Minimally Invasive Glaucoma Surgical Techniques for Open-Angle Glaucoma An Overview of Cochrane Systematic Reviews and Network Meta-analysis
Minimally Invasive Glaucoma Surgical Techniques for Open-Angle Glaucoma An Overview of Cochrane Systematic Reviews and Network Meta-analysis
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DOI：
10.1001/jamaophthalmol.2021.2351
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发表时间：
2021-07-15
影响因子：
8.1
通讯作者：
Li, Tianjing
中科院分区：
文献类型：
--
作者：
Bicket, Amanda K.;Le, Jimmy T.;Li, Tianjing
重要性 青光眼影响全球超过 7500 万人。降低眼压（IOP）手术是治疗这种疾病的重要方法。对降低手术发病率的兴趣导致了微创青光眼手术（MIGS）的引入。了解 MIGS 的相对有效性和安全性对于临床医生和患者来说是必要的。目的 总结 MIGS 治疗开角型青光眼随机临床试验的数据，这些数据在一系列 Cochrane 综述中进行了评估。数据来源 Cochrane 系统评价数据库，包括 2021 年 6 月 1 日之前发表的研究。研究选择 将 MIGS 与单独白内障摘除术、其他 MIGS、传统青光眼手术、激光进行比较的随机临床试验的综述小梁成形术或药物治疗。 数据提取和合成 数据由一名研究者根据系统评价和荟萃分析指南的首选报告项目提取，并由另一名研究者确认。使用 AMSTAR 2 评估工具评估方法的严谨性，并进行随机效应网络荟萃分析。 主要结果和措施 术后不需要使用药物降低眼压 (IOP) 的参与者比例（无滴眼）。对短期（18 个月）随访结果进行分析。 结果 确定了 6 篇符合条件的 Cochrane 综述，讨论了使用 iStent 或 Hydrus 微型支架进行小梁绕道术、使用 Trabectome 进行的腹内小梁切开术、结膜下和睫状体上引流装置以及内镜下睫状体光凝术。中等质量证据表明，添加 Hydrus 可安全提高中期（相对风险 [RR]，1.6；95% CI，1.4 至 1.8）和长期（RR，1.6；95% CI，1.4 至 1.9）随访中无滴眼青光眼控制的可能性，并实现 2.0 mm Hg（95% CI，-2.7 至 -1.3 mm） Hg) 与单独进行白内障手术相比，长期随访时眼压降低幅度更大。与单独的白内障手术相比，添加 iStent 还安全地改善了无滴眼疾病控制（RR，1.4；95% CI，1.2 至 1.6），但 iStent 的短期降低 IOP 的效果并未持续。与单独白内障手术相比，添加 CyPass 微支架可改善无滴眼青光眼控制（RR，1.3；95% CI，1.1 至 1.5），但会增加视力丧失的风险。网络荟萃分析支持了这些结果的方向和程度。 结论和相关性 根据 Cochrane 综述中综合的数据，一些 MIGS 可能为青光眼患者提供比单独白内障手术更好的无滴眼疾病控制。在目前可用的产品中，随机临床试验数据表明，与 iStent 相比，Hydrus 具有更好的无滴眼青光眼控制和降低眼压的效果；然而，这些效应很小。
IMPORTANCE Glaucoma affects more than 75 million people worldwide. Intraocular pressure (IOP)-lowering surgery is an important treatment for this disease. Interest in reducing surgical morbidity has led to the introduction of minimally invasive glaucoma surgeries (MIGS). Understanding the comparative effectiveness and safety of MIGS is necessary for clinicians and patients.OBJECTIVE To summarize data from randomized clinical trials of MIGS for open-angle glaucoma, which were evaluated in a suite of Cochrane reviews.DATA SOURCES The Cochrane Database of Systematic Reviews including studies published before June 1, 2021.STUDY SELECTION Reviews of randomized clinical trials comparing MIGS with cataract extraction alone, other MIGS, traditional glaucoma surgery, laser trabeculoplasty, or medical therapy.DATA EXTRACTION AND SYNTHESIS Data were extracted according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines by one investigator and confirmed by a second. Methodologic rigor was assessed using the AMSTAR 2 appraisal tool and random-effects network meta-analyses were conducted.MAIN OUTCOMES AND MEASURES The proportion of participants who did not need to use medication to reduce intraocular pressure (IOP) postsurgery (drop-free). Outcomes were analyzed at short-term (18 months) follow-up.RESULTS Six eligible Cochrane reviews were identified discussing trabecular bypass with iStent or Hydrus microstents, ab interno trabeculotomy with Trabectome, subconjunctival and supraciliary drainage devices, and endoscopic cyclophotocoagulation. Moderate certainty evidence indicated that adding a Hydrus safely improved the likelihood of drop-free glaucoma control at medium-term (relative risk [RR], 1.6; 95% CI, 1.4 to 1.8) and long-term (RR, 1.6; 95% CI, 1.4 to 1.9) follow-up and conferred 2.0-mm Hg (95% CI, -2.7 to -1.3 mm Hg) greater IOP reduction at long-term follow-up, compared with cataract surgery alone. Adding an iStent also safely improved drop-free disease control compared with cataract surgery alone (RR, 1.4; 95% CI, 1.2 to 1.6), but the short-term IOP-lowering effect of the iStent was not sustained. Addition of a CyPass microstent improved drop-free glaucoma control compared with cataract surgery alone (RR, 1.3; 95% CI, 1.1 to 1.5) but was associated with an increased risk of vraision loss. Network meta-analyses supported the direction and magnitude of these results.CONCLUSIONS AND RELEVANCE Based on data synthesized in Cochrane reviews, some MIGS may afford patients with glaucoma greater drop-free disease control than cataract surgery alone. Among the products currently available, randomized clinical trial data associate the Hydrus with greater drop-free glaucoma control and IOP lowering than the iStent; however, these effect sizes were small.