Laser Trabeculoplasty for Open-Angle Glaucoma: A Systematic Review and Network Meta-Analysis

Epidemiology and Treatment of Patients With Primary Open Angle Glaucoma in Germany: A Health Claims Data Analysis

PRCIS

Based on a large administrative database of German claims data, our study provides current estimates of the prevalence and incidence of primary open angle glaucoma (POAG) in Germany and describes selected outcomes for prevalent patients with POAG.

PURPOSE

To estimate the prevalence and incidence of POAG in Germany, to describe the patient population in terms of comorbidity burden, routine care, and overall healthcare resource utilization (HCRU) and associated costs, and to describe treatment patterns over time in patients undergoing relevant laser procedures.

MATERIALS AND METHODS

Based on anonymized German claims data, we carried out a retrospective, noninterventional study covering calendar years 2016-2021.

RESULTS

For the adult German population (≥18 y), we estimated a POAG 1-year prevalence of 1.70% and a 1-year incidence of 0.17% in 2018; both increased with age, peaking in 80- to 89-year-olds. Prevalence and incidence were lower in 2020 (1.65% and 0.16%, respectively), the first year of the SARS-CoV-2 pandemic. Most patients solely received topical treatment. Most surgically treated patients underwent laser trabeculoplasty, followed by laser iridotomy, trabeculectomy, and filtration operations with implant. In patients undergoing laser trabeculoplasty, the treatment regimen was nearly unchanged in the second year after, compared with 2 years before the procedure. Multimorbidity was commonly observed; 75.5% of patients had arterial hypertension and 50.0% had disorders of lipoprotein metabolism and other lipidemias, compared with 60.1% and 39.2%, respectively, in an age- and sex-matched control sample.

CONCLUSIONS

Our study provides insights into epidemiology and routine care of POAG in Germany and HCRU in prevalent patients. There was little change in treatment regimens in patients who underwent laser trabeculoplasty, 2 years after the procedure. Most patients were multimorbid highlighting the need for comprehensive care.

180- Versus 360-Degree Selective Laser Trabeculoplasty in Open Angle Glaucoma and Ocular Hypertension: A Systematic Review and Meta-Analysis

PRCIS

This systematic review and meta-analysis found that 360-degree selective laser trabeculoplasty (SLT) is significantly more effective than 180-degree SLT at reducing intraocular pressure at 1-month and 1-year follow-ups without increased serious adverse event risk.

PURPOSE

To determine the efficacy of 180- versus 360-degree selective laser trabeculoplasty (SLT) in adults with open angle glaucoma (OAG) and ocular hypertension (OHT).

METHODS

A systematic review was performed using PubMed, Embase, and Scopus databases, from 1995 to December 30, 2023, for studies comparing 180 and 360-degree SLT in adults with OAG and OHT (PROSPERO ID: CRD42024497832). Meta-analyses were performed to calculate nominal percent and raw reductions in intraocular pressure (IOP) between treatment groups at 1-month, 1-year, and 2-year follow-ups, as well as success rates, defined as a 20% or greater IOP reduction.

RESULTS

Nine studies with 1044 eyes were included; 491 received 180-degree SLT, and 553 received 360-degree SLT. At the 1-month follow-up, 360-degree SLT reduced IOP by 3.45% more (WMD=3.45; 95% CI: 2.02-4.88; P <0.00001) and 0.87 mm Hg more (WMD=0.87; 95% CI: 0.35-1.38; P =0.0010). At the 1-year follow-up, 360-degree SLT reduced IOP by 4.33% more (WMD=4.33; 95% CI: 2.35-6.32; P <0.0001) and 1.15 mm Hg more (WMD=1.15; 95% CI: 0.25-2.04; P =0.01). At 2 years of follow-up, 360-degree SLT reduced IOP by 4.86% more (WMD=4.86; 95% CI: -0.32, 10.0; P =0.07) and 1.25 mm Hg more (WMD=1.25; 95% CI: -0.29, 2.79; P =0.11); however, the difference was not statistically significant. Compared with 360-degree SLT, 180-degree SLT had a significantly lower success rate (OR=0.50; 95% CI: 0.35-0.72; P =0.0002). There was no difference in serious complications between interventions.

