Comparison between MIGS with trabeculectomy in the management of open-angle glaucoma with cataract: A systematic review

Author: Zaifar A, Pratomo TG, Suryono AN.

Geographical coverage: Not reported

Sector: Treatment of open-angle glaucoma

Sub–sector: Intraocular pressure reduction

Equity focus: Not explicitly stated

Study population: Patients with open-angle glaucoma and concomitant cataract

Review type: Effectiveness review

Quantitative synthesis method: Narrative synthesis

Qualitative synthesis method: Not applicable

Background

Glaucoma is a leading cause of irreversible blindness worldwide, affecting an estimated 76 million people in 2020 and projected to reach 112 million by 2040. Primary open‑angle glaucoma (POAG) is the most prevalent form, with intraocular pressure (IOP) the principal modifiable risk factor. Cataract, another major cause of blindness, frequently co‑exists with glaucoma as life expectancy increases. Traditionally, trabeculectomy combined with phacoemulsification (phaco‑trabeculectomy, or phaco‑trab) has been the gold‑standard surgical approach for patients with both conditions, delivering substantial IOP reduction but carrying risks such as prolonged recovery and sight‑threatening complications. Microinvasive glaucoma surgery (MIGS) has emerged as an alternative that offers meaningful IOP lowering with fewer complications and faster rehabilitation. Nonetheless, consensus is lacking on the optimal surgical strategy for individuals with concomitant cataract and open‑angle glaucoma (OAG).

Objective

To evaluate current evidence on combined surgery for patients with cataract and OAG and to inform clinical decision‑making.

Main findings

The review included four studies enrolling 276 participants (306 eyes) with OAG. Three were cohort studies and one was a randomised controlled trial (RCT), all published between 2017 and 2019.

• Intraocular pressure reduction: both phaco‑trab and phaco‑MIGS groups achieved significant reductions from baseline (p < 0.05). Phaco‑trab produced a greater short‑term (≤ 3 months) IOP decrease, but the difference was not statistically significant at 6 and 12 months.
• Surgical success: qualified and complete success rates tended to be higher with phaco‑trab, although not consistently reaching statistical significance. Some studies reported superior success in the phaco‑trab group at one‑ and four‑year follow‑up.
• Medication burden: all studies showed a significant postoperative reduction in antiglaucoma medicines in both groups; some reported a higher residual medication requirement in the phaco‑MIGS group.
• Complications: severe adverse events such as hypotony, maculopathy and choroidal effusion occurred only after phaco‑trab, whereas transient IOP spikes were more common after phaco‑MIGS. Late postoperative complications did not differ appreciably between the procedures.

Overall, phaco‑MIGS offers a viable alternative to phaco‑trab for patients with OAG and cataract, delivering comparable IOP control with fewer severe complications, although evidence is limited and longer‑term data are needed.

Methodology

The authors searched MEDLINE, Embase and Scopus on 5 May 2021, supplemented by grey‑literature searches in ProQuest and EBSCO and reference‑list screening. Eligible English‑language studies included adult participants (≥ 18 years) with OAG and cataract undergoing either phaco‑trab or phaco‑MIGS. Two reviewers independently screened studies, extracted data and assessed quality using the Newcastle‑Ottawa Scale (cohort studies) and the PEDro scale (RCT). Findings were synthesised narratively.

Applicability / external validity

Despite providing clinically relevant comparisons of phaco‑MIGS and phaco‑trab, the review’s external validity is constrained by a small sample size, racial homogeneity (predominantly Caucasian cohorts) and inconsistent definitions of surgical success. Short follow‑up in some studies further limits generalisability. Large, multi‑ethnic RCTs with longer follow‑up are required to substantiate these findings.

Geographic focus

The geographic location of the included studies was not reported.

Summary of quality assessment

The review was restricted to English‑language studies, introducing potential language bias.