong[ 10 ]. However, studies on trabeculectomy in mainland Chinese patients are lacking. To evaluate the efficiency and safety for trabeculectomy, we retrospectively review 325 eyes of 261 glaucomatous patients who underwent trabeculectomy with MMC and elucidate the success and failure factors for trabeculectomy in Southwest Chinese patients. Patients And Methods Study design The medical records of patients who were diagnosed as glaucoma and underwent trabeculectomy with MMC in Southwest Hospital of China were retrospectively reviewed from January 2016 to December 2018. This retrospective study was approved by the ethics committee of the Southwest Hospital (KY2020206) and adhered to the tenets of the Declaration of Helsinki. The inclusion criteria were as follows. Patients were over 18 years old, diagnosed of glaucoma, and underwent initial trabeculectomy with MMC. The surgery includes trabeculectomy concomitantly performed with cataract surgery or anterior vitrectomy. Patients had no previous intraocular surgeries except laser peripheral iridotomy (LPI) and selective laser trabeculoplasty (SLT), and had been followed up for minimum 1 year. The exclusion criteria were patients of less than 18 years old, history of cataract surgery or trabeculectomy, and less than 1-year follow-up period. Data collection Preoperative data including the patients’ demographic information, glaucoma type, IOP, number of IOP-lowering medications, best corrected visual acuity (BCVA), mean deviation (MD) of visual field, vertical cup to disc ratio, and surgery type were collected. IOP was measured by non-contact or rebound tonometer. At least 3 consecutive readings were recorded for each patient at each follow-up point. BCVA measurements were converted to logarithm of the minimum angle of resolution (logMAR) equivalents for the purpose of data analysis[11]. Postoperative data included BCVA, IOP, number of IOP-lowering medications, complications, and surgical interventions. According to the World Glaucoma Association guidelines, a complete success for surgery is defined as a postoperative IOP of > 5 and ≤ 21 mmHg and 20% reduction of IOP compared to preoperative without IOP-lowering medications. A qualified success for surgery is defined as the abovementioned postoperative IOP with or without IOP-lowering medications. The primary outcomes were IOP, the number of IOP-lowering medications, and cumulative success rate. The secondary outcomes included BCVA, MD of visual field, major complications, and risk factors for surgical failure. Surgical procedure The surgeries were performed by highly skilled glaucoma specialists. Topical anesthesia or general anesthesia were tailored to the best experience for the patients and their specific needs. After applying a corneal traction suture, a fornix-based conjunctival flap was created. The subconjunctival tissue was then dissected to expose the sclera in an appropriate size. After bipolar coagulation hemostasis and a rectangular partial-thickness scleral flap was made, a sponge soaked with MMC (0.4 mg/mL) was placed on the scleral bed and subconjunctival area for 2-5 min at the surgeon’s discretion. The area was then irrigated thoroughly with balanced salt solution. A paracentesis was then performed to lower intraocular pressure and an anterior ostium was created, followed by peripheral iridectomy. After the scleral flap was sutured, the conjunctiva flap was closed separately to make a watertight closure. Prednisolone and antibiotics were administrated topically immediately post-surgery. Complications such as encapsulated bleb, shallow anterior chamber, hyphema, wound leak, malignant glaucoma, and choroidal effusion were closely observed. Personalized interventions such as removal of adjustable sutures, laser suture lysis, massage, bleb needling, and antifibrotic injection were performed based on the surgeon’s clinical judgement. Statistical analysis Statistical analysis was performed by SPSS software (version 20.0, IBM, USA). Continuous variables were presented as mean ± SD. T -test was used to compare the measurements of IOP, the number of topical medications, BCVA (logMAR), visual field MD. Kaplan Meier survival analysis was applied to draw the survival curves and calculate success rates. Comparison of success rate between groups was performed using the Log rank test. Cox proportional hazards regression analysis was used to identify factors associated with surgical failure. A P ≤ 0.05 was considered statistically significant. Results Eye characteristics A total of 325 eyes of 261 patients were observed in the study, including 116 males (44.4%) and 145 females (55.6%). The mean follow-up time was 22 ± 12 months, ranging from 12 to 57 months. The average age was 59.3 ± 12.8 (19-90) years old, and 189 (58.2%) patients were over 60 years old. PACG was the main type of glaucoma, which accounted for 64.6% of patients. The mean preoperative IOP was 32.9 ± 12.0 mmHg, and the mean number of topical IOP-lowering medications before surgery was 3.0 ± 0.9. Of patients, 245 (75.4%) underwent trabeculectomy alone, and 80 (24.6%) received trabeculectomy combined with cataract surgery. The demographic characteristics of the patients and preoperative ocular characteristics are presented in Table 1. Information about visual field MD was unavailable in 40 cases. Table 1 Demographic and ocular characteristics of patients with trabeculectomy at baseline Gender, no. (%) Female 145 (55.6) Male 116 (44.4) Age (yrs), Mean ± SD 59.3 ± 12.8 < 60, no. (%) 136 (41.8) ≥ 60, no. (%) 189 (58.2) Hypertension, no. (%) Yes 54 (16.6) No 271 (83.4) Diagnosis, no. (%) PACG 210 (64.6) POAG 97 (29.8) SG 10 (3.1) CG 8 (2.5) BCVA (logMAR), Mean ± SD 0.77 ± 0.94 ≤ 1, no. (%) 254 (78.2) > 1, no. (%) 71 (21.8) IOP (mmHg), Mean ± SD 32.9 ± 12.0 Medications, Mean ± SD 3.0 ± 0.9 Visual filed MD (dB), Mean ± SD -19.73 ± 10.03 > -15, no. (%) 100 (30.8) ≤ -15, no. (%) 185 (57.0) Missing data, no. (%) 40 (12.2) Preoperative C/D, Mean ± SD 0.8 ± 0.2 Surgery type, no. (%) Trabeculectomy 245 (75.4) Phacotrabeculectomy 80 (24.6) PACG, primary angle-closure glaucoma; POAG, primary open angle glaucoma; SG, secondary glaucoma; CG, congenital glaucoma; BCVA, best corrected visual acuity; logMAR, logarithm of the minimal angle of resolution; IOP, intraocular pressure; SD, standard deviation; MD, mean deviation; dB, Decibels; C/D, vertical cup to disc ratio. Surgical outcomes and success rate The IOP and the number of topical IOP-lowering medications at each follow-up time are shown in Table 2. The mean IOP and glaucoma medications were significantly decreased from 32.9 ± 12.0 mmHg to 16.4 ± 5.7 mmHg ( P <0.0001) and 3.0 ± 0.9 to 0.9 ± 1.0 ( P <0.0001), respectively, at 3-year follow-up. The IOP values and the number of topical medications were consistently lower than those observed at baseline throughout the follow-up period. Table 2 IOP and the number of glaucoma medications for patients at baseline and follow-up Follow-up IOP (mmHg) P value No. of medications P value Baseline 32.9 ± 12.0 3.0 ± 0.9 1 month 14.2 ± 6.3 < 0.0001 0.1 ± 0.4 < 0.0001 3 months 14.4 ± 5.2 < 0.0001 0.2 ± 0.5 < 0.0001 6 months 14.9 ± 5.5 < 0.0001 0.3 ± 0.5 < 0.0001 12 months 14.2 ± 4.3 < 0.0001 0.3 ± 0.6 < 0.0001 24 months 16.0 ± 5.3 < 0.0001 0.6 ± 0.9 < 0.0001 36 months 16.4 ± 5.7 < 0.0001 0.9 ± 1.0 < 0.0001 IOP, intraocular pressure; No., number. The Kaplan-Meier survival plot of success rate for included patients is demonstrated in Figure 1. The cumulative complete success rate was 77.8%, 66.8% and 47.2% at 1-, 2-, and 3-year follow-up visits, respectively. The cumulative qualified success rate was 92.0%, 88.5% and 77.7% at 1-, 2-, and 3-year follow-up visits, respectively. We compared the surgical outcomes between PACG and POAG patients (Figure 2). Before the surgery, both the IOP values and the number of medications in PACG group were higher. However, after the surgery, both IOP and the number of glaucoma medications were comparable between PACG and POAG throughout 3-year follow-up. The 3-year complete success rates of PACG and POAG were 54.6%, 46.4%, while the qualified success rates were 78.7%, 71.5%, respectively. The cumulative success rates of two groups were similar. For PACG patients who underwent with trabeculectomy alone or phacotrabeculectomy, there was no significant difference in IOP control between the two surgical procedures. There was no significant difference with respect to IOP-lowering medications between the two surgical procedures at all follow up times except 1 month after surgery. The success rates of two surgical procedures were comparable (Figure 3). Visual acuity and visual field test The changes of BCVA (logMAR) and visual field MD are shown in Table 3. The mean BCVA (logMAR) was 0.77 ± 0.94 before surgery and 0.67 ± 0.83 at the last follow-up. There was no significant difference between baseline and last follow-up ( P =0.14). At the last follow-up, the mean visual field MD was -16.80 ± 11.47 dB, which was slightly improved compared with that at baseline ( P =0.04). Table 3 Visual acuity and visual field results at the last follow-up visit. P value BCVA (logMAR), mean ± SD Baseline (n = 325) 0.77 ± 0.94 0.14 Last follow-up (n = 325) 0.67 ± 0.83 MD of VF (dB), mean ± SD Baseline (n = 285) -19.73 ± 10.03 0.04* Last follow-up (n = 66) -16.80 ± 11.47 BCVA, best corrected visual acuity; logMAR, logarithm of the minimal angle of resolution; SD, standard deviation; MD, mean deviation; VF, visual field; dB, Decibels. *Not all patients at baseline returned for perimetry follow up Postoperative complications In our study, a total of 62 (19.1%) eyes developed postoperative complications in the follow up period. Of these, 33 (10.2%) had encapsulated bleb, 10 (3.1%) had shallow anterior chamber, 5 (1.5%) had wound leak, and 4 (1.2%) had malignant glaucoma. Postoperative complications during follow-up visits are displayed in Table 4. Encapsulated bleb