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Review
. 2021 Sep 1;139(9):983-989.
doi: 10.1001/jamaophthalmol.2021.2351.

Minimally Invasive Glaucoma Surgical Techniques for Open-Angle Glaucoma: An Overview of Cochrane Systematic Reviews and Network Meta-analysis

Affiliations
Review

Minimally Invasive Glaucoma Surgical Techniques for Open-Angle Glaucoma: An Overview of Cochrane Systematic Reviews and Network Meta-analysis

Amanda K Bicket et al. JAMA Ophthalmol. .

Abstract

Importance: Glaucoma affects more than 75 million people worldwide. Intraocular pressure (IOP)-lowering surgery is an important treatment for this disease. Interest in reducing surgical morbidity has led to the introduction of minimally invasive glaucoma surgeries (MIGS). Understanding the comparative effectiveness and safety of MIGS is necessary for clinicians and patients.

Objective: To summarize data from randomized clinical trials of MIGS for open-angle glaucoma, which were evaluated in a suite of Cochrane reviews.

Data sources: The Cochrane Database of Systematic Reviews including studies published before June 1, 2021.

Study selection: Reviews of randomized clinical trials comparing MIGS with cataract extraction alone, other MIGS, traditional glaucoma surgery, laser trabeculoplasty, or medical therapy.

Data extraction and synthesis: Data were extracted according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines by one investigator and confirmed by a second. Methodologic rigor was assessed using the AMSTAR 2 appraisal tool and random-effects network meta-analyses were conducted.

Main outcomes and measures: The proportion of participants who did not need to use medication to reduce intraocular pressure (IOP) postsurgery (drop-free). Outcomes were analyzed at short-term (<6 months), medium-term (6-18 months), and long-term (>18 months) follow-up.

Results: Six eligible Cochrane reviews were identified discussing trabecular bypass with iStent or Hydrus microstents, ab interno trabeculotomy with Trabectome, subconjunctival and supraciliary drainage devices, and endoscopic cyclophotocoagulation. Moderate certainty evidence indicated that adding a Hydrus safely improved the likelihood of drop-free glaucoma control at medium-term (relative risk [RR], 1.6; 95% CI, 1.4 to 1.8) and long-term (RR, 1.6; 95% CI, 1.4 to 1.9) follow-up and conferred 2.0-mm Hg (95% CI, -2.7 to -1.3 mm Hg) greater IOP reduction at long-term follow-up, compared with cataract surgery alone. Adding an iStent also safely improved drop-free disease control compared with cataract surgery alone (RR, 1.4; 95% CI, 1.2 to 1.6), but the short-term IOP-lowering effect of the iStent was not sustained. Addition of a CyPass microstent improved drop-free glaucoma control compared with cataract surgery alone (RR, 1.3; 95% CI, 1.1 to 1.5) but was associated with an increased risk of vraision loss. Network meta-analyses supported the direction and magnitude of these results.

Conclusions and relevance: Based on data synthesized in Cochrane reviews, some MIGS may afford patients with glaucoma greater drop-free disease control than cataract surgery alone. Among the products currently available, randomized clinical trial data associate the Hydrus with greater drop-free glaucoma control and IOP lowering than the iStent; however, these effect sizes were small.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Bicket reported receiving grants from W. L. Gore & Associates Inc and serving as institutional grant-funded site principal investigator for surgical device research and development outside the submitted work. Dr Le reported conducting/preparing when he was a methodologist for Cochrane Eyes and Vision at the Johns Hopkins Bloomberg School of Public Health. Dr Gazzard reported receiving personal fees from Alcon, Allergan, Belkin, Equinox, Genetech, Glaukos, McKinsey, Reichert, Santen, Sight Sciences, and Zeiss; and grants from Thea, grants from and Ivantis. Dr Jayaram reported receiving personal fees from Allergan, Santen, and Ivantis, and nonfinancial support from Théa outside the submitted work. Dr Li reported receiving grant UG1EY020522 from the National Institutes of Health/National Eye Institute (NIH/NEI) during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Network Meta-analyses of Primary and Select Secondary Outcomes
Network plots for (A) proportion of participants drop-free, (B) mean change in unmedicated intraocular pressure (IOP) after washout, and (C) mean change in number of IOP-lower drops per day. Hydrus vs iStent comparisons include data from 1 trial (148 participants) that did not involve cataract extraction, assuming an equivalent effect of concurrent cataract extraction on both minimally invasive glaucoma surgery procedures.
Figure 2.
Figure 2.. Network Meta-analyses of Primary and Select Secondary Outcomes
Interval plots for (A) proportion of participants drop-free; (B) mean change in unmedicated intraocular pressure (IOP) after washout; (C) mean change in number of IOP-lowering drops per day. Hydrus vs iStent comparisons include data from 1 trial (148 participants) that did not involve cataract extraction, assuming equivalent outcome of concurrent cataract extraction with both minimally invasive glaucoma surgery procedures. PI indicates prediction interval.

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