Mitomycin C Application during Trabeculectomy-Injection versus Sponge: A Report by the American Academy of...

To evaluate the recently published literature on the efficacy and safety outcomes of delivering mitomycin C (MMC) by either sub-Tenon's/subconjunctival injection (MMC-I) or by sponge (MMC-S) during trabeculectomy surgery.

A literature search was last conducted in the PubMed database in May 2026 and yielded 135 articles. Eighteen full-text articles were reviewed, and 11 met all inclusion criteria for this assessment and were assigned a level of evidence rating by the panel methodologist.

Six studies were rated level I, 2 were rated level II, and 3 were rated level III. The racial and ethnic backgrounds of study participants represented a diverse mix, and in many studies, a variety of glaucoma diagnoses were included, the majority of which were primary open-angle glaucoma. The MMC-I technique was reported to have used a wider range of drug concentrations (0.05-0.4 mg/mL) than MMC-S (0.1-0.4 mg/mL). The complete success rate of intraocular pressure (IOP) control ranged from 40.3% to 90.9% in the MMC-I group compared with 17.7% to 86.5% in the MMC-S group. The wide range of success rates may be a result of differences in definitions of success, follow-up time, and patient populations. Change in IOP from baseline ranged from 2.8 mmHg (17%) to 19.4 mmHg (58%) in the MMC-I group compared with 5.8 mmHg (31%) to 18.0 mmHg (59%) in the MMC-S group. No significant differences in complications, such as rates of bleb leak, hypotony, choroidal effusion, or choroidal hemorrhage, were reported. Two studies reported significantly fewer 5-fluorouracil injections in the MMC-I group, and 1 reported more glaucoma surgery reoperations in the MMC-S group. Several studies reported a more favorable bleb morphology that was diffuse, lower profile, and less vascular in the MMC-I group than in the MMC-S group.

Although MMC-I may offer some advantages over MMC-S trabeculectomy with respect to bleb morphology, level I and II evidence supports the application of MMC using either injection or sponges during trabeculectomy. Both applications result in similar rates of surgical success (a lower IOP and a reduction in medication burden) and have a similar safety profile.

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