efficacy and tolerability of nonpenetrating glaucoma surgery augmented with mitomycin c in treatment...

76 CAN J OPHTHALMOL—VOL. 44, NO. 1, 2009

Efficacy and tolerability of nonpenetrating glaucoma surgery augmented with mitomycin C in treatment of open-angle glaucoma: a meta-analysisJin-Wei Cheng,* MD; Gui-Lin Xi,† MS; Rui-Li Wei,* MD; Ji-Ping Cai,* MD; You Li,* MD

Objective: To evaluate the efficacy and tolerability of nonpenetrating glaucoma surgery (NPGS) augmented with mitomycin C (MMC) compared with trabeculectomy (TE) plus MMC in the treatment of patients with open-angle glaucoma.

Design: Systematic review and meta-analysis.Participants: Eight clinical trials, including 4 cohort and 4 randomized, enrolled 459 eyes.

Pertinent studies were selected through extensive searches of the Cochrane Library, MEDLINE, EMBASE, and meeting abstracts. Efficacy measures were weighted mean differences (WMDs) for the percentage intraocular pressure (IOP) reduction and relative risks (RRs) for success rates. Tolerability measures were RRs for adverse events. Pooled estimates were carried out in RevMan software v. 4.2.

Results: NPGS augmented with MMC was associated with a numerically smaller but nonsignificant percentage reduc-tion in IOP compared with TE plus MMC, with a WMD of −1.27% (95% CI −5.61 to 3.07) at 1 year, −4.55% (−10.35 to 1.24) at 2 years, −0.82% (−8.80 to 7.17) at 3 years, and −6.16% (−25.97 to 13.65) at 4 years. Significantly greater proportions of TE plus MMC patients than NPGS augmented with MMC patients achieved the target IOP without antiglaucoma medication at the end point, with a pooled RR of 0.74 (0.63–0.86). NPGS augmented with MMC was associated with a significantly lower frequency of shallow anterior chamber and cataract than TE plus MMC, with pooled RRs of 0.31 (0.16–0.60) and 0.23 (0.11–0.47), respectively.

NPGS augmented with MMC was associated with IOP-lowering efficacy comparable to that of TE plus MMC. However, significantly fewer patients achieved the target IOP with NPGS augmented with MMC than with TE plus MMC. NPGS augmented with MMC was better tolerated than TE plus MMC.

Objet : Évaluation de l’efficacité et de la tolérabilité de la chirurgie non pénétrante du glaucome (CNPG) avec ajout de mitomycine C (MMC) comparativement à la trabéculectomie (TE) plus MMC dans le traitement du glaucome à angle ouvert.

Nature : Revue systématique et méta-analyse.Participants : Huit essais cliniques : 4 cohortes et 4 randomisés, 459 yeux inscrits.

: Les études pertinentes ont été retenues à la suite d’une recherche exhaustive dans la librairie Cochrane, MEDLINE, EMBASE et les comptes rendus de réunions. Les mesures d’efficacité reposaient sur l’écart de poids moyen (EPM) pour le pourcentage de réduction de la pression intraoculaire (PIO) et les risques relatifs (RR) pour les taux de réussite. La combinaison des évaluations a été faite avec le logiciel RevMan, v. 4.2.

: La CNPG avec ajout de MMC a été associée à un pourcentage numériquement inférieur mais non sig-nificatif de la réduction de la PIO comparativement à la TE plus MMC, avec un ÉPM de −1,27 % (95 % CI −5,61 à 3,07) à 1 an, −4,55 % (−10,35 à 1,24) à 2 ans, −0,82 % (−8,80 à 7.17) à 3 ans et −6,16 % (−25,97 à 13,65) à 4 ans. Des proportions significativement plus grandes de patients de la TE plus MMC que de patients de la CNPG avec ajout de MMC ont en fin de compte atteint la PIO ciblée sans médicament antiglaucome, avec un RR global de 0,74 (0,63–0,86). La CNPG avec ajout de MMC a été associée une fréquence significativement moindre d’athalamie de la chambre antérieure et de cataracte que la TE plus MMC, avec un RR global de 0,31 (0,16–0,60) et 0,23 (0,11–0,47), respectivement.