CONCLUSIONS

360-degree SLT is more effective than 180-degree SLT at lowering IOP at 1-month and 1-year follow-ups as well as achieving successful IOP control without increased risk of serious complications.

Two-Year Performance and Safety Results of the MINIject Supraciliary Implant in Patients With Primary Open-Angle Glaucoma: Meta-Analysis of the STAR-I, II, III Trials

PURPOSE

To evaluate the performance and safety of minimally invasive glaucoma surgery with a supraciliary drainage device (MINIject; iSTAR Medical, Wavre, Belgium) in primary open-angle glaucoma (POAG) as a stand-alone procedure.

DESIGN

Meta-analysis.

METHODS

At 11 sites in Colombia, France, Germany, India, Panama, and Spain, 82 patients were treated in 3 prospective, multicenter, interventional, nonrandomized trials (STAR-I, II, III). Data were pooled in a meta-analysis of up to 2 years of follow-up postimplantation. The main outcome measures were mean relative and absolute reduction in diurnal intraocular pressure (IOP) compared to baseline. Secondary outcomes included patients with IOP ≤18 mmHg, patients with IOP reduction ≥20%, number of IOP-lowering medications, adverse events, and endothelial cell density loss.

RESULTS

At the 2-year follow-up (n = 66), mean IOP was reduced from 23.8 ± 3.3 mmHg at baseline to 14.4 ± 4.5 mmHg (-39.3%; P < 0.0001). An IOP reduction of ≥20% was achieved in 89.4% of patients, with 84.8% having an IOP ≤18 mmHg. IOP-lowering medications were reduced from a mean of 2.4 ± 1.1 to 1.4 ± 1.4 (P < 0.0001), with 37.9% of patients being medication-free at 2 years. Mean endothelial cell density loss at 2 years was 6.2 ± 9.1% compared to baseline and no patient had a loss >30%.

CONCLUSIONS

This meta-analysis demonstrates the favorable safety and efficacy profile of a supraciliary device implanted in a stand-alone, ab-interno procedure in patients with mild-to-moderate POAG. The data demonstrate that MINIject is a safe and effective, bleb-free treatment option for patients requiring low target IOP up to 2 years.

Selective laser trabeculoplasty: An updated narrative review

Selective laser trabeculoplasty (SLT) has experienced a resurgence in interest, primarily driven by promising findings from the Laser in Glaucoma and Ocular Hypertension Trial. By offering SLT as an initial drug-free treatment option, we may be able to thwart issues such as adherence and persistence that plague our current medical management protocols. In this comprehensive narrative review, we delve into the current body of literature that explores the utility of SLT across a wide spectrum of scenarios and glaucoma subtypes. We present evidence that provides valuable insight into the efficacy and benefits of SLT, positioning it as a viable option in the management of glaucoma. Careful consideration of the associated risks and challenges is also necessary for successful adoption into clinical practice. Despite the ample evidence supporting SLT's efficacy, some questions remain regarding its long-term effects and the potential need for retreatment. This review aims to shed light on these aspects to guide clinicians in making informed decisions and tailoring treatment plans to individual patient needs. This review also provides the readers with a bird's eye view of the potential impact of SLT and adds clarity to the various therapeutic protocols that one can follow to ensure optimal clinical outcomes for our patients.

An Exploratory Retrospective Data Analysis Comparing the Outcomes of Selective Laser Trabeculoplasty and Argon Laser Trabeculoplasty in Patients with Open-Angle Glaucoma or Ocular Hypertension in Vienna, Austria, from the Year 2012 to 2022

Background and Objectives: The aim of the present study was to compare the short-term outcomes of selective laser trabeculoplasty (SLT) with argon laser trabeculoplasty (ALT) in patients with glaucoma in a real-world setting. Materials and Methods: The present study was conducted as a retrospective case-control study. The main outcome was the change in intraocular pressure (IOP) three months after laser surgery. In addition, the number of substances used for lowering of IOP and adverse events (AEs) were assessed. Results: Charts from 25 patients were included in the present study, of which 12 had received ALT and 13 SLT. In both groups, IOP significantly decreased from baseline values 6 weeks and 3 months after laser treatment (p < 0.01 vs. baseline at each timepoint for both groups). While after 6 weeks, no difference between groups was found, after 3 months, the decrease in IOP was significantly more pronounced in the SLT group (-26 ± 21% in the ALT group vs. -41 ± 14% in the SLT group, p = 0.018 between groups, ANOVA). Three months after laser treatment, the number of IOP-lowering substances used by each patient had decreased with no difference between groups (ALT: from 2.7 ± 0.8 to 2.3 ± 0.9 substances; SLT: from 1.8 ± 1.2 to 1.3 ± 1.1 substances, p = 0.386). Only a few AEs were observed. Two patients in the ALT and one patient in the SLT group required trabeculectomy within 1 year after laser treatment due to IOP decompensation. Conclusions: In the present study, SLT was at least as effective as ALT with fewer AEs and a similar reduction in concomitant IOP-lowering medication.

