Getting the Details Right in Glaucoma Surgery

Clinical Report: Getting the Details Right in Glaucoma Surgery

Overview

At the 2026 American Academy of Ophthalmology Glaucoma Subspecialty Day, Craig J. Chaya, MD, emphasized meticulous attention to surgical details. His specific pearl was to apply mitomycin C (MMC) diffusely beneath the Tenon capsule rather than directly beneath the conjunctiva. The supplied related guidance and evidence describe MMC’s role in trabeculectomy and report no clear superiority of injection or sponge delivery.

Background

Glaucoma can cause blindness, and the supplied related article reports that some patients become blind despite treatment. The 2026 AAO Preferred Practice Pattern states that incisional surgery remains appropriate when medications and/or laser do not achieve target intraocular pressure. Trabeculectomy uses antimetabolites such as MMC to limit postoperative scarring, according to the supplied web research context. The delivery technique is therefore a relevant operative detail, although the provided evidence does not establish one method as superior.

Data Highlights

Source or evidence	Reported finding
AAO Preferred Practice Pattern for primary open-angle glaucoma (2026), as summarized in supplied web research context	Trabeculectomy with antimetabolite and tube shunts achieve similar intraocular pressure at 5 years; fewer medications are typically needed after trabeculectomy.
AAO Ophthalmic Technology Assessment on MMC delivery (2026), as summarized in supplied web research context	Reported intraocular pressure reduction ranges were approximately 17–58% for injection and 31–59% for sponge application; no consistent safety signal favored either approach.
Randomized controlled trial (January 2024–January 2025), as summarized in supplied web research context	Sponge-applied and sub-Tenon injection MMC had equivalent efficacy at 1 year.
Systematic review and meta-analysis (2025), as summarized in supplied web research context	No clear superiority of one MMC delivery technique over the other was reported.
Three-year observational data, as summarized in supplied web research context	One series reported fewer early and repeated needlings after injection, while overall long-term success was similar between groups.

Key Findings

Chaya emphasized that surgical success reflects attention to multiple small technical details.
His specific MMC technique advice was to avoid placing it directly beneath the conjunctiva and instead distribute it as diffusely as possible beneath the Tenon capsule.
The supplied summary of the 2026 AAO Preferred Practice Pattern states that incisional surgery remains appropriate when medications and/or laser fail to achieve target intraocular pressure.
The same summary reports similar 5-year intraocular pressure outcomes for trabeculectomy with antimetabolite and tube shunts, with fewer medications typically needed after trabeculectomy.
The supplied summary of the AAO technology assessment reports overlapping intraocular pressure reduction ranges for injection and sponge MMC application and no consistent safety signal favoring either method.
A randomized trial and a 2025 systematic review, as summarized in the supplied web research context, reported equivalent efficacy at 1 year and no clear overall superiority of either delivery technique.

Clinical Implications

Chaya’s stated operative pearl is to apply MMC diffusely beneath the Tenon capsule rather than directly beneath the conjunctiva. The supplied comparative evidence does not establish injection or sponge application as generally superior, so the report supports attention to the described placement technique without claiming comparative outcome benefit.

Conclusion

The source highlights meticulous MMC placement as one technical detail in glaucoma surgery. Available comparative findings summarized in the supplied context report no clear overall superiority between injection and sponge delivery.