: La CNPG avec MMC semble avoir une efficacité comparable à celle de la TE plus MMC pour abaisser la PIO. Toutefois, beaucoup moins de patients ont atteint la PIO voulue par CNPG avec ajout de MMC que par TE plus MMC. La CNPG avec ajout de MMC a été mieux tolérée que la TE plus MMC.

Trabeculectomy (TE) is currently the standard surgical procedure to treat medically uncontrolled glaucoma.

Several serious postoperative complications are associated with this procedure. These include early postoperative ex-cessive filtration leading to a shallow anterior chamber,

hypotony, choroidal detachment, hyphema, and late com-plications such as cataract formation.

One of the most recently used antiglaucomatous filtra-tion surgery techniques is nonpenetrating glaucoma surgery (NPGS), which, like viscocanalostomy and deep sclerec-

From *the Department of Ophthalmology, Changzheng Hospital, Second Military Medical University, Shanghai, China, and †the Center for New Drug Evaluation, Second Military Medical University, Shanghai, China

Originally received Feb. 25, 2008. Revised May 7, 2008Accepted for publication July 22, 2008Published online Jan. 23, 2009

Correspondence to Rui-Li Wei, Department of Ophthalmology, Shanghai Changzheng Hospital, 415 Fengyang Road, Shanghai 200003, China; [email protected]

This article has been peer-reviewed. Cet article a été évalué par les pairs.

Can J Ophthalmol 2009;44:76–82doi:10.3129/i08-165

CAN J OPHTHALMOL—VOL. 44, NO. 1, 2009 77

Nonpenetrating glaucoma surgery augmented with mitomycin C—Cheng et al.

tomy, has a low incidence of complications and a satisfac-tory intraocular pressure (IOP)–lowering effect.1–8 As in all antiglaucoma surgical procedures, the problem to be resolved is the healing response, which leads some operated eyes to failure after a period of time. To resolve this problem in NPGS, several implants have been used. Recent studies indicate that NPGS augmented with intraoperative mitom-ycin C (MMC) application appears to be safe and to result in significantly lower IOP.9–12

Recently, many published clinical trials compared the efficacy of NPGS augmented with MMC versus TE plus MMC. In 2 studies, the probability of success was statistic-ally better for TE plus MMC than for NPGS augmented with MMC.13,14 However, several other clinical trials re-ported that NPGS augmented with MMC and TE plus MMC had similar efficacy in achieving a target IOP.15–17 These conflicting results made it difficult to draw conclu-sions that could be applied in clinical practice. Therefore, to determine whether intraoperative mitomycin C applica-tion offers any advantages for medically uncontrolled open-angle glaucoma in terms of efficacy and fewer postoperative complications, we undertook a systematic review and meta-analysis of all relevant clinical trials of NPGS augmented with MMC and TE plus MMC.

METHODS

We included clinical trials (retrospective, prospective nonrandomized, and randomized) that compared NPGS augmented with MMC with TE plus MMC in patients with open-angle glaucoma and that reported efficacy out-comes or postoperative complications.

Outcome measuresFor efficacy, we used the percentage reduction in pre-

operative to postoperative IOP. Secondary efficacy meas-ures were the complete success rate, which was defined as the proportion of patients with an end point IOP <22 mm Hg without antiglaucoma medication, and the probability of qualified success for achieving an end point IOP <22 mm Hg with or without antiglaucoma medica-tions. We also assessed tolerability to the nonpenetrating approaches by considering the proportions of patients with postoperative complications, including hyphema, shallow anterior chamber, hypotony, choroidal detach-ment, and cataract.

Search strategyClinical trials were identified through a systematic search

consisting of (i) an electronic search of MEDLINE, EM-BASE, the Chinese Biomedicine Database, and the Coch-rane Library; (ii) manual searches of the reference lists of original reports and review articles retrieved through the electronic searches; and (iii) extensive Internet searches, in-cluding manufacturers’ databases, Web sites of professional associations, and the Google and Yahoo! search engines.

Searches were conducted using the keywords “deep sclerec-tomy,” “viscocanalostomy,” “nonpenetrating filtering sur-gery,” “nonpenetrating trabecular surgery,” “nonpenetrating glaucoma surgery,” and “mitomycin C.” The computerized searches covered the period 1966 to April 2008.