Selective Laser Trabeculoplasty

Selective laser trabeculoplasty (SLT) is a common ophthalmic procedure used to lower intraocular pressure. The mechanism of SLT action remains controversial but may involve the upregulation of protein expressions in the trabecular meshwork that increases outflow facility. Several prospective trials have demonstrated the safety and efficacy of SLT as both adjunctive and primary glaucoma therapy, and the utilization of SLT in stable, medically-controlled glaucoma patients may decrease medication burden and potentially improve the patients’ quality of life.

Fixed High Energy Versus Standard Titrated Energy Settings for Selective Laser Trabeculoplasty

PRCIS

Fixed high-energy selective laser trabeculoplasty (SLT) is associated with a greater reduction in intraocular pressure (IOP) compared with the standard titrated approach at up to 36 months postprocedure.

PURPOSE

There is no consensus on ideal SLT procedural laser energy settings. This study aims to compare fixed high-energy SLT to the standard titrated-energy approach within the setting of a residency training program.

PATIENTS

Patients over the age of 18 years received SLT between 2011 and 2017, a total of 354 eyes. Patients with a prior history of SLT were excluded.

METHODS

Retrospective review of clinical data from 354 eyes that underwent SLT. Eyes that underwent SLT using fixed high energy (1.2 mJ/spot) were compared with those with the standard titrated approach starting at 0.8 mJ/spot and titrating to "champagne" bubbles. The entirety of the angle was treated using a Lumenis laser set to the SLT setting (532 nm). No repeat treatments were included.

MAIN OUTCOME MEASURE

IOP and glaucoma medications.

RESULTS

In our residency training program, fixed high-energy SLT was associated with a reduction in IOP compared with a baseline of -4.65 (±4.49, n = 120), -3.79 (±4.49, n = 109), and -4.40 (±5.01, n =119) while standard titrated-energy was associated with IOP reduction of -2.07 (±5.06, n = 133), -2.67 (±5.28, n = 107), and -1.88 (±4.96, n = 115) at each respective postprocedural time point (12, 24, and 36 months). The fixed high-energy SLT group had significantly greater IOP reduction at 12 months and 36 months. The same comparison was performed for medication naïve individuals. For these individuals, fixed high-energy SLT resulted in IOP reductions of -6.88 (±3.72, n = 47), -6.01 (±3.80, n = 41), and -6.52 (±4.10, n = 46) while standard titrated-energy had IOP reductions of -3.82 (±4.51, n = 25), -1.85 (±4.88, n = 20), and -0.65 (±4.64, n = 27). For medication naïve individuals, fixed high-energy SLT resulted in a significantly greater reduction in IOP at each respective time point. Complication rates (IOP spike, iritis, and macular edema) were similar between the two groups. The study is limited by overall poor response to standard-energy treatments, whereas high-energy treatments showed similar efficacy to those in literature.

CONCLUSION

This study demonstrates that fixed-energy SLT produces at least equivalent results compared with the standard-energy approach, without an increase in adverse outcomes. Particularly in the medication naïve subpopulation, fixed-energy SLT was associated with a significantly greater IOP reduction at each respective time point. The study is limited by overall poor response to standard-energy treatments, with our results showing decreased IOP reduction compared with those of previous studies. These poor outcomes of the standard SLT group may be responsible for our conclusion that fixed high-energy SLT results in a greater reduction in IOP. These results may be useful when considering optimal SLT procedural energy in future studies for validation.

