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Meta-Analysis
. 2015 Dec 1;2015(12):CD010472.
doi: 10.1002/14651858.CD010472.pub2.

Device-modified trabeculectomy for glaucoma

Xue Wang  1 , Rabeea Khan, Anne Coleman
Affiliations
Meta-Analysis

Device-modified trabeculectomy for glaucoma

Xue Wang et al. Cochrane Database Syst Rev. .

Update in

  • Device-modified trabeculectomy for glaucoma.
    Park J, Rittiphairoj T, Wang X, E JY, Bicket AK. Park J, et al. Cochrane Database Syst Rev. 2023 Mar 13;3(3):CD010472. doi: 10.1002/14651858.CD010472.pub3. Cochrane Database Syst Rev. 2023. PMID: 36912740 Free PMC article.

Abstract

Background: Glaucoma is an optic neuropathy that leads to vision loss and blindness. It is the second most common cause of irreversible blindness worldwide. The main treatment for glaucoma aims to reduce intraocular pressure (IOP) in order to slow or prevent further vision loss. IOP can be lowered with medications, and laser or incisional surgeries. Trabeculectomy is the most common incisional surgical procedure to treat glaucoma. Device-modified trabeculectomy is intended to improve drainage of the aqueous humor to lower IOP. Trabeculectomy-modifying devices include Ex-PRESS, Ologen, amniotic membrane, expanded polytetrafluoroethylene (E-PTFE) membrane, Gelfilm and others. However, the effectiveness and safety of these devices are uncertain.

Objectives: To assess the relative effectiveness, primarily with respect to IOP control and safety, of the use of different devices as adjuncts to trabeculectomy compared with standard trabeculectomy in eyes with glaucoma.

Search methods: We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2014, Issue 12), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to December 2014), EMBASE (January 1980 to December 2014), PubMed (1948 to December 2014), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to December 2014), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 22 December 2014.

Selection criteria: We included randomized controlled trials comparing devices used during trabeculectomy with trabeculectomy alone. We also included studies where antimetabolites were used in either or both treatment groups.

Data collection and analysis: We used standard procedures expected by Cochrane.

Main results: We found 33 studies that met our inclusion criteria, of which 30 were published as full-length journal articles and three as conference abstracts. Only five studies have been registered. The 33 studies included a total of 1542 participants with glaucoma, and compared five types of devices implanted during trabeculectomy versus trabeculectomy alone. Five studies reported the use of Ex-PRESS (386 participants), eight studies reported the use of Ologen (327 participants), 18 studies reported the use of amniotic membrane (726 participants), one study reported the use of E-PTFE (60 participants), and one study reported the use of Gelfilm (43 participants). These studies were conducted in North America, South America, Europe, Asia, and the Middle East. Planned participant follow-up periods ranged from three months to five years. The studies were reported poorly which limited our ability to judge risk of bias for many domains. Only two studies explicitly masked outcome assessment so, we rated 31 studies at high risk of detection bias.Low-quality evidence from three studies showed that use of Ex-PRESS compared with trabeculectomy alone may be associated with a slightly lower IOP at one year (mean difference (MD) -1.58 mm Hg, 95% confidence interval (CI) -2.74 to -0.42; 165 eyes). Cataract surgery and hyphema may be less frequent in the Ex-PRESS group than in the trabeculectomy-alone group (cataract surgery: risk ratio (RR) 0.32, 95% CI 0.14 to 0.74, 3 studies, low-quality evidence; hyphema: RR 0.33, 95% CI 0.12 to 0.94, 4 studies, low-quality evidence). The effect of whether Ex-PRESS prevents hypotony was uncertain (RR 0.92, 95% CI 0.63 to 1.33, 2 studies, very low-quality evidence). All these studies received funding from the device manufacturer.Very low-quality evidence from five studies suggests that use of Ologen compared with trabeculectomy alone is associated with slightly higher IOP at one year (MD 1.40 mm Hg, 95% CI -0.57 to 3.38; 177 eyes). The effect of Ologen on preventing hypotony was uncertain (RR 0.75, 95% CI 0.47 to 1.19, 5 studies, very low-quality evidence). Differences between the two treatment groups for other reported complications also were inconclusive.Low-quality evidence from nine studies suggests that use of amniotic membrane with trabeculectomy may be associated with lower IOP at one year compared with trabeculectomy alone (MD -3.92 mm Hg, 95% CI -5.41 to -2.42; 356 eyes). Low-quality evidence showed that use of amniotic membrane may prevent adverse events and complications, such as hypotony (RR 0.40, 95% CI 0.17 to 0.94, 5 studies, low-quality evidence).The report from the only E-PTFE study (60 eyes) showed no important differences for postoperative IOP at one year (MD -0.44 mm Hg, 95% CI -1.76 to 0.88) between the trabeculectomy + E-PTFE versus the trabeculectomy-alone groups. Hypotony was the only postoperative complication observed less frequently in the E-PTFE group compared to the trabeculectomy-alone group (RR 0.29, 95% CI 0.11 to 0.77).The one Gelfilm study reported uncertainty in the difference in IOP and complication rates between the two groups at one year; no further data were provided in the study report.