Trials selectionPublished and unpublished trials fulfilling the following

selection criteria were included in the present meta-analysis: (i ) study design (controlled clinical studies, including co-hort studies or randomized trials); (ii ) population (patients with open-angle glaucoma, including primary and second-ary, who were all medically uncontrolled with maximal medical therapy); (iii) intervention (NPGS augmented with MMC vs TE plus MMC); and (iv) outcome variables (at least one of the following outcome variables: IOP reduc-tion, complete and qualified success rates). Trial eligibility was determined by 2 authors (Jin-Wei Cheng and Gui-Lin Xi) and checked by Rui-Li Wei. To avoid duplicate publica-tion for data collection from the same group of patients, only the most recent series were included in the present analysis.

Data extractionData were extracted from each clinical trial by 2 in-

dependent reviewers (Jin-Wei Cheng and Gui-Lin Xi). Any disagreement was resolved by discussion. For each study and each type of treatment, the following data were extracted: the authors of the study, year of publication, study design (whether randomized trials or cohort studies), length of study, treatment methods, number of subjects, IOP meas-urements, number of patients with complete and qualified success, and incidence of postoperative complications.

Statistical analysisNot all of the trials reported on all the outcomes of inter-

est. For each comparison and outcome, we undertook sep-arate meta-analyses. Outcome measure was assessed on an intent-to-treat basis. Considering the different clinical char-acteristics among study groups and the variation in sample sizes, we assumed that heterogeneity was present even when no statistical significance was identified, and we decided to combine data by using a random-effects model to achieve more conservative estimates.

For dichotomous outcomes, relative risk (RR) was esti-mated. Weighted mean difference (WMD) was calculated for continuous outcomes. When mean and standard devia-tion (SD) of IOP reduction were reported, they were used directly. When these data were not available, they were com-puted as follows: IOPR = IOP

baseline − IOP

end point and SD

IOPR

= (SD2baseline

+ SD2end point

− SDbaseline

× SDend point

)1/2, where IOPR is IOP reduction. The mean (SD) percentage reduc-tion in IOP was then estimated as follows: IOPR% = IOPR / IOP

baseline and SD

IOPR% = SD

IOPR / IOP

baseline, where IOPR

is IOP reduction and IOPR% is percentage IOP reduction. Analyses were carried out using RevMan software (v. 4.2, Cochrane Collaboration, Oxford, U.K.). The results were



reported with 95% CIs. A p value <0.05 was considered statistically significant on the test for overall effect.

Sensitivity analysisTo evaluate the effect of methodological characteristics

of randomized clinical trials on the results of this meta-analysis, the impact of the components of methodological characteristics on our meta-analysis was assessed using sensitivity analysis.

RESULTS

Nine publications were identified through the literature search, including 8 full studies13–20 and 1 abstract report.21 One study was excluded because of duplicate reports.16 Thus, 8 studies (4 cohort and 4 randomized, with 8 groups) were included in the final meta-analysis.13–15,17–21 These ex-perimental groups thus included 459 eyes of patients with open-angle glaucoma (Table 1): 227 eyes in the NPGS augmented with MMC groups and 232 eyes in the TE plus MMC groups. Length of studies varied from 12 to 48 months.

EfficacyEight studies reported the percentage reduction in IOP

at various time points: 8 at 1 year, 4 at 2 years, 3 at 3 years, and 2 at 4 years (Fig. 1). NPGS augmented with MMC was associated with a numerically lower but nonsignifi-cant percentage reduction in IOP compared with TE plus MMC, with a WMD for the percentage reduction in IOP of −1.27% (95% CI, −5.61 to 3.07) at 1 year, −4.55% (−10.35 to 1.24) at 2 years, −0.82% (−8.80 to 7.17) at 3 years, and −6.16% (−25.97 to 13.65) at 4 years. Then, we divided the studies into 2 groups according to study design (cohort and randomized). There was no significant heterogeneity in these analyses, and the differences in per-centage reduction in IOP were all not statistically signifi-cant (Table 2).

Five studies, involving 359 eyes, reported the propor-tions of patients achieving the end point IOP target of <22 mm Hg without antiglaucoma medication (53.1% NPGS augmented with MMC, 71.7% TE plus MMC);

the difference between groups was statistically significant (pooled RR 0.74 [0.63–0.86]) (Fig. 2). Two cohort studies in 141 eyes reported this outcome (45.1% versus 62.9%, respectively); the difference between groups was statistically significant (pooled RR 0.72 [0.52–0.98]) (Table 3). Three randomized trials involving 218 eyes found that signifi-cantly fewer patients achieved the target IOP with NPGS augmented with MMC than with TE plus MMC (58.3% vs 77.3%; pooled RR 0.74 [0.63–0.88]).

