CSF rhinorrhoea after endonasal intervention to the anterior skull base (CRANIAL): proposal for a prospective multicentre observational cohort study.

BACKGROUND: The endonasal transsphenoidal approach (TSA) has emerged as the preferred approach in order to treat pituitary adenoma and related sellar pathologies. The recently adopted expanded endonasal approach (EEA) has improved access to the ventral skull base whilst retaining the principles of minimally invasive surgery. Despite the advantages these approaches offer, cerebrospinal fluid (CSF) rhinorrhoea remains a common complication. There is currently a lack of comparative evidence to guide the best choice of skull base reconstruction, resulting in considerable heterogeneity of current practice. This study aims to determine: (1) the scope of the methods of skull base repair; and (2) the corresponding rates of postoperative CSF rhinorrhoea in contemporary neurosurgical practice in the UK and Ireland. METHODS: We will adopt a multicentre, prospective, observational cohort design. All neurosurgical units in the UK and Ireland performing the relevant surgeries (TSA and EEA) will be eligible to participate. Eligible cases will be prospectively recruited over 6 months with 6 months of postoperative follow-up. Data points collected will include: demographics, tumour characteristics, operative data), and postoperative outcomes. Primary outcomes include skull base repair technique and CSF rhinorrhoea (biochemically confirmed and/or requiring intervention) rates. Pooled data will be analysed using descriptive statistics. All skull base repair methods used and CSF leak rates for TSA and EEA will be compared against rates listed in the literature. ETHICS AND DISSEMINATION: Formal institutional ethical board review was not required owing to the nature of the study - this was confirmed with the Health Research Authority, UK. CONCLUSIONS: The need for this multicentre, prospective, observational study is highlighted by the relative paucity of literature and the resultant lack of consensus on the topic. It is hoped that the results will give insight into contemporary practice in the UK and Ireland and will inform future studies.

Laparoscopic Inguinal Hernia Repair: Transabdominal Preperitoneal or Totally Extraperitoneal? Results of a 14-year Prospective Study.

Background: Laparoscopic inguinal hernia repairs are most commonly either transabdominal preperitoneal (TAPP) or totally extraperitoneal (TEP) operations. The indications and comparative outcome data for both approaches are often conflicting and thus we sought to compare the two. Methods: 678 consecutive laparoscopic inguinal hernia repairs (190 TAPP and 488 TEP) were prospectively recorded onto a database from June 2004-December 2018. Age, gender, hernia characteristics, operative times, complication and 12-month recurrence rate data were compared. Results: 49.5% of TAPP repairs were recurrent hernias, and 95.5% of TEP repairs were bilateral hernias. TAPP patients were significantly older than TEP patients (60.65 versus 55.60, p 0.01). Unilateral TAPP repairs had a significantly shorter operative time than unilateral TEP repairs (50.94 versus 65.71 minutes, p=0.01). There was no significant difference in overall complication rate between TAPP and TEP repairs (6.84% versus 7.38%, p=0.87), and this was consistent across different hernia groups. TAPP repairs recurred at a significantly higher rate than TEP repairs (3.16% versus 0.61%, p=0.02) overall, but recurrence rates were not significantly different when broken down by hernia group. Conclusions: Applying the broad principle of utilizing the TAPP approach for recurrent hernias and the TEP approach for bilateral hernias, outcomes from both operations are similar.

Multiple metabolic pathways are predictive of ricin intoxication in a rat model.

