Abstract
A report by the American Academy of Ophthalmology Ophthalmic Technology Assessment Committee Glaucoma Panel.Grace M. Richter, MD, MPH;1,2 Hana L. Takusagawa, MD;3 Arthur J. Sit, SM, MD;4Jullia A. Rosdahl, MD, PhD;5 Vikas Chopra, MD;6 Yvonne Ou, MD;7 Stephen J. Kim, MD;8 Darrell WuDunn, MD, PhD9Ophthalmology, Vol. 131, Issue 3, P370-82 © 2023 by the American Academy of Ophthalmology. Click here for free access to the OTA.Purpose: To determine the intraocular pressure (IOP) reduction of various trabecular procedures (a form of minimally invasive glaucoma surgery [MIGS]) combined with cataract surgery compared with cataract surgery alone, to compare the safety of the various trabecular procedures, and to highlight patient characteristics that may favor one trabecular procedure over another.
Methods: A search of English-language peer-reviewed literature in the PubMed database was initially conducted in February 2021 and updated in April 2023. This yielded 279 articles. Twenty studies met initial inclusion and exclusion criteria and were assessed for quality by the panel methodologist. Of these, 10 were rated level I, 3 were rated level II, and 7 were rated level III. Only the 10 level I randomized controlled trials (RCTs) were included in this assessment, and all were subject to potential industry-sponsorship bias.
Results: The current analysis focuses on the amount of IOP reduction (in studies that involved medication washout) and on IOP reduction with concurrent medication reduction (in studies that did not involve medication washout). Based on studies that performed a medication washout, adding a trabecular procedure to cataract surgery provided an additional 1.6 to 2.3 mmHg IOP reduction in subjects with hypertensive, mild to moderate open-angle glaucoma (OAG) at 2 years over cataract surgery alone, which itself provided approximately 5.4 to 7.6 mmHg IOP reduction. In other words, adding a trabecular procedure provided an additional 3.8% to 8.9% IOP reduction over cataract surgery alone, which itself provided 21% to 28% IOP reduction. There was no clear benefit of one trabecular procedure over another. Patient-specific considerations that can guide procedure selection include uveitis predisposition, bleeding risk, metal allergy, and narrowing of Schlemm’s canal. There are no level I data on the efficacy of trabecular procedures in subjects with pretreatment IOP of 21 mmHg or less.
Conclusions: Trabecular procedures combined with cataract surgery provide an additional mild IOP reduction over cataract surgery alone in hypertensive OAG subjects. Additional research should standardize outcome definitions, avoid industry sponsorship bias, and study the efficacy of these procedures in normotensive OAG.
1Department of Ophthalmology, Southern California Permanente Medical Group, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
2USC Roski Eye Institute, Keck Medicine of University of Southern California, Los Angeles, California
3VA Eugene Healthcare Center, Eugene, Oregon and Casey Eye Institute, Oregon Health & Sciences University, Portland, Oregon
4Mayo Clinic, Department of Ophthalmology, Rochester, Minnesota
5Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina
6Doheny Eye Centers UCLA and Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California
7Department of Ophthalmology, University of California San Francisco, San Francisco, California
8Department of Ophthalmology, Vanderbilt University School of Medicine, Nashville, TN
9University of Florida College of Medicine—Jacksonville, Department of Ophthalmology, Jacksonville, Florida