Pigment dispersion syndrome and pigmentary glaucoma: overview and racial disparities

Pigment dispersion syndrome (PDS) and pigmentary glaucoma (PG) are two stages within the same ophthalmic disease spectrum, which are known to be affected by race. The prevalence of PDS is underestimated, largely due to its minor clinical symptoms. Although the prevalence of PG is low, the visual impairment associated with PG is extremely severe. The prevalence of PDS-PG is four or more times higher in Caucasians than in Blacks or Asians, and the "classic" PDS in Caucasians has long been used as a benchmark diagnostic criterion. Following extensive research focused on African Americans and Asians, the standard for diagnosing PDS-PG was refined. At the same time, the pathogenesis of PDS is not the same in different races. Hence, the effectiveness of preventive treatment and the need for treatment may not be equivalent in different races. The rate of conversion of PDS to PG is nearly 1/3 in Caucasians and higher in blacks and Asians, requiring more aggressive treatment and monitoring. We systematically searched a PubMed database from inception to March 2022 to provide an overview of research progress in various aspects of PDS-PG. Specifically, this paper considers the effects of race on disease prevalence, clinical manifestation, diagnostic criteria, disease mechanism, hereditary traits, treatment, and prevention to provide an accurate and comprehensive guide for the diagnosis and treatment of PDS-PG in various races.

[Glaucoma care in Germany-results of a survey among German ophthalmologists-part 2: treatment]

BACKGROUND

The options for glaucoma treatment are quite diverse. The question therefore arises what is considered beneficial and feasible in daily practice. Our anonymized survey among members of the German Ophthalmological Society (DOG) and the Professional Association of Ophthalmologists in Germany (BVA) intends to explore treatment patterns and strategies in routine glaucoma care in Germany.

OBJECTIVE

The current article reflects current opinions of German ophthalmologists regarding glaucoma care, therapeutic strategies, and the role of glaucoma surgery.

MATERIALS AND METHODS

The survey was conducted using an online questionnaire with 26 questions (107 items) regarding care practice for glaucoma diagnosis and treatment. Complete responses were available from 1361 participants.

RESULTS

A total of 84.8% of responders define a target pressure regularly. A systemic therapeutic approach is followed by 44.9%. Two thirds consider side effects of eye drops to impair quality of life. Most common are conjunctival hyperemia and burning. Non-adherence to treatment is estimated to occur in 32% of patients. Approximately 5-10% of glaucoma patients are treated surgically. Among interventional treatment options, 90% consider trabeculectomy beneficial, followed by minimally invasive glaucoma surgery (MIGS) and selective laser trabeculoplasty (SLT), which are, however, the most commonly performed procedures.

CONCLUSION

The choice of treatment should intend a long-lasting reduction of intraocular pressure and yet to be reasonable and manageable. There is a demand for more overview and structured care.

Evaluation of the Efficacy Duration of Topical Therapies in Eyes with Primary Open-Angle Glaucoma

Background: To investigate the efficacy interval of the topical therapies available for primary open-angle glaucoma (POAG) and the ocular and systemic features potentially associated. Methods: This retrospective study included 190 patients with POAG undergoing first topical therapy, throughout a follow-up of 15 years. The patients started one topical intraocular pressure (IOP)-lowering drug within single molecules such betablockers, prostaglandin or dorzolamide, or fixed combinations such as betablockers + prostaglandin, betablockers + dorzolamide, or betablockers + brimonidine. Efficacy duration was measured as the time between the start of the therapy and the change due to IOP increase or visual field worsening. For each patient, ocular and systemic features and comorbidities were analysed to detect any significant correlation with the length of effectiveness of every drug used. Results: The molecules explored showed some discrepancies in terms of mean duration of efficacy; however, no significant differences were demonstrated (p > 0.05). Furthermore, when evaluating the overall cohort, no systemic or ocular features correlated significantly with the effectiveness of the molecules explored. However, the same analysis carried out upon stratifying the different groups according to the IOP-lowering drops they received, demonstrated that the drug efficacy could be influenced by several ocular and systemic features. Conclusion: Data observed in this study suggest that there is no difference in using one of the medications evaluated as first choice of treatment of POAG if the patients are accurately evaluated and the most recent guidelines are adopted.

Laser trabeculoplasty for open-angle glaucoma and ocular hypertension

BACKGROUND

Open-angle glaucoma (OAG) is an important cause of blindness worldwide. Laser trabeculoplasty, a treatment modality, still does not have a clear position in the treatment sequence.

