Efficacy and complications of microcatheter-assisted minimally invasive glaucoma surgery for open-angle glaucoma: A systematic review and network meta-analysis.

Microcatheter-assisted minimally invasive glaucoma surgery (MIGS) procedures are increasingly being used as an alternative to trabeculectomy combined with mitomycin C (MMC Trab) for controlling intraocular pressure (IOP) in open-angle glaucoma (OAG), but there are no head-to-head trials comparing different microcatheter-assisted MIGS procedures and MMC Trab. We evaluate the relative efficacy and safety of microcatheter-assisted MIGS procedures, including microcatheter-assisted trabeculotomy (MAT), gonioscopy-assisted transluminal trabeculotomy (GATT), Ab-interno Canaloplasty(ABiC), ab externo canaloplasty(ABeC), and trabeculotome tunnelling trabeculoplasty surgery (3 T), through a network meta-analysis with a focus on their priority ranking in IOP reduction and medication use. MMC Trab was included as the reference standard to contextualize the performance of emerging microcatheter-assisted techniques. We conducted searches for studies published between 01/01/2009 and 16/10/2024, with no restrictions regarding participant age or language of publication. We followed a protocol registered on PROSPERO (CRD42024557637). PRISMA guidelines were followed for reporting. For observational studies and randomized clinical trials, use the Newcastle-Ottawa Quality Assessment Scale and Cochrane Risk of Bias tool for Randomized Trials (RoB 2) respectively for evaluation. Data extraction was conducted by 2 independent reviewers, and then checked and adjudicated by a third reviewer. The mean differences for continuous variables, risk ratios for binary variables, 95 % credible intervals, and ranks of interventions were estimated. The outcomes examined included the reduction (%) in IOP and the reduction in medication used from baseline at 3 months and 1 year. We also extracted adverse events reported, such as hyphema, IOP spike and hypotony. Sixteen studies (a total of 1081 eyes) were included in the NMA. For efficacy at 1 year, MAT showed no significant difference compared to MMC Trab in both percent reduction in IOP (MD -4.78 % (95 %CI -3.01-3.45 %), SUCRA 65.7) and reduction in medication used (MD 0.18 (95 %CI -0.19-0.54 %), SUCRA 97.4), GATT (MD -7.20 % (95 %CI -13.73 % to -0.67 %), SUCRA 53.1 %) showed no significant difference from MMC Trab in terms of reduction in medication use. For complications within 3 months postoperatively, all microcatheter-assisted MIGS procedures showed no significant difference versus MMC Trab in terms of postoperative IOP spike. GATT (RR 0.06 (95 %CI, 0.01-0.35), SUCRA 87 %) and ABeC (RR 0.3 (95 %CI, 0.1-2.92), SUCRA 44.3 %) were associated with a lower risk of hypotony compared to MMC Trab. All microcatheter-assisted MIGS procedures were associated with a higher risk of hyphema. Compared to MMC Trab, MAT showed no significant difference in efficacy at 1 year postoperatively, and certain microcatheter-assisted MIGS procedures have specific advantages over MMC Trab in terms of postoperative complications.