In 4 studies that reported the probability of qualified suc-cess, no significant difference was found between NPGS augmented with MMC and TE plus MMC (pooled RR 0.93 [0.87–1.01]) (Table 3). There was also no significant difference between NPGS augmented with MMC and TE plus MMC in the sensitivity analyses according to study design (pooled RR 0.90 [0.72–1.12] of cohort; 0.94 [0.87–1.02] of randomized).

TolerabilityShallow anterior chamber was one of the most common-

ly reported postoperative complications. NPGS augmented with MMC was associated with a significantly lower fre-quency of shallow anterior chamber than TE plus MMC (8.9% vs 32.1%, respectively; pooled RR 0.31 [0.16–0.60]) (Table 4). NPGS augmented with MMC also was signifi-cantly associated with a lower proportion of cataract than TE plus MMC (pooled RR 0.23 [0.11–0.47]). Numeric-ally lower but nonsignificant proportions of NPGS aug-mented with MMC patients than TE plus MMC patients had other postoperative complications, such as hypotony (pooled RR 0.47 [0.16–1.38]), hyphema (pooled RR 0.55 [0.27–1.11]), and choroidal detachment (pooled RR 0.59 [0.19–1.82]).

CONCLUSIONS

Glaucoma, which causes optic nerve damage and visual field loss, is the most important cause of irreversible blind-ness worldwide. About 66.8 million people have glaucoma, 6.7 million of whom are bilaterally blind.22 The mainstay of surgical treatment for glaucoma is TE. However, this tech-nique is associated with complications. NPGS is an evolving

Table 1—Characteristics of clinical trials comparing nonpenetrating glaucoma surgery augmented with mitomycin C with trabeculectomy plus mitomycin C

Treatment group Control group

Trial DesignSurgical

procedurePatients

(n)Eyes (n)

Mean length (mo)

Surgical procedure

Patients (n)

Eyes (n)

Mean length (mo)

Miller et al. 2003 Cohort DS-MMC 13 16 18 TE-MMC NR 16 18Schwenn et al. 2004 Randomized DSHA-MMC 12 12 12 TE-MMC 10 10 12Agarwal et al. 2005 Randomized SST-MMC 34 34 20 TE-MMC 33 33 20Huang et al. 2006 Randomized DSHA-MMC 52 55 40 TE-MMC 53 56 40Fukuchi et al. 2007 Cohort DS-MMC 39 39 20 TE-MMC 38 38 26Qian et al. 2007 Cohort DS-MMC 32 32 24 TE-MMC 32 32 24Cillino et al. 2008 Randomized DS-MMC 19 19 48 TE-MMC 21 21 48Liu et al. 2008 Cohort DS-MMC 15 20 12 TE-MMC 15 26 12Note: DS, deep sclerectomy; MMC, mitomycin C; TE, trabeculectomy; NR, not reported; DSHA, deep sclerectomy with hyaluronic acid implant; SST, subscleral partial-thickness sclerectomy plus trabeculotomy.



surgical technique for treatment of open-angle glaucoma. The need to avoid the complications of the classic TE led to the development of this nonpenetrating procedure. However, the IOP levels obtained with this nonpenetrating procedure have not always been satisfactory,1,23–27 especially given the need to achieve a target IOP consistently to avoid further visual field loss.28,29 Mitomycin C may help reach

this goal by modulating wound healing. Its use lowers the IOP an additional 4 to 7 mm Hg in NPGS.30–32

Previous studies have prospectively evaluated the efficacy and safety of NPGS augmented with MMC compared with TE plus MMC.14–18 All trials reported that the techniques were comparable in lowering IOP efficaciously. However, these randomized clinical trials showed conflicting results in

Fig. 1—Effect of nonpenetrating glaucoma surgery augmented with mitomycin C and trabeculectomy plus mitomycin C on intraocular pressure reduction. (NPGSMMC, nonpenetrating glaucoma surgery augmented with mitomycin C; TEMMC, trabeculectomy plus mitomy-cin C; N, number of patients; SD, standard deviation; WMD, weighted mean difference.)



the proportion of patients achieving a target IOP, and also included small sample sizes, which hindered the drawing of conclusions for clinical practice.