OBJECTIVES

To assess the effects of laser trabeculoplasty for treating OAG and ocular hypertension (OHT) when compared to medication, glaucoma surgery or no intervention. We also wished to compare the effectiveness of different laser trabeculoplasty technologies for treating OAG and OHT.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2021, Issue 10); Ovid MEDLINE; Ovid Embase; the ISRCTN registry; LILACS, ClinicalTrials.gov and the WHO ICTRP. The date of the search was 28 October 2021. We also contacted researchers in the field.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing laser trabeculoplasty with no intervention, with medical treatment, or with surgery in people with OAG or OHT. We also included trials comparing different types of laser trabeculoplasty technologies.

DATA COLLECTION AND ANALYSIS

We used standard methods expected by Cochrane. Two authors screened search results and extracted data independently. We considered the following outcomes at 24 months: failure to control intraocular pressure (IOP), failure to stabilise visual field progression, failure to stabilise optic neuropathy progression, adverse effects, quality of life, and costs. We graded the 'certainty' of the evidence using GRADE.

MAIN RESULTS

We included 40 studies (5613 eyes of 4028 people) in this review. The majority of the studies were conducted in Europe and in the USA. Most of the studies were at risk of performance and/or detection bias as they were unmasked. None of the studies were judged as having low risk of bias for all domains. We did not identify any studies of laser trabeculoplasty alone versus no intervention. Laser trabeculoplasty versus medication Fourteen studies compared laser trabeculoplasty with medication in either people with primary OAG (7 studies) or primary or secondary OAG (7 studies); five of the 14 studies also included participants with OHT. Six studies used argon laser trabeculoplasty and eight studies used selective laser trabeculoplasty. There was considerable clinical and methodological diversity in these studies leading to statistical heterogeneity in results for the primary outcome "failure to control IOP" at 24 months.  Risk ratios (RRs) ranged from 0.43 in favour of laser trabeculoplasty to 1.87 in favour of medication (5 studies, I2 = 89%). Studies of argon laser compared with medication were more likely to show a beneficial effect compared with studies of selective laser (test for interaction P = 0.0001) but the argon laser studies were older and the medication comparator group in those studies may have been less effective. We considered this to be low-certainty evidence because the trials were at risk of bias (they were not masked) and there was unexplained heterogeneity. There was evidence from two studies (624 eyes) that argon laser treatment was associated with less failure to stabilise visual field progression compared with medication (7% versus 11%, RR 0.70, 95% CI 0.42 to 1.16) at 24 months and one further large recent study of selective laser also reported a reduced risk of failure at 48 months (17% versus 26%) RR 0.65, 95% CI 0.52 to 0.81, 1178 eyes). We judged this outcome as moderate-certainty evidence, downgrading for risk of bias. There was only very low-certainty evidence on optic neuropathy progression. Adverse effects were more commonly seen in the laser trabeculoplasty group including peripheral anterior synechiae (PAS) associated with argon laser (32% versus 26%, RR 11.74, 95% CI 5.94 to 23.22; 624 eyes; 2 RCTs; low-certainty evidence); 5% of participants treated with laser in three studies of selective laser group had early IOP spikes (moderate-certainty evidence). One UK-based study provided moderate-certainty evidence that laser trabeculoplasty was more cost-effective.  Laser trabeculoplasty versus trabeculectomy Three studies compared laser trabeculoplasty with trabeculectomy. All three studies enrolled participants with OAG (primary or secondary) and used argon laser. People receiving laser trabeculoplasty may have a higher risk of uncontrolled IOP at 24 months compared with people receiving trabeculectomy (16% versus 8%, RR 2.12, 95% CI 1.44 to 3.11; 901 eyes; 2 RCTs). We judged this to be low-certainty evidence because of risk of bias (trials were not masked) and there was inconsistency between the two trials (I2 = 68%). There was limited evidence on visual field progression suggesting a higher risk of failure with laser trabeculoplasty. There was no information on optic neuropathy progression, quality of life or costs. PAS formation and IOP spikes were not reported but in one study trabeculectomy was associated with an increased risk of cataract (RR 1.78, 95% CI 1.46 to 2.16) (very low-certainty evidence).