was treated with massage, needling, or antifibrotic injection based on surgeon’s clinical judgement. Table 4 Postoperative complications during follow-up visits. Complications n (%) Encapsulated bleb 33 (10.2) Shallow anterior chamber 10 (3.1) Hyphema 8 (2.5) Wound leak 5 (1.5) Malignant glaucoma 4 (1.2) Choroidal effusion 2 (0.6) Total 62 (19.1) Risk factors for surgical failure The risk factors for surgical failure were investigated using Cox proportional hazard analysis (see Table 5). Hypertension (HR=1.904, P =0.011), encapsulated bleb (HR=2.756, P <0.001), and preoperative more topical medications (HR=2.475, P =0.008) were associated with a higher risk of surgical failure. Table 5 Cox proportional hazard ratio of risk factors for failure Factor Complete success Qualified success HR (95%CI) P value HR (95%CI) P value Gender 1.265 (0.808 - 1.981) 0.304 0.985 (0.479 - 2.206) 0.966 Age 0.971 (0.602 - 1.565) 0.902 1.326 (0.632 - 2.781) 0.455 Hypertension 1.904 (1.156 - 3.136) 0.011* 1.742 (0.815 - 3.723) 0.152 Glaucoma type 1.288 (0.781 - 2.123) 0.321 1.261 (0.558 - 2.850) 0.577 Preoperative medications 1.189 (0.767 - 1.846) 0.439 2.475 (1.267 - 4.835) 0.008* Preoperative BCVA 0.771 (0.453 - 1.314) 0.339 1.491 (0.739 - 3.008) 0.265 Encapsulated bleb 2.756 (1.592 - 4.770) < 0.001* 1.679 (0.662 - 4.260) 0.275 Surgery type 1.034 (0.628 - 1.703) 0.896 1.159 (0.550 - 2.442) 0.698 HR, hazard ratio; CI, confidence interval; BCVA, best corrected visual acuity. *, P value ≤ 0.05. Discussion Our study is designed to evaluate the effect of trabeculectomy with MMC in glaucomatous patients in Southwest China. We retrospectively reviewed the medical records of glaucomatous patients underwent trabeculectomy in Southwest Hospital from January 2016 to December 2018. The cumulative success rate, visual function, postoperative complications, and risk factors for surgical failure were analyzed. Several lines of studies had evaluated the efficiency of trabeculectomy[ 12 – 22 ]. The success rate of trabeculectomy appeared to be lower in Asian than that of in Caucasians. A multicenter retrospective study conducted in the United Kingdom showed that the complete and qualified success rates were 80% and 87% respectively at the 2-year follow-up[ 23 ]. Ng et al conducted a study on MMC-augmented trabeculectomy in Hong Kong and revealed that the complete and qualified success rates were 47.9% and 75%, respectively, after a mean follow-up period of 21.8 months[ 10 ]. In the present study, the IOP decreased from 32.9 ± 12.0 mmHg to 16.4 ± 5.7 mmHg at 3-year follow up, with a mean 50.2% IOP reduction. The complete and qualified success rates were 47.2% and 77.7% respectively at 3-year follow-up. The success rate is consistent with that of Hong Kong, but lower than that of European and American. This could be explained by the fact that the Chinese patients tend to show a more robust inflammatory response than Caucasians after trabeculectomy. This will lead to scarring and will therefore lower the success rate 24 . Nevertheless, it is difficult to compare the surgical results among different studies, due to differences in ethnicity, definition of success, and follow-up periods. We assume that the differences in study design, intraocular surgical history, and glaucoma subtypes have contributed to the disparity in success rate among different studies. There are limited studies to compare the surgical outcomes after trabeculectomy in PACG versus POAG. We suppose this is partly due to POAG is the main glaucoma type in European and American patients. While in China, PACG is the most common type of glaucoma. We find that there is no significant difference in surgical outcomes between the two types of glaucoma. Although both types of glaucoma are characterized by aqueous humor outflow obstruction and progressive irreversible optic nerve degeneration, the pathophysiology of PACG is different from POAG. PACG is characterized by apposition of the peripheral iris against the trabecular meshwork and closure of an already narrow angle of the anterior chamber. While POAG is caused by increased resistance to aqueous outflow through the trabecular meshwork and the angle is open. For both types of glaucoma, the aim of trabeculectomy is to reconstruct the aqueous humor outflow pathway and will have similar outcomes to lower IOP. It’s known that trabeculectomy, cataract surgery, or combined surgeries of these two are the three options for PACG patients, depending on the patient’s severity of glaucoma and visual compromise from a cataract. Previous studies have compared the effectiveness of these surgical modalities[ 15 , 25 – 27 ]. It is noteworthy that cataract or clear lens removal has been advocated as initial treatment for PACG[ 28 ]. In China, the doctors prefer to perform cataract surgery only for PACG patients with peripheral angle synechiae less than 180 degrees. So, the patients who underwent solo cataract surgery were not included in this study. The results show that both IOP control and the success rates of trabeculectomy are comparable to those of phacotrabeculectomy, which indicate that cataract surgery has poor IOP-lowering efficacy in PACG patients with angle closed totally. At the last follow-up, BCVA was slightly better than that at baseline. One possible reason is that some patients had acute attack of PACG before surgeries. The recorded preoperative vision is worse than their real vision. Another explanation is some patients underwent trabeculectomy together with cataract surgery which will result in better postoperative vision due to clear lens. The mean visual field MD was improved at the last follow-up visit when compared with before surgeries. However, it’s not conclusive that trabeculectomy can improve visual field, because visual field is difficult to restore once damaged. Kashiwagi et al reported that visual function may deteriorate, despite effective control of IOP after trabeculectomy[ 29 ]. Studies have shown that IOP is not the specific factor responsible for glaucomatous optic nerve damage, but rather some circulating and metabolic factors. We presume that visual function may be maintained when the IOP is controlled at the target level by surgery or topical medications[ 30 ]. The rate of postoperative encapsulated bleb was 7.7–12% in previous studies[ 21 , 23 ]. The incidence of postoperative encapsulated bleb in our study is 10.2%, similar to those reports. The incidences of shallow anterior chamber (3.1%) and hyphema (2.5%) were lower in our study. We think this is due to the retrospective nature of our study, which may lead to underestimation of these postoperative complications. In addition, interventions including removal of adjustable sutures or laser suture lysis were performed aforehand to reduce early postoperative complications. The low incidence of malignant glaucoma (1.2%) and choroidal effusion (0.6%) may be attributed to trabeculectomy combined with anterior vitrectomy for those high-risk patients, such as PACG with short axial length or several fundus diseases. Anterior vitrectomy can reduce these complications through balancing the pressure of anterior chamber and vitreous cavity. In further, we did Cox proportional hazard plots and identified that hypertension, encapsulated bleb, and more preoperational topical medications were associated with high risk of surgical failure. To the best of our knowledge, this is the first study to reveal the effect of hypertension on trabeculectomy. Previous studies had shown that hypertension may increase the risk of glaucoma because the common pathogenetic mechanisms in ciliary and renal tubular epithelia[ 31 ]. Patients with hypertension may have higher risk of intraoperative bleeding, which might result in localized inflammatory response and fibrous proliferation in the filtration zone[ 32 ]. Long-term topical IOP-lowering medications has been shown to induce subclinical ocular inflammation with proliferation of fibroblasts, lymphocytes, and macrophages. This will significantly lower trabeculectomy success rate[ 33 ]. Encapsulated bleb is the main cause of failure in glaucoma filtering surgery. For a successful filtration surgery, an appropriate amount of filtration might be necessary, especially in the early stage of post-operation. Ocular massage or needling procedures are necessary when the adhesion between the sclera and the conjunctiva are firm for those with encapsulated bleb[ 8 ]. There are also some limitations in the present study. First, the study is designed as a retrospective study. Some key statistics cannot be measured. Researchers cannot control exposure or outcome assessments, but instead must rely on others for accurate recordkeeping. Second, patients are reviewed from a single tertiary referral center, which would limit the application of the data to other centers. Third, the operations are performed by three skilled surgeons. Different surgeons have their inherent deviations and might affect the surgical outcomes. Fourth, we exclude the patients who are followed up for less than 1 year, which would lead to selective bias of the cohort. Conclusion Our study reports the clinical outcomes of trabeculectomy with MMC in glaucomatous patients in Southwest China. Based on the criteria of 5 < IOP ≤ 21 mmHg and 20% reduction of preoperative IOP, the complete and qualified success rates are 47.2% and 77.7% at 3-year follow up. This data is consistent with previous studies in Chinese population[ 9 , 10 ]. There are no significant differences in surgical outcomes between PACG and POAG. For PACG patients with peripheral angle synechiae more than 180 degrees, the success rates of trabeculectomy and phacotrabeculectomy are comparable. Hypertension, encapsulated bleb, and more topical preoperative medications are associated with surgical failure. Therefore, glaucoma professionals should choose the appropriate glaucoma surgical approach based on the patient's disease condition. Intensive proactive preoperative and postoperative management is essential to prevent the deterioration of visual function. Declarations Acknowledgements The authors thank Professor Hui Lin for his help in statistical analysis of this study. Authors’ contributions ZQ and XY conceived and designed the study. QH, LW, LT and YX contributed to the data acquisition and analysis. ZQ, XY, NW and YL drafted and revised the manuscript. All authors read and approved the manuscript. Funding This study was supported by the National Natural Science Foundation of China (grant number 81770972). The sponsors played no role in the study design, data collection, data analysis, manuscript preparation nor the decision to submit the manuscript for publication. Availability of data and materials The data that support the findings of this study are available from the corresponding author on reasonable request. Ethics approval and consent to participate The study was approved by the human research ethics committee of the Southwest Hospital (KY2020206). Informed consent was obtained from all patients. 