In the present meta-analysis, we reviewed 8 controlled clinical studies, including cohort and randomized, using a wider range of clinically relevant outcome measures, and found that NPGS augmented with MMC was associated with IOP-lowering efficacy comparable to that of TE plus MMC, with a numerically lower but nonsignificant per-centage reduction in IOP at all measurement times. How-ever, the proportion of patients achieving the target IOP without antiglaucoma medication at end point was signifi-cantly greater with TE plus MMC than with NPGS aug-mented with MMC. NPGS augmented with MMC was better tolerated than TE plus MMC, with a significantly lower frequency of shallow anterior chamber and cataract.

Disadvantages of meta-analyses include acknowledged and covert duplication of data, and publication bias. To avoid acknowledged and covert duplication of data, only the

most recent series of the same patient group were included in our analysis. To avoid publication bias, we conducted not only an electronic search but also a manual search of the references of all the retrieved trials to identify all the potentially relevant articles, including published ones and nonpublished ones.

Overall, because disparate studies were included in separate meta-analyses at various time points, the pooled results for the different measurement times were not al-ways consistent with each other. A specific limitation of this analysis is that examination of the rates of success and complications was based on pooled data from trials of different durations. Another potential limitation of this meta-analysis is that many of the clinical trials included in the analysis were not randomized, which may have led to the failure to detect actual results.33 We undertook separ-ate meta-analyses by dividing the studies into cohort and randomized groups and found that study design was not a significant factor.

Fig. 2—Effect of nonpenetrating glaucoma surgery augmented with mitomycin C and trabeculectomy plus mitomycin C on complete success rate. (NPGSMMC, nonpenetrating glaucoma surgery augmented with mitomycin C; n, number of patients achieving the endpoint intraocular pressure target of <22 mm Hg; N, number of patients; TEMMC, trabeculectomy plus mitomycin C; RR, relative risk.)

Table 2—Percentage intraocular pressure reduction comparing nonpenetrating glaucoma surgery augmented with mitomycin C with trabeculectomy plus mitomycin C

NPGSMMC TEMMC

TrialNo. of

studies n IOPR% n IOPR% WMD (95% CI)

Test for heterogeneity,

Q (p)

Test for overall effect, Z-score (p)

1 year All trials 8 227 43.97 232 45.24 –1.27 (–5.61 to 3.07) 8.52 (0.29) 0.57 (0.57) Cohort 4 107 41.59 112 41.61 –0.02 (–5.20 to 5.17) 2.52 (0.47) 0.01 (1.00) Randomized 4 120 46.05 120 48.41 –2.36 (–10.55 to 5.84) 540 (0.14) 0.56 (0.57)2 years All trials 4 145 38.94 147 43.48 –4.55 (–10.35 to 1.24) 4.58 (0.21) 1.54 (0.12) Cohort 2 71 38.50 70 43.63 –5.13 (–12.35 to 2.08) 1.40 (0.24) 1.39 (0.16) Randomized 2 74 39.64 77 42.98 –3.34 (–16.34 to 9.67) 3.15 (0.08) 0.50 (0.62)3 years All trials 3 113 37.82 115 38.64 –0.82 (–8.80 to 7.17) 4.45 (0.11) 0.20 (0.84) Cohort 1 39 39.06 38 36.31 2.75 (–4.64 to 10.11) NA 0.73 (0.46) Randomized 2 74 37.08 77 40.12 –3.04 (–15.78 to 9.69) 3.00 (0.08) 0.47 (0.64)4 years All trials 2 74 30.62 77 35.76 –6.16 (–25.97 to 13.65) 7.13 (0.008) 0.61 (0.54) Randomized 2 74 30.62 77 35.76 –6.16 (–25.97 to 13.65) 7.13 (0.008) 0.61 (0.54)Note: NPGSMMC, nonpenetrating glaucoma surgery augmented with mitomycin C; IOPR%, percentage reduction in intraocular pressure; TEMMC, trabeculectomy plus mitomycin C; WMD, weighted mean difference, computed by using a random-effects model; Q, variance factor χ2 test; NA, not applicable.