AUTHORS' CONCLUSIONS

Laser trabeculoplasty may work better than topical medication in slowing down the progression of open-angle glaucoma (rate of visual field loss) and may be similar to modern eye drops in controlling eye pressure at a lower cost. It is not associated with serious unwanted effects, particularly for the newer types of trabeculoplasty, such as selective laser trabeculoplasty.

Energy Dose-Response in Selective Laser Trabeculoplasty: A Review

PRCIS

A literature review of selective laser trabeculoplasty (SLT) energy dose-response found no definitive relationship between intraocular pressure (IOP) reduction with respect to total or pulse energy, race, pigmentation, or application pattern.

PURPOSE

SLT is a safe and effective treatment for lowering IOP. Although evidence is mounting for the advantage of its use as a first-line treatment for IOP reduction, the SLT procedures in use vary widely. The purpose of this literature review was to investigate whether there were any relationships between SLT energy and efficacy for lowering IOP in the published literature.

METHODS

A literature review was undertaken that included studies in which energy levels required for successful SLT treatment were investigated: in general, with respect to angle pigmentation, race or ethnicity, and treatment arc extent.

RESULTS

There was no indication that higher (or lower) energy used in the treatment leads to greater (or less) IOP reduction. Similar results were obtained regarding the level of trabecular meshwork pigmentation. Race was not found to be associated with altered dose response in SLT. There were indications that treating the full 360 degrees, as opposed to smaller arcs, could be beneficial for more IOP reduction. IOP reduction from SLT was found to be similar to that provided by topical medications.

CONCLUSIONS

The optimal energy level of SLT needed for IOP reduction has not yet been definitively established, with all reported pulse energies resulting in similar IOP reduction. Furthermore, similar lack of conclusive findings exists regarding optimal SLT energy dosage for use in different races and degrees of trabecular meshwork pigmentation. This parameter and each of the abovementioned factors requires further research.

A Review of Selective Laser Trabeculoplasty: “The Hype Is Real”

Presently, there is no efficacious treatment for glaucomatous optic neuropathy; the current treatment is focused on lowering intraocular pressure (IOP). Studies have demonstrated the safety and efficacy of selective laser trabeculoplasty (SLT) in reducing the IOP in eyes with open-angle (OAG) glaucoma or ocular hypertension (OH). Moreover, the European Glaucoma Society has instated SLT as the first-line or adjunctive treatment in OAG or OH, reiterating its clinical significance. In this review, we outline the old and the new roles of SLT, with an emphasis on clinical practice, and look further into its renewed appeal and future developments.

Selective laser trabeculoplasty for steroid-induced ocular hypertension following endothelial keratoplasty

Purpose: To examine the safety and efficacy of selective laser trabeculoplasty (SLT) in patients responding to topical steroids with elevated intraocular pressure following endothelial keratoplasty.Methods: Patients that underwent Descemet Membrane Endothelial Keratoplasty (DMEK) or Descemet Stripping Automated Endothelial Keratoplasty (DSAEK) were offered SLT as first-line therapy if they presented with steroid response and met inclusion criteria. Patient demographics, best-corrected visual acuity (BCVA), steroid and glaucoma regimens were recorded before and after SLT.Results: Twelve eyes of 8 patients were recruited to the study. All patients demonstrated a reduction in IOP and only one patient remained on anti-glaucoma drops after SLT. The mean (±SD) reduction in IOP following SLT was 8.8 (±4.9) mmHg (p < 0.0001). BCVA remained stable and no adverse events following treatment were observed.Conclusions: SLT may be a safe and effective treatment option that reduces topical antihypertensive burden while allowing continuance of corticosteroids in steroid-responsive eyes at high risk of rejection following endothelial keratoplasty. Larger randomized studies are needed to compare SLT efficacy with topical medication in this patient group and to review any impact on graft survival and glaucoma progression.

Comparisons of the short-term effectiveness and safety of surgical treatment for neovascular glaucoma: a systematic review and network meta-analysis

OBJECTIVE

To compare the effectiveness and safety of the six interventions for neovascular glaucoma.

DESIGN

A systematic review and network meta-analysis.

