Efficacy and safety of non‐penetrating surgery versus trabeculectomy in open‐angle glaucoma: A systematic review and meta‐analysis

Aims/Purpose: Whilst trabeculectomies (TE) remain the gold‐standard treatment for open‐angle glaucoma (OAG), non‐penetrating surgery (NPS) are rising in popularity as an alternative. This systematic review and meta‐analysis compared the efficacy and safety of trabeculectomy and NPS for OAG.

Methods: The following databases of PubMed, Embase, Medline, Scopus and Cochrane Library were searched for original studies comparing TE to NPS (from inception to 23/01/2024). The primary outcome was IOP reduction, with secondary outcomes including success rate, medication score, visual acuity (BCVA) and complications. A random‐effects model on ReviewManager (RevMan) was used for the meta‐analysis. Sub‐group analyses for concomitant mitomycin C and hyaluronate were performed, unlike current existing reviews.

Results: Initially 529 papers were identified. Of these, 20 studies containing 1422 participants (1565 eyes) were included. 16 studies reported higher complete success rates with TE. Meta‐analysis showed that although the IOP reduction was larger in TE, this was not statistically significant (mean difference = ‐1.31, 95% CI: ‐3.12 to 0.50). There was no significant difference in reduction of medications but there was significant improvement in BCVA at 12 months with NPS (unweighted average: TE = 0.078, NPS = ‐0.015, p < 0.00652). The relative risk of complications (hypotony, choroidal detachment, cataract, shallow anterior chamber and hyphaema) were higher in TE than all NPS (RR: 2.80, 95% CI: 2.13 to 3.68, p < 0.0001). However, hyphaema was less likely to occur in TE compared to canaloplasty (NPS) (RR: 0.14, 95% CI: 0.03 to 0.62, p < 0.0090).

Conclusions: Findings show trabeculectomy and NPS appear to reduce IOP comparably, a finding not found in previous reviews. However, complication risks increased in trabeculectomy, potentially favouring the use of NPS. However, the training requirement for NPS may limit its universal uptake.