In conclusion, our systematic review indicates that NPGS augmented with MMC, as a safer filtration surgery than TE plus MMC, is as effective as TE plus MMC in lowering IOP. However, a significantly lower proportion of patients reached the IOP target with NPGS augmented with MMC than with TE plus MMC. There is a need for randomized, controlled comparisons of NPGS augmented with MMC and TE plus MMC in patients with open-angle glaucoma that is of at least 5 years’ duration. In particular, multicen-ter, large sample-size, randomized, controlled trials would be important to evaluate the efficacy of NPGS augmented with MMC on the proportion of patients achieving an IOP target without antiglaucoma medication.

Jin-Wei Cheng and Gui-Lin Xi contributed equally to this work. All authors designed the review and revised the manuscript, which was drafted by Jin-Wei Cheng. Jin-Wei Cheng and Gui-Lin Xi decided on the inclusion of trials, extracted data, assessed study quality, and carried out the statistical analyses. All authors interpreted the findings. Rui-Li Wei is guarantor. The authors have no proprietary or commercial interest in any materials dis-cussed in this article.

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Table 3—The proportion of patients with an end point IOP of <22 mm Hg comparing nonpenetrating glaucoma surgery augmented with mitomycin C with trabeculectomy plus mitomycin C

Success rate, n/N (%)

TrialNo. of

studies NPGSMMC TEMMC RR (95% CI)Test for

heterogeneity, Q (p)Test for overall

effect, Z-score (p)

Complete success All trials 5 95/179 (53.1) 129/180 (71.7) 0.74 (0.63–0.86) 0.15 (1.00) 3.99 (<0.0001) Cohort 2 32/71 (45.1) 44/70 (62.9) 0.72 (0.52–0.98) 0.00 (0.97) 2.11 (0.03) Randomized 3 63/108 (58.3) 85/110 (77.3) 0.74 (0.63–0.88) 0.11 (0.95) 3.40 (0.0007)Qualified success All trials 4 82/101 (81.2) 90/102 (88.2) 0.93 (0.87–1.01) 1.08 (0.78) 1.75 (0.08) Cohort 2 35/48 (72.9) 39/48 (81.3) 0.90 (0.72–1.12) 0.71 (0.40) 0.97 (0.33) Randomized 2 47/53 (88.7) 51/54 (94.4) 0.94 (0.87–1.02) 0.04 (0.85) 1.51 (0.13)Note: n, number of patients achieving the end point IOP target of <22 mm Hg; N, number of patients; NPGSMMC, nonpenetrating glaucoma surgery augmented with mitomycin C; TEMMC, trabeculectomy plus mitomycin C; RR, relative risk, computed by using a random-effects model; Q, variance factor χ2 test.

Table 4—Postoperative complications between nonpenetrating glaucoma surgery augmented with mitomycin C and trabeculectomy plus mitomycin C

Adverse event

Crude rate, n/N (%)

No. of studies NPGSMMC TEMMC RR (95% CI)

Test for heterogeneity,

Q (p)

Test for overall effect, Z-score

(p)

Shallow anterior chamber 6 17/191 (8.9) 61/190 (32.1) 0.31 (0.16–0.60) 6.08 (0.30) 3.46 (0.0005)Hypotony 6 19/191 (9.9) 32/190 (16.8) 0.47 (0.16–1.38) 14.62 (0.01) 1.38 (0.17)Hyphema 5 10/136 (7.4) 20/134 (14.9) 0.55 (0.27–1.11) 2.50 (0.64) 1.68 (0.09)Choroidal detachment 3 6/70 (8.6) 11/69 (15.9) 0.59 (0.19–1.82) 2.47 (0.29) 0.91 (0.36)Cataract 3 8/121 (6.6) 36/121 (29.8) 0.23 (0.11–0.47) 0.45 (0.80) 4.02 (<0.0001)Note: n, number of patients with postoperative complications; N, number of patients; NPGSMMC, nonpenetrating glaucoma surgery augmented with mitomycin C; TEMMC, trabeculectomy plus mitomycin C; RR, relative risk, computed by using a random-effects model; Q, variance factor χ2 test.



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Keywords: glaucoma, filtering surgery, trabeculectomy, mitomycin C, meta-analysis

efficacy and tolerability of nonpenetrating glaucoma surgery augmented with mitomycin c in treatment...

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