INTRODUCTION: Exposure to ricin can be lethal and treatments that are under development have short windows of opportunity for administration after exposure. It is therefore essential to achieve early detection of ricin exposure to provide the best prognosis for exposed individuals. Ricin toxin can be detected in clinical samples via several antibody-based techniques, but the efficacy of these can be limited due to the rapid processing and cellular uptake of toxin in the body and subsequent low blood ricin concentrations. Other diagnostic tools that perform, in an orthogonal manner, are therefore desirable. OBJECTIVES: To determine time-dependent metabolic changes in Sprague-Dawley rats following intravenous exposure to ricin. METHODS: Sprague-Dawley rats were intravenously exposed to ricin and multiple blood samples were collected from each animal for up to 48 h following exposure in two independent studies. Plasma samples were analysed applying HILIC and C18 reversed phase UHPLC-MS assays followed by univariate and multivariate analysis. RESULTS: In Sprague-Dawley rats we have demonstrated that metabolic changes measured in blood can distinguish between rats exposed intravenously to ricin and controls prior to the onset of behavioral signs of intoxication after 24 h. A total of 37 metabolites were significantly altered following exposure to ricin when compared to controls. The arginine/proline, bile acid and triacylglyceride metabolic pathways were highlighted as being important with two triacylglycerides at 8 h post exposure giving an AUROC score of 0.94. At 16 h and 24 h the AUROC score increased to 0.98 and 1.0 with the number of metabolites in the panel increasing to 5 and 7, respectively. CONCLUSIONS: These data demonstrate that metabolites may be a useful tool to diagnose and detect ricin exposure, thus increasing the effectiveness of supportive therapy and future ricin-specific medical treatments.

Unintentional endotracheal tube cuff deflation during routine checks: a simulation study.

BACKGROUND: Endotracheal tube cuff pressures should be maintained between 20 and 30 cm H2 O to prevent the aspiration of subglottic secretions past the cuff. Guidance recommends regular monitoring of the cuff pressure, performed using a handheld manometer/inflator. Poor technique can lead to transient deflation of the cuff, leading to the bolus aspiration of upper respiratory tract secretions, tracheal colonization and, ultimately, ventilator-associated pneumonia. AIMS AND OBJECTIVES: To determine whether intensive care staff transiently deflate the endotracheal tube cuff to below 20 cm H2 O during routine cuff pressure checks when using a handheld manometer/inflator device. DESIGN: This was an exploratory simulation study. METHODS: A sample of medical (n = 10) and nursing staff (n = 10), capable of caring for a tracheally intubated patient, participated in the study on a single day. A mannequin was intubated with a standard oral endotracheal tube with the cuff pressure set at 50 cm H2 O. Participants were required to check and correct the cuff pressure to the appropriate level with a manometer. The lowest attained and the final target pressures were recorded. RESULTS: Three doctors were unfamiliar with the manometer and did not attempt measurement. During cuff pressure readjustment, 59% (10/17) of participants transiently deflated the cuff below 20 cm H2 O and then re-inflated to attain the final pressure. Of these participants, four deflated the cuff pressure to 0 cm H2 O before re-adjusting it back into range. Most participants, 88% (15/17), corrected the final cuff pressure to between 20 and 30 cm H2 O. CONCLUSIONS: Poor technique when using the manometer led to unintentional cuff deflation during routine checks. In clinical practice, this could increase the risk of pulmonary aspiration and ventilator-associated pneumonia. Further research into alternatives for handheld manometers, such as automated continuous cuff pressure monitors, is warranted. RELEVANCE TO CLINICAL PRACTICE: Cuff deflations can easily occur during routine cuff pressure checks. Staff should be aware of the implications of cuff deflations and seek to improve training with manometers.

WireSafeTM - A pilot study of a novel safety engineered device designed to prevent guidewire retention and reduce sharps injuries during central venous catheter insertion.