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Tham CCY, Kwong YYY, Leung DYL, Lam SW, Li FCH, Chiu TYH, Chan JCH, Lam DSC, Lai JSM: Phacoemulsification versus Combined Phacotrabeculectomy in Medically Uncontrolled Chronic Angle Closure Glaucoma with Cataracts. OPHTHALMOLOGY 2009, 116(4):725-731. Hansapinyo L, Choy BNK, Lai JSM, Tham CC: Phacoemulsification Versus Phacotrabeculectomy in Primary Angle-closure Glaucoma With Cataract. J GLAUCOMA 2020, 29(1):15–23. Azuara-Blanco A, Burr J, Ramsay C, Cooper D, Foster PJ, Friedman DS, Scotland G, Javanbakht M, Cochrane C, Norrie J: Effectiveness of early lens extraction for the treatment of primary angle-closure glaucoma (EAGLE): a randomised controlled trial. LANCET 2016, 388(10052):1389–1397. Kashiwagi K, Kogure S, Mabuchi F, Chiba T, Yamamoto T, Kuwayama Y, Araie M: Change in visual acuity and associated risk factors after trabeculectomy with adjunctive mitomycin C. ACTA OPHTHALMOL 2016, 94(7):e561-e570. Yuasa Y, Sugimoto Y, Hirooka K, Ohkubo S, Higashide T, Sugiyama K, Kiuchi Y: Effectiveness of trabeculectomy with mitomycin C for glaucomatous eyes with low intraocular pressure on treatment eye drops. ACTA OPHTHALMOL 2020, 98(1):e81-e87. Langman MJS: Systemic hypertension and glaucoma: mechanisms in common and co-occurrence. BRIT J OPHTHALMOL 2005, 89(8):960–963. Schlunck G, Meyer-ter-Vehn T, Klink T, Grehn F: Conjunctival fibrosis following filtering glaucoma surgery. EXP EYE RES 2016, 142:76–82. Broadway DC, Chang LP: Trabeculectomy, Risk Factors for Failure and the Preoperative State of the Conjunctiva. J GLAUCOMA 2001, 10(3):237–249. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1080435","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":63978002,"identity":"363ee92a-c7d7-4144-bec3-f62c847b9bd2","order_by":0,"name":"Zuoxin Qin","email":"","orcid":"","institution":"Southwest Hospital/Southwest Eye Hospital, Third Military Medical University (Army Medical University)","correspondingAuthor":false,"prefix":"","firstName":"Zuoxin","middleName":"","lastName":"Qin","suffix":""},{"id":63978003,"identity":"534e8c96-b9c3-450d-9d93-bdfe6fdc358b","order_by":1,"name":"Xi Ying","email":"","orcid":"","institution":"Southwest Hospital/Southwest Eye Hospital, Third Military Medical University (Army Medical University)","correspondingAuthor":false,"prefix":"","firstName":"Xi","middleName":"","lastName":"Ying","suffix":""},{"id":63978004,"identity":"63850c68-aa03-4f01-b178-02b0ae22d5c1","order_by":2,"name":"Qing Han","email":"","orcid":"","institution":"Southwest Hospital/Southwest Eye Hospital, Third Military Medical University (Army Medical University)","correspondingAuthor":false,"prefix":"","firstName":"Qing","middleName":"","lastName":"Han","suffix":""},{"id":63978005,"identity":"14fb5fe6-52eb-4179-81f7-3a57dcc45f6e","order_by":3,"name":"Lu Wang","email":"","orcid":"","institution":"Southwest Hospital/Southwest Eye Hospital, Third Military Medical University (Army Medical University)","correspondingAuthor":false,"prefix":"","firstName":"Lu","middleName":"","lastName":"Wang","suffix":""},{"id":63978006,"identity":"505792dc-7f2a-4405-9640-6fa62c22ef29","order_by":4,"name":"Lian Tan","email":"","orcid":"","institution":"Southwest Hospital/Southwest Eye Hospital, Third Military Medical University (Army Medical University)","correspondingAuthor":false,"prefix":"","firstName":"Lian","middleName":"","lastName":"Tan","suffix":""},{"id":63978007,"identity":"d740c1f1-1863-477c-a0d2-44928f0c28d0","order_by":5,"name":"Yufei Xu","email":"","orcid":"","institution":"Southwest Hospital/Southwest Eye Hospital, Third Military Medical University (Army Medical University)","correspondingAuthor":false,"prefix":"","firstName":"Yufei","middleName":"","lastName":"Xu","suffix":""},{"id":63978008,"identity":"6b0386ae-29f7-4817-bb80-b5423fdcbaca","order_by":6,"name":"Nan Wu","email":"","orcid":"","institution":"Southwest Hospital/Southwest Eye Hospital, Third Military Medical University (Army Medical University)","correspondingAuthor":false,"prefix":"","firstName":"Nan","middleName":"","lastName":"Wu","suffix":""},{"id":63978009,"identity":"c6e099e8-d824-4ee9-aea8-007c4a8d3172","order_by":7,"name":"Yong Liu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAsElEQVRIiWNgGAWjYBACPmYQWWEjx8befoA4LWxgLWfSjPl4ziQQqQVEMLYdTpwn4WBApBZ2HjNp3rbD6W0SDAkMPyq2EeMwoBaec+m5bdKNBxh7ztwmVkuZdW6bzIEEZsY2orWwMaezSSQYkKKlzTmBFC1sxZZzzqQZtgED+SBRfuHnP7zxxpsKG3n59vaDD35UEKEFCFikeKCsA0SpBwLmjz+IVToKRsEoGAUjEwAAZZ8yFhOLzvwAAAAASUVORK5CYII=","orcid":"","institution":"Southwest Hospital/Southwest Eye Hospital, Third Military Medical University (Army Medical University)","correspondingAuthor":true,"prefix":"","firstName":"Yong","middleName":"","lastName":"Liu","suffix":""}],"badges":[],"createdAt":"2021-11-15 04:29:01","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1080435/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1080435/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":15684732,"identity":"52330f1b-5338-4b4d-a2f2-17e07e0a4f9e","added_by":"auto","created_at":"2021-11-18 17:07:07","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":87463,"visible":true,"origin":"","legend":"Kaplan-Meier survival plot of the cumulative probability of success until the last follow-up visit based on the criteria of complete success and qualified success definitions.","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-1080435/v1/270cfc1a6c08d7269e4abc36.jpeg"},{"id":15685023,"identity":"e7ec83b6-8f17-4506-a152-fcc99f194208","added_by":"auto","created_at":"2021-11-18 17:10:07","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":118941,"visible":true,"origin":"","legend":"The mean IOP (A) and the number of glaucoma medications (B) at baseline and each follow-up visit of the PACG and POAG patients. There were no significant differences in IOP control and need for glaucoma medications between the PACG group and POAG group after surgery. Error bars represent SD. The complete success rate (C) and qualified success rate (D) of the PACG and POAG patients are displayed by the Kaplan-Meier survival curve plot. The cumulative success rates of two groups were similar.","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-1080435/v1/fa96381d414391ef8bee2e79.jpeg"},{"id":15684734,"identity":"a2b29f62-c65d-4feb-b2bd-893515780023","added_by":"auto","created_at":"2021-11-18 17:07:08","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":121100,"visible":true,"origin":"","legend":"The mean IOP (A) and the number of glaucoma medications (B) at baseline and each follow-up visit of the PACG patients who underwent solo trabeculectomy or phacotrabeculectomy. There were no significant differences in IOP control between the two groups after surgery. There were no significant differences for the need for glaucoma medications between the two groups at all time points except 1 month after surgery. Error bars represent SD. The Kaplan-Meier survival curve plot showing complete success rate (C) and qualified success rate (D) of the two groups. There were no significant differences in the cumulative success rates between the trabeculectomy group and phacotrabeculectomy group after surgery.","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-1080435/v1/64b9513a67aedeb07034a3b9.jpeg"},{"id":19061847,"identity":"46219019-1341-4cf6-822f-ef32b1bf2fb0","added_by":"auto","created_at":"2022-03-10 05:14:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":480639,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1080435/v1/f6dc6db4-988e-420f-8162-83be96c686b2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eSuccess and Failure Factors for Trabeculectomy in Glaucomatous Patients in Southwest China: A 325 Eyes Analysis\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eGlaucoma is an irreversible optic neuropathy that considered to be one of the leading causes of blindness worldwide. More than 90% of patients are unaware of their vision loss and many risk factors are associated with physiopathology of glaucoma. Among them, intraocular pressure (IOP) remains the main modifiable risk factor, and surgical treatment is the standard care for glaucomatous patient aiming to lower IOP if not controlled by pharmacological agents.