Minimally-invasive glaucoma surgeries (MIGS) for open angle glaucoma: A systematic review and meta-analysis

Abstract

BackgroundMIGS have been developed as a surgical alternative for glaucomatous patients.PurposeTo analyze the change in intraocular pressure (IOP) and glaucoma medications using different MIGS devices (Trabectome, iStent, Excimer Laser Trabeculotomy (ELT), iStent Supra, CyPass, XEN, Hydrus, Fugo Blade, Ab interno canaloplasty, Goniscopy-assisted transluminal trabeculotomy) as a solo procedure or in association with phacoemulsification.MethodsRandomized control trials (RCT) and non-RCT (non randomized comparative studies, NRS, and before-after studies) were included. Studies with at least one year of follow-up in patients affected by primary open angle glaucoma, pseudoexfoliative glaucoma or pigmentary glaucoma were considered. Risk of Bias assessment was performed using the Cochrane Risk of Bias and the ROBINS-I tools. The main outcome was the effect of MIGS devices compared to medical therapy, cataract surgery, other glaucoma surgeries and other MIGS on both IOP and use of glaucoma medications 12 months after surgery. Outcomes measures were the mean difference in the change of IOP and glaucoma medication compared to baseline at one and two years and all ocular adverse events. The current meta-analysis is registered on PROSPERO (reference n° CRD42016037280).ResultsOver a total of 3,069 studies, nine RCT and 21 case series with a total of 2.928 eyes were included. Main concerns about risk of bias in RCTs were lack of blinding, allocation concealment and attrition bias while in non-RCTs they were represented by patients’ selection, masking of participants and co-intervention management. Limited evidence was found based on both RCTs and non RCTs that compared MIGS surgery with medical therapy or other MIGS. In before-after series, MIGS surgery seemed effective in lowering both IOP and glaucoma drug use. MIGS showed a good safety profile: IOP spikes were the most frequent complications and no cases of infection or BCVA loss due to glaucoma were reported.ConclusionsAlthough MIGS seem efficient in the reduction of the IOP and glaucoma medication and show good safety profile, this evidence is mainly derived from non-comparative studies and further, good quality RCTs are warranted.

What is the role of iStent in glaucoma management in 2019?

“…The effect size reported by Hooshmand et al is smaller than reported separately for the phaco‐iStent or phaco‐iStent inject . This may reflect a “real‐world” setting compared to that of a clinical trial—for example, pre‐ and post‐operative drop washout periods were not included.…”

“…The quality of evidence continues to improve, with a recent publication of meta‐analyses of the first‐generation iStent—both combined with phacoemulsification and as stand‐alone surgery—and a 2‐year prospective randomized control trial of the second‐generation iStent inject . The safety of these devices is well‐established in the short term—the most common adverse events are transient hyphema, stent malposition or blockage—and long‐term data are awaited.…”

The future of canine glaucoma therapy

“…The introduction of microinvasive or minimally invasive glaucoma surgeries (MIGS) in the surgical management of open‐angle glaucoma in humans represents an innovative development. The impact of the various MIGS remains to be determined with long‐term outcomes of effective IOP reduction and complications, and with appropriate comparative effectiveness trials and meta‐analyses . Because of their minimal invasiveness with moderate IOP reductions, these aqueous humor draining techniques are being considered more often as alternatives for the treatment of early glaucoma stages, instead of medical therapies .…”

Effect of combined goniotomy and phacoemulsification on intraocular pressure in open‐angle glaucoma patients

“…Minimally invasive glaucoma surgery (MIGS) has recently been introduced and is becoming popular for controlling IOP in patients with glaucoma . MIGS results in IOP reduction via an ab interno or externo approach to facilitate aqueous outflow with minimizing adjacent tissue damage, and has a high safety profile and rapid recovery .…”

“…8,9 Minimally invasive glaucoma surgery (MIGS) has recently been introduced and is becoming popular for controlling IOP in patients with glaucoma. [10][11][12] MIGS results in IOP reduction via an ab interno or externo approach to facilitate aqueous outflow with minimizing adjacent tissue damage, and has a high safety profile and rapid recovery. 11 MIGS involves specialized implants or devices, and can be performed simultaneously at the time of cataract surgery through a small corneal incision without damaging the conjunctiva.…”