Background: Guidewire retention and sharps injury during central venous catheter insertion are errors that cause patient and healthcare professional harm. The WireSafeTM is a novel procedure safety pack engineered to prevent guidewire retention and sharps injury during central venous catheter insertion. This is a pilot study aimed to determine its acceptability, usability and safety during clinical practice. Methods: An observational time and motion study was conducted comparing central venous catheter insertion and sharps disposal practice using standard versus WireSafeTM techniques. One-year following implementation, a structured survey was conducted to determine clinician opinion and experiences of using the WireSafeTM. Results: 15 procedures were observed using standard practice and 16 using the WireSafeTM technique. The WireSafeTM technique decreased the time taken from removal of the guidewire to disposal of sharps (standard 11.4 ± 5.6 min vs WireSafeTM 8.7 ± 1.4 min, p = 0.035), as well as total procedure time (standard 16 ± 7 min vs WireSafeTM 14.2 ± 2 min, p = 0.17), although this latter trend did not reach significance. Clinicians frequently practiced unsafe behaviour during sharps disposal in the standard group (53%), but when using the WireSafeTM technique, 100% exhibited safe practice by transferring sharps to the bin inside the sealed WireSafeTM box. One-year following implementation, 20 clinicians participated in the structured survey. Clinicians across three different departments used the WireSafeTM in varying clinical situations and reported that its use for central line insertion was either easier (10/20) or no different (10/20) compared to standard practice. All clinicians (20/20) felt that the WireSafeTM reduced the risk of guidewire retention and all stated that they approved of the WireSafeTM technique, and supported its use for convenience and safety benefits. Conclusion: Utilising the WireSafeTM for central line insertion facilitated earlier and safer sharps disposal, and the device was well supported by clinicians for its convenience and safety benefits.

Orbital Rosai-Dorfman disease with subperiosteal bone involvement mimicking eosinophilic granuloma.

The presentation of RDD as an anterior subperiosteal orbital mass with bone involvement has, to the authors' knowledge, not been previously reported. We describe a case of Rosai-Dorfman disease (RDD) presenting as an anterior superolateral subperiosteal orbital mass with erosion of overlying bone mimicking eosinophilic granuloma. It was debulked using endoscopic-guided curettage and the patient was given both local and systemic corticosteroids. Careful histological analysis revealed the diagnosis of RDD and the patient remains asymptomatic and recurrence free at 16 months follow-up. Involvement of the pituitary gland, a recognized yet unusual finding in this condition was also noted. RDD should be considered in the differential diagnosis of a soft tissue mass of the superolateral orbit.

Central Venous Catheter Guidewire Retention: Lessons From England's Never Event Database.

OBJECTIVES: Guidewire retention during central venous catheter (CVC) insertion is considered a "never event." We analyzed the National Health Service England Never Event database (2004-2015) to explore the process of guidewire retention and identify potential preventative measures. METHODS: We performed a systematic analysis of reported retained guidewire incidents by 3 independent reviewers. RESULTS: There was a rising frequency of reported retained CVC guidewires, with an average of 2 never events per month. Only 11% of retained guidewires are identified during the procedure itself, with the remainder identified during equipment clear-up (6%), after the procedure (4%), at the first check radiograph (23%), or after the first radiograph (55%). In 59 cases, the grade of the operator was reported, and among these, 88% were inserted by trainee doctors. Analysis of causative factors was only possible for 38 cases, and of these, operator's mistake (32%), operator/human error (16%), and distraction (16%) were the most common. Of 163 reported cases, preventative measures instigated were actions taken against the individual clinician (36%), departmental actions such as investigations, additional teaching or reminders (37%), and additional checklists (27%). CONCLUSIONS: Most retained guidewires are discovered after the procedure. Despite the introduction of safety measures, guidewire retention still occurs because the checks, alerts, reminders, and additional checklists all solely rely on the operator remembering not to make the mistake. System changes or design modifications to the CVC equipment are needed to prevent guidewire retention, this being at the top of the hierarchy of intervention effectiveness.

Blink lagophthalmos and dry eye keratopathy in patients with non-facial palsy: clinical features and management with upper eyelid loading.