\u003c/p\u003e \u003cp\u003eNowadays, minimally invasive glaucoma surgeries are blooming[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Recent studies of the American Glaucoma Society have demonstrated a rise in the proportion of using tube shunts and a decline in the popularity of trabeculectomy[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Nevertheless, trabeculectomy still remains the most effective procedure\u003csup\u003e5\u003c/sup\u003e for glaucoma management in China since most patients suffer from primary angle-closure glaucoma (PACG). The success rate of trabeculectomy has been increasing along with innovation of intraoperative techniques such as wide application of antifibrotics and placement of adjustable sutures. It is believed that the postoperative interventions, for instance, removal of adjustable sutures or laser suture lysis, ocular massage, and bleb needling, have reduced complications and improved outcomes of trabeculectomy[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere are some studies report the efficacy and safety of trabeculectomy in Asian. The 5-year success rate was 87.3% according to the Japanese Collaborative Bleb-Related Infection Incidence and Treatment Study (CBIITS)[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. A research in Taiwan described a cumulative qualified success rate of 67.1% in a 10-year follow-up period[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. A retrospective study on mitomycin C (MMC)-augmented trabeculectomy revealed that the qualified success rate was 75% after a follow-up period of 21.8 months in Hong Kong[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, studies on trabeculectomy in mainland Chinese patients are lacking. To evaluate the efficiency and safety for trabeculectomy, we retrospectively review 325 eyes of 261 glaucomatous patients who underwent trabeculectomy with MMC and elucidate the success and failure factors for trabeculectomy in Southwest Chinese patients.\u003c/p\u003e"},{"header":"Patients And Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe medical records of patients who were diagnosed as glaucoma and underwent trabeculectomy with MMC in Southwest Hospital of China were retrospectively reviewed from January 2016 to December 2018. This retrospective study was approved by the ethics committee of the Southwest Hospital (KY2020206) and adhered to the tenets of the Declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe inclusion criteria were as follows. Patients were over 18 years old, diagnosed of glaucoma, and underwent initial trabeculectomy with MMC. The surgery includes trabeculectomy concomitantly performed with cataract surgery or anterior vitrectomy. Patients had no previous intraocular surgeries except laser peripheral iridotomy (LPI) and selective laser trabeculoplasty (SLT), and had been followed up for minimum 1 year. The exclusion criteria were patients of less than 18 years old, history of cataract surgery or trabeculectomy, and less than 1-year follow-up period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePreoperative data including the patients\u0026rsquo; demographic information, glaucoma type, IOP, number of IOP-lowering medications, best corrected visual acuity (BCVA), mean deviation (MD) of visual field, vertical cup to disc ratio, and surgery type were collected. IOP was measured by non-contact or rebound tonometer.\u0026nbsp;At least 3 consecutive readings were recorded for each patient at each follow-up point. BCVA measurements were converted to logarithm of the minimum angle of resolution (logMAR) equivalents for the purpose of data analysis[11]. Postoperative data included BCVA, IOP, number of IOP-lowering medications, complications, and surgical interventions.\u003c/p\u003e\n\u003cp\u003eAccording to the World Glaucoma Association guidelines, a complete success for surgery is defined as a postoperative IOP of \u0026gt; 5 and \u0026le; 21 mmHg and 20% reduction of IOP compared to preoperative without IOP-lowering medications. A qualified success for surgery is defined as the abovementioned postoperative IOP with or without IOP-lowering medications. The primary outcomes were IOP, the number of IOP-lowering medications, and cumulative success rate. The secondary outcomes included BCVA, MD of visual field, major complications, and risk factors for surgical failure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe surgeries were performed by highly skilled glaucoma specialists. Topical anesthesia or general anesthesia were tailored to the best experience for the patients and their specific needs. After applying a corneal traction suture, a fornix-based conjunctival flap was created. The subconjunctival tissue was then dissected to expose the sclera in an appropriate size. After bipolar coagulation hemostasis and a rectangular partial-thickness scleral flap was made, a sponge soaked with MMC (0.4 mg/mL) was placed on the scleral bed and subconjunctival area for 2-5 min at the surgeon\u0026rsquo;s discretion. The area was then irrigated thoroughly with balanced salt solution. A paracentesis was then performed to lower intraocular pressure and an anterior ostium was created, followed by peripheral iridectomy. After the scleral flap was sutured, the conjunctiva flap was closed separately to make a watertight closure. Prednisolone and antibiotics were administrated topically immediately post-surgery. Complications such as encapsulated bleb, shallow anterior chamber, hyphema, wound leak, malignant glaucoma, and choroidal effusion were closely observed. Personalized interventions such as removal of adjustable sutures, laser suture lysis, massage, bleb needling, and antifibrotic injection were performed based on the surgeon\u0026rsquo;s clinical judgement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analysis was performed by SPSS software (version 20.0, IBM, USA). Continuous variables were presented as mean \u0026plusmn; SD. \u003cem\u003eT\u003c/em\u003e-test was used to compare the measurements of IOP, the number of topical medications, BCVA (logMAR), visual field MD. Kaplan Meier survival analysis was applied to draw the survival curves and calculate success rates. Comparison of success rate between groups was performed using the \u003cem\u003eLog rank\u003c/em\u003e test. Cox proportional hazards regression analysis was used to identify factors associated with surgical failure. A \u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u0026le; 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eEye characteristics\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 325 eyes of 261 patients were observed in the study, including 116 males (44.4%) and 145 females (55.6%). The mean follow-up time was 22 \u0026plusmn; 12 months, ranging from 12 to 57 months. The average age was 59.3 \u0026plusmn; 12.8 (19-90) years old, and 189 (58.2%) patients were over 60 years old. PACG was the main type of glaucoma, which accounted for 64.6% of patients. The mean preoperative IOP was 32.9 \u0026plusmn;\u0026nbsp;12.0 mmHg, and the mean number of topical IOP-lowering medications before surgery was 3.0 \u0026plusmn;\u0026nbsp;0.9. Of patients, 245 (75.4%) underwent trabeculectomy alone, and 80 (24.6%) received trabeculectomy combined with cataract surgery. The demographic characteristics of the patients and preoperative ocular characteristics are presented in Table 1. Information about visual field MD was unavailable in 40 cases.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e Demographic and ocular characteristics of patients with trabeculectomy at baseline\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.86507936507937%\"\u003e\n \u003cp\u003eGender, no. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.13492063492063%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.86507936507937%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.13492063492063%\"\u003e\n \u003cp\u003e145 (55.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.86507936507937%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.13492063492063%\"\u003e\n \u003cp\u003e116 (44.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.86507936507937%\"\u003e\n \u003cp\u003eAge (yrs), Mean \u0026plusmn; SD \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.13492063492063%\"\u003e\n \u003cp\u003e59.3 \u0026plusmn; 12.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.86507936507937%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026lt; 60, no. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.13492063492063%\"\u003e\n \u003cp\u003e136 (41.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.86507936507937%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026ge; 60, no. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.13492063492063%\"\u003e\n \u003cp\u003e189 (58.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.86507936507937%\"\u003e\n \u003cp\u003eHypertension, no. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.13492063492063%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.86507936507937%\"\u003e\n \u003cp\u003e\u0026nbsp; Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.13492063492063%\"\u003e\n \u003cp\u003e54 (16.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.86507936507937%\"\u003e\n \u003cp\u003e\u0026nbsp; No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.13492063492063%\"\u003e\n \u003cp\u003e271 (83.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.86507936507937%\"\u003e\n \u003cp\u003eDiagnosis, no. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.13492063492063%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.86507936507937%\"\u003e\n \u003cp\u003ePACG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.13492063492063%\"\u003e\n \u003cp\u003e210 (64.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.86507936507937%\"\u003e\n \u003cp\u003ePOAG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.13492063492063%\"\u003e\n \u003cp\u003e97 (29.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.86507936507937%\"\u003e\n \u003cp\u003eSG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.13492063492063%\"\u003e\n \u003cp\u003e10 (3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.86507936507937%\"\u003e\n \u003cp\u003eCG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.13492063492063%\"\u003e\n \u003cp\u003e8 (2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.86507936507937%\"\u003e\n \u003cp\u003eBCVA (logMAR), Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.13492063492063%\"\u003e\n \u003cp\u003e0.77\u0026nbsp;\u0026plusmn; 0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.86507936507937%\"\u003e\n \u003cp\u003e\u0026le;\u0026nbsp;1, no. