Minimally Invasive Glaucoma Surgical Techniques for Open-Angle Glaucoma

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 MEASURESThe 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 RELEVANCEBased 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.

Defining the role of ab externo Xen gel stent in glaucomatous eyes with prior failed surgical intervention

“…In addition, despite this difference, the overall percent reduction of IOP was not significantly different: 25% in the Xen group and 40% in the control group ( P = 0.90). The final IOP achieved at year 1 in both groups likely represents the surgical floor reached by filtering surgery [ 2 , 12 – 14 , 18 ].…”

“…An estimated 76.0 million people were affected by glaucoma in 2020, with 111.8 million people projected to be affected by 2040 [ 1 ]. Surgical treatment options have increased since the introduction of microinvasive glaucoma surgery (MIGS) [ 2 , 3 ]. These newer surgical options are aimed at lowering intraocular pressure (IOP) with less risk than traditional glaucoma filtering surgery.…”

Comparative Evaluation of Lamina Cribrosa Anatomical Parameters with Retinal Nerve Fiber Layer Thickness Defects In Primary Open-angle Glaucoma Cases And Controls

“…A massive gure of more than 75 million people are aected globally, and POAG is the most prevalent type of glaucoma worldwide. 2 It is estimated that around 57.5 million people are suerers of POAG. 3 Since glaucoma remains silent for decades, it usually remains undiagnosed, hence is a dire need for exploration of measures focused towards the screening of the disease and the methods employed that can prove prophylactic against its deleterious effects.…”

Identifying Glaucoma in Primary Care Offices

“…1 Clearly, this area is receiving substantial attention from the ophthalmic community to document the association between standard clinical measures and patientreported outcomes. 6,7 Methods to measure patient experience, such as quality-of-life questionnaires, are inherently subjective and may face difficulties in generalizability across different patient groups. There can be little doubt that severe visual function loss, as experienced in later-stage glaucoma, adversely impacts important aspects of daily living.…”

“…The USPSTF concluded there is “Inadequate evidence that treatment of primary open-angle glaucoma improves health outcomes such as reduced visual impairment, vision-related function, and quality of life.” Clearly, this area is receiving substantial attention from the ophthalmic community to document the association between standard clinical measures and patient-reported outcomes . Methods to measure patient experience, such as quality-of-life questionnaires, are inherently subjective and may face difficulties in generalizability across different patient groups.…”