PURPOSE: To evaluate the outcome of using upper eyelid gold weight implantation for patients with non-paralytic lagophthalmos on blink (LOB) only. We highlight the features of incomplete blink and reduced blink rate in patients with non-facial palsy as an exacerbating factor in dry eye keratopathy. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: Twelve patients (21 procedures) who underwent upper eyelid gold weight implantation for non-paralytic LOB only. METHODS: Retrospective case note review of patients who underwent upper eyelid loading for non-paralytic LOB only over a 5-year period at a single institution. MAIN OUTCOME MEASURES: Improvement in LOB, gentle and forced closure, increased frequency of blinking (FOB), degree of corneal staining, incidence of epithelial defects or corneal ulcer, improvement in vision, and subjective improvement in ocular discomfort. RESULTS: Twenty-one procedures in 12 patients. Nine patients underwent bilateral surgery. Mean age was 56 (range, 8-80) years. Median postoperative follow-up was 15 months, and mean follow-up was 20.38 ± 16.61 (6-58) months. Eleven of 12 patients had an improvement in LOB and increased FOB, resulting in improvement of keratopathy and reduced ocular discomfort. One patient developed superior corneal thinning and descemetocele, requiring removal of the gold weight; 1 patient required ptosis surgery; and 1 patient developed a gold allergy and underwent platinum chain exchange. CONCLUSIONS: We highlight the need to consider incomplete blink and reduced FOB as exacerbating factors for corneal-related disorders, including dry eye. Upper eyelid loading with gold weight implantation is a useful and predictive method of improving exposure-related keratopathy due to LOB in the absence of facial palsy.

Early experience using a new modified bone nibbler for superior osteotomy during endonasal dacryocystorhinostomy.

PURPOSE: The authors report their experience of using a modified bone nibbler as an adjunct to achieving an adequate superior osteotomy for full lacrimal sac exposure during endoscopic dacryocystorhinostomy. METHODS: Prospective interventional case series of 19 procedures performed from September 2008 to May 2009. Nasal mucosal flaps were fashioned and osteotomy was started using a Kerrison punch. The modified bone nibbler was then used to complete superior osteotomy to allow full sac exposure beyond its fundus. Lacrimal sac marsupialization and flaps were completed. Primary success was defined as full sac exposure equivalent to that normally achieved using powered instrumentation (PI) in our unit. PI was used if adequate osteotomy had not been achieved. Secondary success was defined as anatomical patency and symptom relief based on fluorescein flow on nasoendoscopy and patency to lacrimal syringing. RESULTS: Nineteen endoscopic dacryocystorhinostomy procedures in 18 patients were carried out with the nibbler by, or under supervision of, the senior surgeon over an 8-month period. The mean patient age was 52 years (range, 26-78 years). The median follow up was 6 months (4-36 weeks). Septoplasty was required in 4 (21%) cases. In 16/19 (84.2%) cases, full sac exposure was achieved with the nibbler. Three patients required PI to complete the osteotomy. Symptomatic and anatomical success with a patent nasolacrimal system was achieved in all cases (100%). CONCLUSIONS: We report the use of a new modified bone nibbler for removal of superior bone, even as high as the nasal roof, which previously in our practice could be removed only with PI. It allows a large osteotomy comparable to that achieved with powered endoscopic dacryocystorhinostomy yet avoids the disposable costs of PI.

An endoscopic approach for the management of congenital lacrimal fistulae.

A 26-year-old male presented with left epiphora from a congenital lacrimal fistula. A dacryocystogram confirmed fistulous origin from the lacrimal sac, while syringing demonstrated coexisting partial nasolacrimal duct obstruction. Endoscopic dacryocystorhinostomy was performed with marsupialization of the lacrimal sac medial wall, facilitating direct visualization of the internal fistula origin on the lateral wall, and excision with a 3-mm punch biopsy trephine over a cannula guide. Postoperatively, his symptoms resolved with a minimal cutaneous scar. The authors present this modified surgical technique for fistula excision using an endoscopic dacryocystorhinostomy approach.

Humidicare - an implementation study of a novel HME safety device designed to prevent ventilator circuit occlusion due to inadvertent dual humidification.