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.13492063492063%\"\u003e\n \u003cp\u003e254 (78.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.86507936507937%\"\u003e\n \u003cp\u003e\u0026gt; 1, no. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.13492063492063%\"\u003e\n \u003cp\u003e71 (21.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.86507936507937%\"\u003e\n \u003cp\u003eIOP (mmHg), Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.13492063492063%\"\u003e\n \u003cp\u003e32.9\u0026nbsp;\u0026plusmn;\u0026nbsp;12.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.86507936507937%\"\u003e\n \u003cp\u003eMedications, Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.13492063492063%\"\u003e\n \u003cp\u003e3.0\u0026nbsp;\u0026plusmn;\u0026nbsp;0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.86507936507937%\"\u003e\n \u003cp\u003eVisual filed MD (dB), Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.13492063492063%\"\u003e\n \u003cp\u003e-19.73\u0026nbsp;\u0026plusmn; 10.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.86507936507937%\"\u003e\n \u003cp\u003e\u0026gt; -15, no. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.13492063492063%\"\u003e\n \u003cp\u003e100 (30.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.86507936507937%\"\u003e\n \u003cp\u003e\u0026le;\u0026nbsp;-15, no. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.13492063492063%\"\u003e\n \u003cp\u003e185 (57.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.86507936507937%\"\u003e\n \u003cp\u003eMissing data, no. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.13492063492063%\"\u003e\n \u003cp\u003e40 (12.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.86507936507937%\"\u003e\n \u003cp\u003ePreoperative C/D, Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.13492063492063%\"\u003e\n \u003cp\u003e0.8\u0026nbsp;\u0026plusmn;\u0026nbsp;0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.86507936507937%\"\u003e\n \u003cp\u003eSurgery type, no. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.13492063492063%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.86507936507937%\"\u003e\n \u003cp\u003e\u0026nbsp; Trabeculectomy\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.13492063492063%\"\u003e\n \u003cp\u003e245 (75.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.86507936507937%\"\u003e\n \u003cp\u003e\u0026nbsp; Phacotrabeculectomy\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.13492063492063%\"\u003e\n \u003cp\u003e80 (24.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ePACG, primary angle-closure glaucoma; POAG, primary open angle glaucoma; SG, secondary glaucoma; CG, congenital glaucoma; BCVA, best corrected visual acuity; logMAR, logarithm of the minimal angle of resolution; IOP, intraocular pressure; SD, standard deviation; MD, mean deviation; dB, Decibels; C/D, vertical cup to disc ratio.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical outcomes and success rate \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe IOP and the number of topical IOP-lowering medications at each follow-up time are shown in Table 2. The mean IOP and glaucoma medications were significantly decreased from 32.9 \u0026plusmn; 12.0 mmHg to 16.4 \u0026plusmn; 5.7 mmHg (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.0001) and 3.0 \u0026plusmn; 0.9 to 0.9 \u0026plusmn; 1.0 (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.0001), respectively, at 3-year follow-up. The IOP values and the number of topical medications were consistently lower than those observed at baseline throughout the follow-up period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e IOP and the number of glaucoma medications for patients at baseline and follow-up\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.104536489151872%\"\u003e\n \u003cp\u003eFollow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.104536489151872%\"\u003e\n \u003cp\u003eIOP (mmHg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.357001972386588%\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.04930966469428%\"\u003e\n \u003cp\u003eNo. of medications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.384615384615385%\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.104536489151872%\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.104536489151872%\"\u003e\n \u003cp\u003e32.9 \u0026plusmn; 12.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.357001972386588%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.04930966469428%\"\u003e\n \u003cp\u003e3.0 \u0026plusmn; 0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.384615384615385%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.104536489151872%\"\u003e\n \u003cp\u003e1 month\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.104536489151872%\"\u003e\n \u003cp\u003e14.2 \u0026plusmn; 6.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.357001972386588%\"\u003e\n \u003cp\u003e\u0026lt; 0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.04930966469428%\"\u003e\n \u003cp\u003e0.1 \u0026plusmn; 0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.384615384615385%\"\u003e\n \u003cp\u003e\u0026lt; 0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.104536489151872%\"\u003e\n \u003cp\u003e3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.104536489151872%\"\u003e\n \u003cp\u003e14.4 \u0026plusmn; 5.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.357001972386588%\"\u003e\n \u003cp\u003e\u0026lt; 0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.04930966469428%\"\u003e\n \u003cp\u003e0.2 \u0026plusmn; 0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.384615384615385%\"\u003e\n \u003cp\u003e\u0026lt; 0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.104536489151872%\"\u003e\n \u003cp\u003e6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.104536489151872%\"\u003e\n \u003cp\u003e14.9 \u0026plusmn; 5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.357001972386588%\"\u003e\n \u003cp\u003e\u0026lt; 0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.04930966469428%\"\u003e\n \u003cp\u003e0.3 \u0026plusmn; 0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.384615384615385%\"\u003e\n \u003cp\u003e\u0026lt; 0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.104536489151872%\"\u003e\n \u003cp\u003e12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.104536489151872%\"\u003e\n \u003cp\u003e14.2 \u0026plusmn; 4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.357001972386588%\"\u003e\n \u003cp\u003e\u0026lt; 0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.04930966469428%\"\u003e\n \u003cp\u003e0.3 \u0026plusmn; 0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.384615384615385%\"\u003e\n \u003cp\u003e\u0026lt; 0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.104536489151872%\"\u003e\n \u003cp\u003e24 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.104536489151872%\"\u003e\n \u003cp\u003e16.0 \u0026plusmn; 5.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.357001972386588%\"\u003e\n \u003cp\u003e\u0026lt; 0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.04930966469428%\"\u003e\n \u003cp\u003e0.6 \u0026plusmn; 0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.384615384615385%\"\u003e\n \u003cp\u003e\u0026lt; 0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.104536489151872%\"\u003e\n \u003cp\u003e36 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.104536489151872%\"\u003e\n \u003cp\u003e16.4 \u0026plusmn; 5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.357001972386588%\"\u003e\n \u003cp\u003e\u0026lt; 0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.04930966469428%\"\u003e\n \u003cp\u003e0.9 \u0026plusmn; 1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.384615384615385%\"\u003e\n \u003cp\u003e\u0026lt; 0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;IOP, intraocular pressure; No., number.\u003c/p\u003e\n\u003cp\u003eThe Kaplan-Meier survival plot of success rate for included patients is demonstrated in Figure 1. The cumulative complete success rate was 77.8%, 66.8% and 47.2% at 1-, 2-, and 3-year follow-up visits, respectively. The cumulative qualified success rate was 92.0%, 88.5% and 77.7% at 1-, 2-, and 3-year follow-up visits, respectively.\u003c/p\u003e\n\u003cp\u003eWe compared the surgical outcomes between PACG and POAG patients (Figure 2). Before the surgery, both the IOP values and the number of medications in PACG group were higher. However, after the surgery, both IOP and the number of glaucoma medications were comparable between PACG and POAG throughout 3-year follow-up. The 3-year complete success rates of PACG and POAG were 54.6%, 46.4%, while the qualified success rates were 78.7%, 71.5%, respectively. The cumulative success rates of two groups were similar.\u003c/p\u003e\n\u003cp\u003eFor PACG patients who underwent with trabeculectomy alone or phacotrabeculectomy, there was no significant difference in IOP control between the two surgical procedures. There was no significant difference with respect to IOP-lowering medications between the two surgical procedures at all follow up times except 1 month after surgery. The success rates of two surgical procedures were comparable (Figure 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVisual acuity and visual field test\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe changes of BCVA (logMAR) and visual field MD are shown in Table 3. The mean BCVA (logMAR) was 0.77 \u0026plusmn; 0.94 before surgery and 0.67 \u0026plusmn; 0.83 at the last follow-up. There was no significant difference between baseline and last follow-up (\u003cem\u003eP\u003c/em\u003e=0.14). At the last follow-up, the mean visual field MD was -16.80 \u0026plusmn; 11.47 dB, which was slightly improved compared with that at baseline (\u003cem\u003eP\u003c/em\u003e=0.04).