Intraoperative Mitomycin C in Trabeculectomy: Principles, Techniques, and Clinical Outcomes

Glaucoma is a leading cause of irreversible visual loss worldwide. Although medical therapy, laser procedures, and newer micro-invasive glaucoma surgeries (MIGS) have expanded the armamentarium for pressure control, trabeculectomy remains the gold standard operation for long-term lowering of intraocular pressure (IOP) and tube surgeries are performed when other measures fail. Excessive post-operative wound healing, resulting in subconjunctival fibrosis, remains the principal cause of trabeculectomy failure. Mitomycin C (MMC), an alkylating antimetabolite, has been in clinical use since the 1980s as an intraoperative adjunct to modulate wound healing and reduce scarring. This comprehensive review provides the pharmacology, molecular mechanism of action, application techniques, dosing strategies, clinical evidence from randomized trials and long-term cohorts, complications and their management, comparisons with other antifibrotic strategies, and emerging directions for safer and more effective delivery of MMC in glaucoma surgery. We summarize practical recommendations for patient selection and stepwise intraoperative application and provide guidance for post-operative follow-up and management of common adverse events.