Mechanical ventilation bypasses the protective mechanisms of the upper respiratory tract which are designed to heat and humidify inspired air to 37 °C and 44 mg H2O/L respectively. Artificial humidification systems are therefore incorporated into ventilation circuits to condition cold and dry medical gases before they reach the lower respiratory tract and cause patient harm. Commonly either a heat and moisture exchanger (HME) or a heated humidifier (HH) are utilised for this purpose, however the inadvertent simultaneous use of both devices within the same circuit can cause critical airway occlusion within 24 h. The Humidicare HME (Medovate, Cambridge, UK) is a safety engineered temperature-dependent warning system designed to activate when inadvertently placed into a warm circuit containing a HH. This study aimed to determine the efficacy of the Humidicare HME warning system in simulated clinical conditions. The threshold temperature for activation of the device was determined in a digital incubator, and the device was tested for efficacy with a HH present or absent from the breathing circuit. The device performed reliably and activated rapidly when required across all simulations. The Humidicare HME warning system is a simple and unobtrusive device which can effectively alert the operator to the error of dual humidification.

The glucose error in arterial sampling: assessing staff awareness and the effect of sampling technique.

BACKGROUND: Using a dextrose-containing solution, instead of normal saline, to maintain the patency of an arterial cannula results in the admixture of glucose in line samples. This can misguide the clinician down an inappropriate treatment pathway for hyperglycaemia. METHODS: Following a near-miss and subsequent educational and training efforts at our institution, we conducted two simulations: (1) to observe whether 20 staff would identify a 5% dextrose/0.9% saline flush solution as the cause for a patient's refractory hyperglycaemia, and (2) to compare different arterial line sampling techniques for glucose contamination. RESULTS: (1) Only 2/20 participants identified the incorrect dextrose-containing flush solution, with the remainder choosing to escalate insulin therapy to levels likely to risk fatality, and (2) glucose contamination occurred regardless of sampling technique. CONCLUSION: Despite national guidance and local educational efforts, this is still an under-recognised error. Operator-focussed preventative strategies have not been effective and an engineered solution is needed.

A bedside rescue method for retrieving retained guidewires: The 'Suck Out' technique.

BACKGROUND: Central venous catheter guidewire retention is classed as a 'never event' in the United Kingdom, with the potential for significant patient harm. If the retained guidewire remains within the central venous catheter lumen, bedside techniques may facilitate guidewire retrieval. However, these techniques may be ineffective if the guidewire has already passed below skin level. We investigated a novel 'suck out' technique for bedside guidewire retrieval and compared this against traditional retrieval methods. METHODS: Simulation 1: in a benchtop model, seven different central venous catheters had their corresponding guidewire placed in the last 2 cm of the catheter tip which was immersed horizontally in fluid. A 50-mL syringe was attached to the distal lumen central venous catheter hub and suction applied for 5 s, and the distance of guidewire retraction was recorded. Simulation 2: a central venous catheter guidewire was intentionally retained within the catheter at either 5 cm above or below skin level in a pigskin model. Simple catheter withdrawal, catheter clamping withdrawal and the 'suck out' method were compared for efficacy using Fisher's exact test. RESULTS: Simulation 1: retained guidewires were retracted by 13 cm on average. Simulation 2: when guidewires were retained 5 cm above skin level, all retrieval methods were 100% effective; however, when retained 5 cm below skin level, simple catheter withdrawal was ineffective, clamping and withdrawal was only 10% effective and the 'suck out' technique was 90% effective (p < 0.001). CONCLUSION: The 'suck out' technique can effectively retract guidewires retained within central venous catheter lumens and demonstrates superiority over traditional methods of retained guidewire extraction in simulated models.

The use of pericranial flaps for reconstruction and elevation of the lower eyelid.