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e Visual acuity and visual field results at the last follow-up visit.\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 40.5312%;\" valign=\"top\" width=\"41.260162601626014%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.9931%;\" valign=\"top\" width=\"30.48780487804878%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.3602%;\" valign=\"top\" width=\"28.252032520325205%\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 40.5312%;\" valign=\"top\" width=\"41.260162601626014%\"\u003e\n \u003cp\u003eBCVA (logMAR), mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.9931%;\" valign=\"top\" width=\"30.48780487804878%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.3602%;\" valign=\"top\" width=\"28.252032520325205%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 40.5312%;\" valign=\"top\" width=\"41.260162601626014%\"\u003e\n \u003cp\u003e\u0026nbsp; Baseline (n = 325)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.9931%;\" valign=\"top\" width=\"30.48780487804878%\"\u003e\n \u003cp\u003e0.77 \u0026plusmn; 0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 18.3602%;\" width=\"28.252032520325205%\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 40.5312%;\" valign=\"top\" width=\"57.507082152974505%\"\u003e\n \u003cp\u003eLast follow-up (n = 325)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.9931%;\" valign=\"top\" width=\"42.492917847025495%\"\u003e\n \u003cp\u003e0.67 \u0026plusmn; 0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 40.5312%;\" valign=\"top\" width=\"41.260162601626014%\"\u003e\n \u003cp\u003eMD of VF (dB), mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.9931%;\" valign=\"top\" width=\"30.48780487804878%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.3602%;\" valign=\"top\" width=\"28.252032520325205%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 40.5312%;\" valign=\"top\" width=\"41.260162601626014%\"\u003e\n \u003cp\u003eBaseline (n = 285)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.9931%;\" valign=\"top\" width=\"30.48780487804878%\"\u003e\n \u003cp\u003e-19.73 \u0026plusmn; 10.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 18.3602%;\" width=\"28.252032520325205%\"\u003e\n \u003cp\u003e0.04*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 40.5312%;\" valign=\"top\" width=\"57.507082152974505%\"\u003e\n \u003cp\u003e\u0026nbsp; Last follow-up (n = 66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40.9931%;\" valign=\"top\" width=\"42.492917847025495%\"\u003e\n \u003cp\u003e-16.80 \u0026plusmn; 11.47\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eBCVA, best corrected visual acuity; logMAR, logarithm of the minimal angle of resolution; SD, standard deviation; MD, mean deviation; VF, visual field; dB, Decibels.\u003c/p\u003e\n\u003cp\u003e*Not all patients at baseline returned for perimetry follow up\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePostoperative complications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn our study, a total of 62 (19.1%) eyes developed postoperative complications in the follow up period. Of these, 33 (10.2%) had encapsulated bleb, 10 (3.1%) had shallow anterior chamber, 5 (1.5%) had wound leak, and 4 (1.2%) had malignant glaucoma. Postoperative complications during follow-up visits are displayed in Table 4. Encapsulated bleb was treated with massage, needling, or antifibrotic injection based on surgeon\u0026rsquo;s clinical judgement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e Postoperative complications during follow-up visits.\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"60.4%\"\u003e\n \u003cp\u003eComplications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.6%\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"60.4%\"\u003e\n \u003cp\u003eEncapsulated bleb\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.6%\"\u003e\n \u003cp\u003e33 (10.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"60.4%\"\u003e\n \u003cp\u003eShallow anterior chamber\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.6%\"\u003e\n \u003cp\u003e10 (3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"60.4%\"\u003e\n \u003cp\u003eHyphema\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.6%\"\u003e\n \u003cp\u003e8 (2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"60.4%\"\u003e\n \u003cp\u003eWound leak\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.6%\"\u003e\n \u003cp\u003e5 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"60.4%\"\u003e\n \u003cp\u003eMalignant glaucoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.6%\"\u003e\n \u003cp\u003e4 (1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"60.4%\"\u003e\n \u003cp\u003eChoroidal effusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.6%\"\u003e\n \u003cp\u003e2 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"60.4%\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"39.6%\"\u003e\n \u003cp\u003e62 (19.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRisk factors for surgical failure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe risk factors for surgical failure were investigated using Cox proportional hazard analysis (see Table 5). Hypertension (HR=1.904, \u003cem\u003eP\u003c/em\u003e=0.011), encapsulated bleb (HR=2.756, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001), and preoperative more topical medications (HR=2.475, \u003cem\u003eP\u003c/em\u003e=0.008) were associated with a higher risk of surgical failure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5\u003c/strong\u003e Cox proportional hazard ratio of risk factors for failure\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" width=\"27.75800711743772%\"\u003e\n \u003cp\u003eFactor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"37.90035587188612%\"\u003e\n \u003cp\u003eComplete success\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" width=\"34.34163701067616%\"\u003e\n \u003cp\u003eQualified success\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29.6767%;\" valign=\"top\" width=\"35.38083538083538%\"\u003e\n \u003cp\u003eHR (95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.515%;\" valign=\"top\" width=\"17.1990171990172%\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"31.695331695331696%\"\u003e\n \u003cp\u003eHR (95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"15.724815724815725%\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.75800711743772%\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29.6767%;\" valign=\"top\" width=\"25.622775800711743%\"\u003e\n \u003cp\u003e1.265 (0.808 - 1.981)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.515%;\" valign=\"top\" width=\"12.455516014234876%\"\u003e\n \u003cp\u003e0.304\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"24.555160142348754%\"\u003e\n \u003cp\u003e0.985 (0.479 - 2.206)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.608540925266905%\"\u003e\n \u003cp\u003e0.966\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.75800711743772%\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29.6767%;\" valign=\"top\" width=\"25.622775800711743%\"\u003e\n \u003cp\u003e0.971 (0.602 - 1.565)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.515%;\" valign=\"top\" width=\"12.455516014234876%\"\u003e\n \u003cp\u003e0.902\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"24.555160142348754%\"\u003e\n \u003cp\u003e1.326 (0.632 - 2.781)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.608540925266905%\"\u003e\n \u003cp\u003e0.455\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.75800711743772%\"\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29.6767%;\" valign=\"top\" width=\"25.622775800711743%\"\u003e\n \u003cp\u003e1.904 (1.156 - 3.136)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.515%;\" valign=\"top\" width=\"12.455516014234876%\"\u003e\n \u003cp\u003e0.011*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"24.555160142348754%\"\u003e\n \u003cp\u003e1.742 (0.815 - 3.723)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.608540925266905%\"\u003e\n \u003cp\u003e0.152\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.75800711743772%\"\u003e\n \u003cp\u003eGlaucoma type\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29.6767%;\" valign=\"top\" width=\"25.622775800711743%\"\u003e\n \u003cp\u003e1.288 (0.781 - 2.123)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.515%;\" valign=\"top\" width=\"12.455516014234876%\"\u003e\n \u003cp\u003e0.321\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"24.555160142348754%\"\u003e\n \u003cp\u003e1.261 (0.558 - 2.850)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.608540925266905%\"\u003e\n \u003cp\u003e0.577\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.75800711743772%\"\u003e\n \u003cp\u003ePreoperative medications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29.6767%;\" valign=\"top\" width=\"25.622775800711743%\"\u003e\n \u003cp\u003e1.189 (0.767 - 1.846)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.515%;\" valign=\"top\" width=\"12.455516014234876%\"\u003e\n \u003cp\u003e0.439\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"24.555160142348754%\"\u003e\n \u003cp\u003e2.475 (1.267 - 4.835)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.608540925266905%\"\u003e\n \u003cp\u003e0.008*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.75800711743772%\"\u003e\n \u003cp\u003ePreoperative BCVA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29.6767%;\" valign=\"top\" width=\"25.622775800711743%\"\u003e\n \u003cp\u003e0.771 (0.453 - 1.314)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.515%;\" valign=\"top\" width=\"12.455516014234876%\"\u003e\n \u003cp\u003e0.339\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"24.555160142348754%\"\u003e\n \u003cp\u003e1.491 (0.739 - 3.008)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.608540925266905%\"\u003e\n \u003cp\u003e0.265\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.75800711743772%\"\u003e\n \u003cp\u003eEncapsulated bleb\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29.6767%;\" valign=\"top\" width=\"25.622775800711743%\"\u003e\n \u003cp\u003e2.756 (1.592 - 4.770)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.515%;\" valign=\"top\" width=\"12.455516014234876%\"\u003e\n \u003cp\u003e\u0026lt; 0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"24.555160142348754%\"\u003e\n \u003cp\u003e1.679 (0.662 - 4.260)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.608540925266905%\"\u003e\n \u003cp\u003e0.275\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.75800711743772%\"\u003e\n \u003cp\u003eSurgery type\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29.6767%;\" valign=\"top\" width=\"25.622775800711743%\"\u003e\n \u003cp\u003e1.034 (0.628 - 1.703)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.515%;\" valign=\"top\" width=\"12.455516014234876%\"\u003e\n \u003cp\u003e0.896\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"24.555160142348754%\"\u003e\n \u003cp\u003e1.159 (0.550 - 2.442)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.608540925266905%\"\u003e\n \u003cp\u003e0.698\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eHR, hazard ratio; CI, confidence interval; BCVA, best corrected visual acuity. *, \u003cem\u003eP\u003c/em\u003e value \u0026le; 0.05.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study is designed to evaluate the effect of trabeculectomy with MMC in glaucomatous patients in Southwest China. We retrospectively reviewed the medical records of glaucomatous patients underwent trabeculectomy in Southwest Hospital from January 2016 to December 2018. The cumulative success rate, visual function, postoperative complications, and risk factors for surgical failure were analyzed.\u003c/p\u003e \u003cp\u003eSeveral lines of studies had evaluated the efficiency of trabeculectomy[\u003cspan additionalcitationids=\"CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The success rate of trabeculectomy appeared to be lower in Asian than that of in Caucasians. A multicenter retrospective study conducted in the United Kingdom showed that the complete and qualified success rates were 80% and 87% respectively at the 2-year follow-up[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. \u003cem\u003eNg et al\u003c/em\u003e conducted a study on MMC-augmented trabeculectomy in Hong Kong and revealed that the complete and qualified success rates were 47.9% and 75%, respectively, after a mean follow-up period of 21.8 months[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In the present study, the IOP decreased from 32.9 \u0026plusmn; 12.0 mmHg to 16.4 \u0026plusmn; 5.7 mmHg at 3-year follow up, with a mean 50.2% IOP reduction. The complete and qualified success rates were 47.2% and 77.7% respectively at 3-year follow-up. The success rate is consistent with that of Hong Kong, but lower than that of European and American. This could be explained by the fact that the Chinese patients tend to show a more robust inflammatory response than Caucasians after trabeculectomy. This will lead to scarring and will therefore lower the success rate\u003csup\u003e24\u003c/sup\u003e. Nevertheless, it is difficult to compare the surgical results among different studies, due to differences in ethnicity, definition of success, and follow-up periods. We assume that the differences in study design, intraocular surgical history, and glaucoma subtypes have contributed to the disparity in success rate among different studies.\u003c/p\u003e \u003cp\u003eThere are limited studies to compare the surgical outcomes after trabeculectomy in PACG versus POAG. We suppose this is partly due to POAG is the main glaucoma type in European and American patients. While in China, PACG is the most common type of glaucoma. We find that there is no significant difference in surgical outcomes between the two types of glaucoma. Although both types of glaucoma are characterized by aqueous humor outflow obstruction and progressive irreversible optic nerve degeneration, the pathophysiology of PACG is different from POAG. PACG is characterized by apposition of the peripheral iris against the trabecular meshwork and closure of an already narrow angle of the anterior chamber. While POAG is caused by increased resistance to aqueous outflow through the trabecular meshwork and the angle is open. For both types of glaucoma, the aim of trabeculectomy is to reconstruct the aqueous humor outflow pathway and will have similar outcomes to lower IOP.\u003c/p\u003e \u003cp\u003eIt\u0026rsquo;s known that trabeculectomy, cataract surgery, or combined surgeries of these two are the three options for PACG patients, depending on the patient\u0026rsquo;s severity of glaucoma and visual compromise from a cataract. Previous studies have compared the effectiveness of these surgical modalities[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. It is noteworthy that cataract or clear lens removal has been advocated as initial treatment for PACG[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In China, the doctors prefer to perform cataract surgery only for PACG patients with peripheral angle synechiae less than 180 degrees. So, the patients who underwent solo cataract surgery were not included in this study. The results show that both IOP control and the success rates of trabeculectomy are comparable to those of phacotrabeculectomy, which indicate that cataract surgery has poor IOP-lowering efficacy in PACG patients with angle closed totally.\u003c/p\u003e \u003cp\u003eAt the last follow-up, BCVA was slightly better than that at baseline. One possible reason is that some patients had acute attack of PACG before surgeries. The recorded preoperative vision is worse than their real vision. Another explanation is some patients underwent trabeculectomy together with cataract surgery which will result in better postoperative vision due to clear lens. The mean visual field MD was improved at the last follow-up visit when compared with before surgeries. However, it\u0026rsquo;s not conclusive that trabeculectomy can improve visual field, because visual field is difficult to restore once damaged. \u003cem\u003eKashiwagi et al\u003c/em\u003e reported that visual function may deteriorate, despite effective control of IOP after trabeculectomy[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Studies have shown that IOP is not the specific factor responsible for glaucomatous optic nerve damage, but rather some circulating and metabolic factors. We presume that visual function may be maintained when the IOP is controlled at the target level by surgery or topical medications[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe rate of postoperative encapsulated bleb was 7.7\u0026ndash;12% in previous studies[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The incidence of postoperative encapsulated bleb in our study is 10.2%, similar to those reports. The incidences of shallow anterior chamber (3.1%) and hyphema (2.5%) were lower in our study. We think this is due to the retrospective nature of our study, which may lead to underestimation of these postoperative complications. In addition, interventions including removal of adjustable sutures or laser suture lysis were performed aforehand to reduce early postoperative complications. The low incidence of malignant glaucoma (1.2%) and choroidal effusion (0.6%) may be attributed to trabeculectomy combined with anterior vitrectomy for those high-risk patients, such as PACG with short axial length or several fundus diseases. Anterior vitrectomy can reduce these complications through balancing the pressure of anterior chamber and vitreous cavity.\u003c/p\u003e \u003cp\u003eIn further, we did Cox proportional hazard plots and identified that hypertension, encapsulated bleb, and more preoperational topical medications were associated with high risk of surgical failure. To the best of our knowledge, this is the first study to reveal the effect of hypertension on trabeculectomy. Previous studies had shown that hypertension may increase the risk of glaucoma because the common pathogenetic mechanisms in ciliary and renal tubular epithelia[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Patients with hypertension may have higher risk of intraoperative bleeding, which might result in localized inflammatory response and fibrous proliferation in the filtration zone[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Long-term topical IOP-lowering medications has been shown to induce subclinical ocular inflammation with proliferation of fibroblasts, lymphocytes, and macrophages. This will significantly lower trabeculectomy success rate[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Encapsulated bleb is the main cause of failure in glaucoma filtering surgery. For a successful filtration surgery, an appropriate amount of filtration might be necessary, especially in the early stage of post-operation. Ocular massage or needling procedures are necessary when the adhesion between the sclera and the conjunctiva are firm for those with encapsulated bleb[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere are also some limitations in the present study. First, the study is designed as a retrospective study. Some key statistics cannot be measured. Researchers cannot control exposure or outcome assessments, but instead must rely on others for accurate recordkeeping. Second, patients are reviewed from a single tertiary referral center, which would limit the application of the data to other centers. Third, the operations are performed by three skilled surgeons. Different surgeons have their inherent deviations and might affect the surgical outcomes. Fourth, we exclude the patients who are followed up for less than 1 year, which would lead to selective bias of the cohort.