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 is 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 diNerent 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 (3T), through a network meta-analysis (NMA), 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. The conduct of review followed a protocol registered on PROSPERO (CRD42024557637). PRISMA guidelines were followed for reporting. For observational studies and RCTs, use the Newcastle-Ottawa Quality Assessment Scale (NOS) 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 (CI), 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 one year, MAT showed no significant difference compared to MMC Trab in both percent reduction in IOP (MD -4.78% (95%CI -3.01% to 3.45%), SUCRA 65.7) and reduction in medication used (MD 0.18 (95%CI -0.19 to 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 three 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 to 0.35), SUCRA 87%) and ABeC (RR 0.3 (95%CI, 0.1 to 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 one year postoperatively, and certain microcatheter-assisted MIGS procedures have specific advantages over MMC Trab in terms of postoperative complications.