METHODS

Randomised controlled trials and cohort studies which compared the six interventions in neovascular glaucoma were identified using the following databases searched up to 1 September 2020: PubMed, Cochrane Library, Embase and Web of Science. The quality assessment was conducted by using the Cochrane risk of bias tool and the Newcastle-Ottawa scale. The primary outcome measure was the weighted mean differences for intraocular pressure reduction. Secondary one was ORs for success rate. Outcome measures were reported with a 95% CI and p<0.05 was considered statistically significant. Network meta-analysis was performed using Stata V.15.0.

RESULTS

Twenty-three studies involving a total of 1303 patients were included. The types of surgical treatments included Ahmed glaucoma valve (AGV) implant surgery, AGV combined with intravitreal anti-vascular endothelial growth factor (AGV +IVAV), cyclophotocoagulation (CPC), cyclocryotherapy (CCT), trabeculectomy with mitomycin (Trab(MMC)) and Trab(MMC) combined with IVAV (Trab(MMC)+IVAV). Network meta-analysis showed that in comparison with AGV, AGV +IVAV (MD=4.74, 95% CI 1.04 to 8.45) and Trab(MMC)+IVAV (MD=6.19, 95% CI 0.99 to 11.40) showed a favourable effect in intraocular pressure reduction (IOPR) 6 months after surgery. Compared with CCT, AGV (OR=-0.17, 95% CI -0.53 to -0.05), AGV +IVAV (OR=-0.10, 95% CI -3.48 to -1.19), CPC (OR=-0.12, 95% CI -0.53 to -0.05), Trab(MMC) (OR=3.54, 95% CI 1.15 to 10.91) and Trab(MMC)+IVAV (OR=5.78, 95% CI 2.29 to 14.61) showed a superior impact in success rate. The order of efficacy as best intervention ranked as follows: Trab(MMC)+IVAV (IOPR 6 months after surgery, surface under the cumulative ranking (SUCRA)=88.1), CPC (IOPR 12 months after surgery, SUCRA=81.9), AGV +IVAV (IOPR 12 months after surgery, SUCRA=79.9) and AGV +IVAV (success rate, SUCRA=92.7). Adverse events were also summarised in detail.

CONCLUSION

In the treatment of neovascular glaucoma, AGV+IVAV and CPC were more effective in IOPR and success rate than the other four interventions. Additionally, AGV+IVAV is superior to CPC concerning the success rate in the long-term treatment. However, considering the limitations of this review, more high-quality trials, especially those surgical interventions not mentioned in this review, should be carried out in the future to further confirm the current findings.

Comparison of Outcomes for Laser Trabeculoplasty after Kahook Dual Blade Goniotomy Versus in Goniotomy-Naive Eyes

Introduction

This was a comparison of laser trabeculoplasty (LTP) outcomes in eyes with prior Kahook Dual Blade (KDB) goniotomy versus in goniotomy-naive control eyes.

Methods

This was a retrospective matched comparative case series. We identified a cohort of patients undergoing LTP between February 2017 and July 2020 at University of Missouri. Patients were grouped by history of KDB goniotomy versus goniotomy-naivety as a control group. Inclusion criteria included age at least 18 years, minimum of 6 months follow-up after LTP, and minimum period of 6 months between KDB goniotomy and LTP. All KDB procedures were combined with uncomplicated phacoemulsification. Patients who had any additional intraocular pressure (IOP)-lowering procedures between KDB goniotomy and LTP were excluded. Patients in the control group received a single LTP procedure.

Primary outcome consisted of the comparison of LTP success, defined as IOP reduction of at least 20% or reduction of glaucoma medications from pre-LTP baseline. Secondary outcomes included IOP and medication reduction from pre-LTP baseline.

Results

Twenty-one eyes of 19 patients with history of KDB goniotomy and 42 eyes of 36 control patients without previous angle or laser procedures were included. Baseline characteristics including age, gender, ethnicity, type and severity of glaucoma, baseline IOP, and baseline medications were matched between groups. The LTP success rate was higher in the control group, but was not statistically significant (64% vs 57%, p = 0.58). IOP reduction was only significant in the control eyes (2.50 ± 4.0 mmHg, p = 0.01 vs 2.35 ± 4.7 mmHg, p = 0.08). The number of glaucoma medications was not significantly reduced in either group.

Conclusion

LTP may have a limited IOP- and medication-lowering effect in eyes with a history of KDB goniotomy compared to goniotomy-naive eyes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40123-021-00378-7.