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study reports the clinical outcomes of trabeculectomy with MMC in glaucomatous patients in Southwest China. Based on the criteria of 5 \u0026lt; IOP \u0026le; 21 mmHg and 20% reduction of preoperative IOP, the complete and qualified success rates are 47.2% and 77.7% at 3-year follow up. This data is consistent with previous studies in Chinese population[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. There are no significant differences in surgical outcomes between PACG and POAG. For PACG patients with peripheral angle synechiae more than 180 degrees, the success rates of trabeculectomy and phacotrabeculectomy are comparable. Hypertension, encapsulated bleb, and more topical preoperative medications are associated with surgical failure. Therefore, glaucoma professionals should choose the appropriate glaucoma surgical approach based on the patient's disease condition. Intensive proactive preoperative and postoperative management is essential to prevent the deterioration of visual function.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank Professor Hui Lin for his help in statistical analysis of this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZQ and XY conceived and designed the study. QH, LW, LT and YX contributed to the data acquisition and analysis. ZQ, XY, NW and YL drafted and revised the manuscript. All authors read and approved the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the National Natural Science Foundation of China (grant number 81770972). The sponsors played no role in the study design, data collection, data analysis, manuscript preparation nor the decision to submit the manuscript for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the human research ethics committee of the Southwest Hospital (KY2020206). Informed consent was obtained from all patients. All methods were performed in accordance with the relevant guidelines and regulations adhered to the tenets of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest associated with this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFrancis BA, Singh K, Lin SC, Hodapp E, Jampel HD, Samples JR, Smith SD: Novel Glaucoma Procedures. \u003cem\u003eOPHTHALMOLOGY\u003c/em\u003e 2011, 118(7):1466-1480.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChang TC, Vanner EA, Parrish RK: Glaucoma surgery preferences when the surgeon adopts the role of the patient. \u003cem\u003eEYE\u003c/em\u003e 2019, 33(10):1577\u0026ndash;1583.\u003c/span\u003e\u003c/li\u003e 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\u003cem\u003eOPHTHALMOLOGY\u003c/em\u003e 2016, 123(4):789-795.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGedde SJ, Feuer WJ, Lim KS, Barton K, Goyal S, Ahmed IIK, Brandt JD: Treatment Outcomes in the Primary Tube Versus Trabeculectomy Study after 3 Years of Follow-up. \u003cem\u003eOPHTHALMOLOGY\u003c/em\u003e 2020, 127(3):333\u0026ndash;345.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGedde SJ, Schiffman JC, Feuer WJ, Herndon LW, Brandt JD, Budenz DL: Treatment Outcomes in the Tube Versus Trabeculectomy (TVT) Study After Five Years of Follow-up. \u003cem\u003eAM J OPHTHALMOL\u003c/em\u003e 2012, 153(5):789\u0026ndash;803.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKirwan JF, Lockwood AJ, Shah P, Macleod A, Broadway DC, King AJ, McNaught AI, Agrawal P: Trabeculectomy in the 21st century: a multicenter analysis. \u003cem\u003eOPHTHALMOLOGY\u003c/em\u003e 2013, 120(12):2532\u0026ndash;2539.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHusain R, Clarke JC, Seah SK, Khaw PT: A review of trabeculectomy in East Asian people--the influence of race. \u003cem\u003eEye (Lond)\u003c/em\u003e 2005, 19(3):243\u0026ndash;252.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTsai H, Liu CJ, Cheng C: Combined trabeculectomy and cataract extraction versus trabeculectomy alone in primary angle-closure glaucoma. \u003cem\u003eBRIT J OPHTHALMOL\u003c/em\u003e 2009, 93(7):943\u0026ndash;948.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTham CCY, Kwong YYY, Leung DYL, Lam SW, Li FCH, Chiu TYH, Chan JCH, Lam DSC, Lai JSM: Phacoemulsification versus Combined Phacotrabeculectomy in Medically Uncontrolled Chronic Angle Closure Glaucoma with Cataracts. \u003cem\u003eOPHTHALMOLOGY\u003c/em\u003e 2009, 116(4):725-731.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHansapinyo L, Choy BNK, Lai JSM, Tham CC: Phacoemulsification Versus Phacotrabeculectomy in Primary Angle-closure Glaucoma With Cataract. \u003cem\u003eJ GLAUCOMA\u003c/em\u003e 2020, 29(1):15\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAzuara-Blanco A, Burr J, Ramsay C, Cooper D, Foster PJ, Friedman DS, Scotland G, Javanbakht M, Cochrane C, Norrie J: Effectiveness of early lens extraction for the treatment of primary angle-closure glaucoma (EAGLE): a randomised controlled trial. \u003cem\u003eLANCET\u003c/em\u003e 2016, 388(10052):1389\u0026ndash;1397.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKashiwagi K, Kogure S, Mabuchi F, Chiba T, Yamamoto T, Kuwayama Y, Araie M: Change in visual acuity and associated risk factors after trabeculectomy with adjunctive mitomycin C. \u003cem\u003eACTA OPHTHALMOL\u003c/em\u003e 2016, 94(7):e561-e570.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYuasa Y, Sugimoto Y, Hirooka K, Ohkubo S, Higashide T, Sugiyama K, Kiuchi Y: Effectiveness of trabeculectomy with mitomycin C for glaucomatous eyes with low intraocular pressure on treatment eye drops. \u003cem\u003eACTA OPHTHALMOL\u003c/em\u003e 2020, 98(1):e81-e87.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLangman MJS: Systemic hypertension and glaucoma: mechanisms in common and co-occurrence. \u003cem\u003eBRIT J OPHTHALMOL\u003c/em\u003e 2005, 89(8):960\u0026ndash;963.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchlunck G, Meyer-ter-Vehn T, Klink T, Grehn F: Conjunctival fibrosis following filtering glaucoma surgery. \u003cem\u003eEXP EYE RES\u003c/em\u003e 2016, 142:76\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBroadway DC, Chang LP: Trabeculectomy, Risk Factors for Failure and the Preoperative State of the Conjunctiva. \u003cem\u003eJ GLAUCOMA\u003c/em\u003e 2001, 10(3):237\u0026ndash;249.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Glaucoma, Trabeculectomy, Outcomes, Risk factors","lastPublishedDoi":"10.21203/rs.3.rs-1080435/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1080435/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eTo evaluate the outcomes and elucidate the success and failure factors for trabeculectomy with mitomycin C (MMC) in Southwest Chinese patients.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e A retrospective correlational study was conducted on the glaucomatous patients who underwent initial trabeculectomy with MMC in Southwest Hospital and had been followed up for 1-3 years. A complete success for surgery is defined as a postoperative intraocular pressure (IOP) \u0026gt; 5 and \u0026le; 21 mmHg and 20% reduction of IOP compared to preoperative, without IOP-lowering medications. A qualified success for surgery is defined as the abovementioned postoperative IOP with or without IOP-lowering medications. The primary outcomes were IOP, the number of IOP-lowering medications, and cumulative success rate. The secondary outcomes included best corrected visual acuity (BCVA), mean deviation (MD) of visual field, major complications, and risk factors for surgical failure.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 325 eyes of 261 glaucomatous patients had been included in our study. Both the mean IOP and the number of IOP-lowering medications were significantly decreased from 32.9 \u0026plusmn; 12.0 mmHg to 16.4 \u0026plusmn; 5.7 mmHg (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.0001) and 3.0 \u0026plusmn; 0.9 to 0.9 \u0026plusmn; 1.0 (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.0001), respectively, at the last visit. The cumulative complete success rate and qualified success rate were 77.8% and 92.0% at 1-year follow-up, and 47.2% and 77.7% at 3-year follow up. There were no significant differences in surgical outcomes between primary angle-closure glaucoma (PACG) and primary open angle glaucoma (POAG). In PACG patients, the success rates of trabeculectomy were comparable with those of phacotrabeculectomy. Hypertension (HR=1.904, \u003cem\u003eP\u003c/em\u003e=0.011), encapsulated bleb (HR=2.756, \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001), and more preoperative topical medications (HR=2.475, \u003cem\u003eP\u003c/em\u003e=0.008) were risk factors for surgical failure.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe qualified success rate of trabeculectomy with MMC in glaucomatous patients in Southwest China is 92.0% at 1-year follow-up, and 77.7% at 3-year follow up. Hypertension, encapsulated bleb, and more preoperative topical medications are associated with surgical failure.\u003c/p\u003e","manuscriptTitle":"Success and Failure Factors for Trabeculectomy in Glaucomatous Patients in Southwest China: A 325 Eyes Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-11-18 17:07:06","doi":"10.21203/rs.3.rs-1080435/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"50c0436d-31aa-4928-8ad5-09738c381db9","owner":[],"postedDate":"November 18th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":8591495,"name":"Ophthalmology"}],"tags":[],"updatedAt":"2022-03-10T05:14:15+00:00","versionOfRecord":[],"versionCreatedAt":"2021-11-18 17:07:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1080435","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1080435","identity":"rs-1080435","version":["v1"]},"buildId":"J0_U0BvcaRcwD8yVFaRlm","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}