PURPOSE: We present the novel approach of using pericranial flaps to reconstruct posterior lamellar eyelid defects or to achieve lower eyelid elevation. This technique has been employed in patients where standard tarso-conjunctival flaps are not an option and free posterior lamellar grafts cannot be supported due to the lack of viable anterior lamellar flaps. METHODS: Pericranial flap, comprising inferiorly based forehead periosteum and the overlying loose areolar tissue, is constructed using a vertical paramedian forehead incision. Flaps are tunnelled subcutaneously to emerge at the proximal aspect of the eyelid defect and extend to the lateral orbital rim. They are secured with absorbable sutures. An overlying full-thickness free skin-graft or flap is used for the anterior lamella. RESULTS: Eight patients underwent reconstruction or lower lid elevation. All patients achieved the predicted lower eyelid height with good cosmesis. Median follow-up 7.5 months (6-24 months). Indications were lower lid scarring/retraction (4), facial palsy (1), post BCC reconstruction (2), and exposed keratoprosthesis (1). In 2 (of 5) patients who had free skin-grafting, the overlying free skin-graft did not survive but acted as a biological dressing. All such patients still had good outcomes after epithelialisation of the flap. The posterior aspect of the pericranial flaps seems to act as an ideal substrate for conjunctivalisation, with little detrimental effect on the cornea. The robustness of the flap prevents the development of lid laxity over time. CONCLUSION: The pericranial flap is a versatile and robust flap that yields good cosmetic and functional outcomes when used in the reconstruction of posterior lamellar eyelid deficits. It is likely that, even when not viable, overlying free skin-grafts act as an excellent biological dressing until epithelialisation occurs.

Prostatic adenocarcinoma presenting with metastatic frontal bone involvement and orbital invasion.

We present a rare case of prostatic adenocarcinoma presenting with metastatic frontal bone involvement with subsequent spread to the orbit. Although prostatic adenocarcinoma has a strong tendency to metastasize to bone, particularly axial skeletal bone, frontal bone involvement is rare and subsequent orbital involvement is even more so.

An unexpected diagnosis of paediatric subcutaneous sacrococcygeal extraspinal ependymoma: lessons learnt and review of the literature.

This case describes a 9-year-old male who presented to general surgical clinic with a 3-year history of persistent natal cleft swelling, previously unsuccessfully treated as a pilonidal abscess in the community with multiple courses of antibiotics. In clinic, a 50 × 30-mm soft tissue swelling was found in the natal cleft and a clinical diagnosis of a pilonidal cyst was made. A cream-coloured solid mass measuring 50 × 35 × 30 mm was subsequently excised under general anaesthetic, with specialist histology and immunostaining confirming an unexpected diagnosis of a subcutaneous extraspinal myxopapillary ependymoma, a tumour usually found in the neuraxis. Given the atypical anatomical site of the tumour, the case presented a unique management challenge. Ultimately, the patient underwent a re-operation after specialist multi-disciplinary discussion and is currently disease free at 18 months post-surgery. The authors wish to contribute their experiences of managing this rare extraspinal ependymoma to the few existing reports in the literature.

Features and management of an acute allergic response to acrylic ocular prostheses.

PURPOSE: To report the occurrence, causes and treatment of an acute allergic response to the acrylic resin used in ocular prostheses. METHODS: Retrospective review of presenting history, clinical findings and treatment of two cases. RESULTS: Both patients developed an acute onset hypersensitivity reaction thought to be due to the acrylic resin found in the ocular prosthesis. The first patient was successfully switched to a glass eye. The prosthesis of the second patient was treated with an extra long curing cycle, after which, the patient was able to tolerate their prosthesis with no complications. CONCLUSION: The residual unpolymerized monomer that is present within poly-methylmethacrylate (PMMA) can rarely cause an allergic reaction. As an alternative to a glass eye the prosthesis may be subjected to an extended curing cycle converting more of the monomer to polymer.

Posterior reversible encephalopathy syndrome, preeclampsia or stroke? A diagnostic dilemma.

