IntroductionPrimary open-angle glaucoma is estimated to affect 3% of the population aged 40–80 years. Trabeculectomy is considered the gold standard in surgical management of glaucoma; however, it is a technically complex procedure that may result in a range of adverse outcomes. Device-augmented, minimally invasive procedures (micro-invasive glaucoma surgeries, MIGS) have been developed aiming for safer and less invasive intraocular pressure (IOP) reduction compared with traditional surgery.MethodsThis paper presents results from a systematic literature review conducted in accordance with National Institute for Health and Care Excellence requirements for the Medical Technology Evaluation Programme via multiple databases from 2005 to 2016. For clinical outcomes, randomized clinical trials (RCTs) comparing MIGS with trabeculectomy or other therapies, observational studies, and other non-RCTs were included. Clinical outcomes reviewed were the change from baseline in mean IOP levels and change in topical glaucoma medication. Safety was assessed by reported harm and adverse events. For economic evidence, trials on cost-effectiveness, cost-utility, cost-benefit, cost-consequences, cost-minimization, cost of illness, and specific procedure costs were included. Risk of bias was assessed for clinical studies using the Cochrane Risk of Bias tool.ResultsA total of nine RCTs (seven iStents®, one Hydrus®, and one CyPass®), seven non-RCTs (three iStent®, three CyPass®, and one Hydrus®), and 23 economic studies were analyzed. While various forms of trabeculectomy can achieve postoperative IOP of between 11.0 and 13.0 mmHg, MIGS devices described in this review were typically associated with higher postoperative IOP levels. In addition, MIGS devices may result in increased hypotony rates or bleb needling in subconjunctival placed devices, requiring additional medical resources to manage. There is limited available evidence on the cost-effectiveness of MIGS and therefore it remains unclear whether the cost of using MIGS is outweighed by cost savings through decreased medication and need for further interventions.ConclusionLarger randomized trials and real-world observational studies are needed for MIGS devices to better assess clinical and economic effectiveness. Given the shortage of published data and increasing use of such procedures, living systematic reviews may help to provide ongoing and timely evidence-based direction for clinicians and decision makers. This review highlights the current unmet need for treatments that are easy to implement and reduce long-term IOP levels without increasing postoperative aftercare and cost.FundingSanten GmbH, Germany.Electronic supplementary materialThe online version of this article (10.1007/s40123-018-0131-0) contains supplementary material, which is available to authorized users.

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the a1A-adrenergic receptors on the iris dilator muscle, resulting in disuse atrophy of the muscle; this in turn affects iris rigidity. 1 Controversy exists over the receptor subtypes present in the prostate and the precise mechanism of action of this type of agents. [2][3][4] Recent experience in our unit is in accord with Chang's report; 1 the majority of patients treated with tamsulosin undergoing cataract surgery seem to display the features of IFIS. We have noted no benefit from the temporary cessation of treatment preoperatively.The case we present here was, we believe, typical of IFIS. We are not aware of any previous reports of IFIS in patients treated with a1-adrenergic receptor blockers other than tamsulosin. It has been suggested that the a1A-subtype selectivity of tamsulosin might be accountable for the clinical manifestation of IFIS. 1 Alfuzosin, although not a1A-subtype-selective in vitro, 2,3,5-9 displays uroselective properties in vivo. [5][6][7] We postulate that the overall in vivo affinity of the a1-adrenergic receptor blockers towards a1A-subtype receptors might be responsible for IFIS rather than the in vitro a1A-selectivity per se. 2,7 We agree with previous authors that preoperative recognition of patients at risk of IFIS allows for appropriate surgical planning in anticipation of IFIS, with the intention of reducing the risk of preoperative complications. 1 It is our practice to insert, at commencement of surgery, disposable flexible translimbal iris retractors in a diamond configuration, as described by Oetting and Omphroy. 10 This seems to allow the operation to be completed safely and with little added difficulty.We believe that surgeons should anticipate IFIS in patients taking alfuzosin, in addition to those taking tamsulosin, and quite possibly in patients taking any of the uroselective a1-adrenergic receptor blockers. We are not aware of any reports of the nonuroselective a1-adrenergic receptor blockers causing IFIS. Comparison of tamsulosin with alfuzosin in the treatment of patients with lower urinary tract symptoms suggestive of bladder outlet obstruction (symptomatic benign prostatic hyperplasia). The European Tamsulosin Study Group. Br J Urol 1997; 80(4): 597-605. 9 Martin DJ, Lluel P, Guillot E, Coste A, Jammes D, Angel I.Comparative alpha-1 adrenoceptor subtype selectivity and functional uroselectivity of alpha-1 adrenoceptor antagonists.

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