Efficacy and Safety of Manual Small-incision Cataract Surgery with Trabeculectomy Versus Phacotrabeculectomy in Patients with Glaucoma and Cataract: A Systematic Review and Meta-Analysis

Authors: Andini EA, Avianty A, Herman H, Choliq A.

Geographical coverage: India and Indonesia

Sector: Cataract and glaucoma

Sub-sector: Efficacy and safety

Equity focus: Not reported

Study population: Patients with cataract and glaucoma

Review type: Effectiveness review

Quantitative synthesis method: Meta-analysis

Qualitative synthesis method: Not applicable

Background: Cataract and glaucoma—two of the world’s leading causes of blindness—frequently coexist in older adults, particularly after the age of 60. Combined trabeculectomy and cataract surgery is commonly undertaken to manage this dual pathology, yet the procedure is longer and carries the cumulative risks of both operations. Both phacoemulsification and manual small‑incision cataract surgery (MSICS) offer several advantages over other techniques. Previous evidence indicates that the two approaches have similar intra‑operative and post‑operative complication rates, although phacoemulsification generally induces less surgically‑induced astigmatism.

Objective: To compare the efficacy and safety of MSICS combined with trabeculectomy with those of phacotrabeculectomy in patients with coexistent cataract and glaucoma.

Main findings: Seven retrospective studies were included, comparing manual small‑incision cataract surgery with trabeculectomy (MSICST; 352 eyes) with phacoemulsification combined with trabeculectomy (PT; 348 eyes). Six of the seven studies, all conducted in India, scored 7 on the Newcastle–Ottawa Scale, while the Indonesian study scored 6.

All seven studies reported post‑operative intra‑ocular pressure (IOP). Meta‑analysis showed no significant difference between MSICST and PT in post‑operative IOP (mean difference, MD = –0.45 mmHg; 95 % confidence interval [CI] –1.07 to 0.16; p = 0.15). Three studies compared post‑operative visual acuity; again, no significant difference was found (odds ratio, OR = 1.26; 95 % CI 0.62 to 2.53; p = 0.52).

Complete surgical success (reported in three studies) did not differ significantly between the two procedures (OR = 0.92; 95 % CI 0.51 to 1.67; p = 0.78). Four studies reported post‑operative complications, again with no significant difference (OR = 1.27; 95 % CI 0.75 to 2.15; p = 0.38). Overall, the evidence suggests that MSICST and PT have comparable efficacy and safety profiles.

Methodology:  Searches of PubMed, ScienceDirect and the Cochrane Library from inception to March 2023 identified retrospective or prospective studies and randomised controlled trials comparing MSICS‑trabeculectomy with phaco‑trabeculectomy. Website searches and citation tracking supplemented the electronic searches. Two reviewers independently screened records, extracted data and assessed quality using the Newcastle–Ottawa Scale. Random‑effects meta‑analysis was performed; heterogeneity was assessed with the I² statistic and publication bias with funnel plots.

Applicability/external validity: All included studies were retrospective and undertaken in Asia; the results may therefore not be applicable to other populations. The authors advise cautious interpretation.

Geographic focus: The review did not apply any geographical limits. The included studies were conducted in India and Indonesia.

Summary of quality assessment: Overall confidence in the findings is medium. Electronic searches were comprehensive; eligibility criteria were clear; two reviewers independently screened, extracted and appraised studies; and appropriate meta‑analytic methods were applied. Nonetheless, language restrictions were not reported, a list of excluded studies was missing, and results were not stratified by risk‑of‑bias status.