When a pregnant woman presents with headaches, visual disturbances, epigastric pain and nausea, preeclampsia quickly springs to mind. This case describes a primigravid 22-year-old female of 32 weeks gestation who presented with the symptoms described but was found to be apparently normotensive. Due to ongoing symptoms and diagnostic uncertainty in the absence of definitive evidence of preeclampsia, the patient was further investigated with an MRI brain scan, which was reported as either an acute stroke or an atypical presentation of posterior reversible encephalopathy syndrome. Together with blood results that showed heterozygosity for Factor V Leiden, we concluded that while the patient's clinical diagnosis was certainly preeclampsia, her investigations also supported an unexpected diagnosis of silent brain infarction. This report outlines a diagnostic dilemma that required multidisciplinary working between obstetricians, neurologists, radiologists and stroke physicians to manage the patient who went on to make a full recovery and deliver a healthy baby.

Accidental dual humidification in intensive care units: Repeated alerts and system changes are not enough.

PURPOSE: The inadvertent, simultaneous use of heat and moisture exchangers (HMEs) and heated humidifiers (HHs) can result in waterlogging of the filter and sudden ventilation tube occlusion, with potentially fatal consequences. Following an NHS England Safety Alert, a near miss and educational reminders in our institution, we introduced new guidelines to solely use HHs in the intensive care unit and HMEs only for patient transfers. No further incidents have occurred, however this solution is potentially fallible. Two years later, we sought to assess staff knowledge and likelihood of recognising this error should it occur. MATERIALS AND METHODS: In a simulation study, a tracheally intubated and ventilated mannequin had a breathing circuit containing both a HME and a HH. Participants were asked to assess the circuit, identify errors and undertake corrective measures. RESULTS: Only 30% (6/20) recognised and undertook corrective measures. CONCLUSIONS: Despite educational efforts and system changes, recognition of this error remained poor. System changes may reduce the likelihood of the error occurring, but when it does, recognition may not occur. Substantial reductions or elimination of this error may be achieved through a safety-engineered fail-safe within the equipment, which alerts staff to improve recognition and prevent the mistake.

Predictive value of early IOP in mitomycin-C augmented trabeculectomy.

PURPOSE: To determine whether early intraocular pressure (IOP) after mitomycin-C (MMC) augmented trabeculectomy has any predictive value for intermediate IOP outcome. METHODS: Retrospective case note review. All cases of trabeculectomy using MMC augmentation and at least 1-year follow-up during the study period were included. Cases where a bleb leak occurred were excluded from the analysis. Only first eyes operated upon during the study period were included. Patient demographics and postoperative course were documented and analyzed. Early IOP measurements at day 1, day 7, and month 1 postoperatively were correlated to IOP at 1 year or final follow-up. RESULTS: One hundred nineteen trabeculectomies were identified. Of these 27 (22.7%) had an early bleb leak and were excluded. Further analysis was carried out on the remaining 92 cases. Mean age of cases was 70.8 years. Nine cases (9.8%) were repeat trabeculectomies. Mean follow-up time was 18.5 months (range 12 to 60 mo). Patients with a final IOP of < or =16 mm Hg (without drops or further surgery) (unqualified successes) had a mean day 1 IOP of 12.5 mm Hg compared with 17.4 mm Hg in those with an IOP more than 16 mm Hg at final follow-up (P=0.02). Patients with a final IOP of < or =16 mm Hg (with or without drops) (qualified successes) had mean day 1 IOP of 13.3 mm Hg compared with 17.1 mm Hg in those with an IOP of >16 mm Hg at final follow-up (P=0.06). At 1 month the mean IOPs were 10.7 mm Hg and 19.5 mm Hg, respectively (P<0.001). By logistic regression analysis at final recorded visit those cases in the lowest IOP quartile at 1 month were 14 times more likely to have an IOP < or =16 mm Hg without treatment than those in the highest quartile at 1 month. CONCLUSIONS: Our data suggests that a low early postoperative IOP measurement is a predictive factor for IOP value and success after intermediate length follow-up in patients undergoing trabeculectomy surgery augmented with MMC.