Authors' conclusions: Overall, the use of devices with standard trabeculectomy may help with greater IOP reduction at one-year follow-up than trabeculectomy alone; however, due to potential biases and imprecision in effect estimates, the quality of evidence is low. When we examined outcomes within subgroups based on the type of device used, our findings suggested that the use of an Ex-PRESS device or an amniotic membrane as an adjunct to trabeculectomy may be slightly more effective in reducing IOP at one year after surgery compared with trabeculectomy alone. The evidence that these devices are as safe as trabeculectomy alone is unclear. Due to various limitations in the design and conduct of the included studies, the applicability of this evidence synthesis to other populations or settings is uncertain. Further research is needed to determine the effectiveness and safety of other devices and in subgroup populations, such as people with different types of glaucoma, of various races and ethnicity, and with different lens types (e.g. phakic, pseudophakic).

PubMed Disclaimer

Conflict of interest statement

AC reports grants unrelated to this work from the National Eye Institute, National Institutes of Health, US and the Agency for Healthcare Research and Quality (AHRQ), US. The AHRQ Comparativeness Effectiveness of glaucoma treatment trial is an observational study on the management of glaucoma patients with additional medications, laser trabeculoplasty, or incisional surgery. Modified trabeculectomies are one of the types of incisional surgeries allowed in the trial if the treating physician and patient choose that method to lower eye pressures. Since the study is observational, AC has no role in which treatment modality is chosen.

XW: None known.

RK: None known.

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Forest plot of comparison: 2 Trabeculectomy + Ex‐PRESS versus Trabeculectomy, outcome: Postoperative IOP at one year.
4
4
Forest plot of comparison: 2 Trabeculectomy (Trab) + Ologen versus Trabeculectomy (Trab), outcome: 2.1 IOP at one year.
5
5
Forest plot of comparison: 4 Trabeculectomy + AMT (amniotic membrane) versus Trabeculectomy, outcome: 4.1 Postoperative IOP at one year.
6
6
Forest plot of comparison: 1 Trabeculectomy + E‐PTFE versus Trabeculectomy, outcome: 1.1 Postoperative IOP at one year.
1.1
1.1. Analysis
Comparison 1 Trabeculectomy (Trab) + Ex‐PRESS versus Trabeculectomy (Trab), Outcome 1 Postoperative IOP at one year.
1.2
1.2. Analysis
Comparison 1 Trabeculectomy (Trab) + Ex‐PRESS versus Trabeculectomy (Trab), Outcome 2 Postoperative IOP at six months.
1.3
1.3. Analysis
Comparison 1 Trabeculectomy (Trab) + Ex‐PRESS versus Trabeculectomy (Trab), Outcome 3 Postoperative IOP at two years.
1.4
1.4. Analysis
Comparison 1 Trabeculectomy (Trab) + Ex‐PRESS versus Trabeculectomy (Trab), Outcome 4 Postoperative logMAR BCVA at one year.
1.5
1.5. Analysis
Comparison 1 Trabeculectomy (Trab) + Ex‐PRESS versus Trabeculectomy (Trab), Outcome 5 Complications.
2.1
2.1. Analysis
Comparison 2 Trabeculectomy (Trab) + Ologen versus Trabeculectomy (Trab), Outcome 1 IOP at one year.
2.2
2.2. Analysis
Comparison 2 Trabeculectomy (Trab) + Ologen versus Trabeculectomy (Trab), Outcome 2 Postoperative IOP at day one.
2.3
2.3. Analysis
Comparison 2 Trabeculectomy (Trab) + Ologen versus Trabeculectomy (Trab), Outcome 3 Postoperative IOP at six months.
2.4
2.4. Analysis
Comparison 2 Trabeculectomy (Trab) + Ologen versus Trabeculectomy (Trab), Outcome 4 Postoperative IOP at two years.
2.5
2.5. Analysis
Comparison 2 Trabeculectomy (Trab) + Ologen versus Trabeculectomy (Trab), Outcome 5 Complications.
3.1
3.1. Analysis
Comparison 3 Trabeculectomy (Trab) + AMT (amniotic membrane) versus Trabeculectomy (Trab), Outcome 1 Postoperative IOP at one year.
3.2
3.2. Analysis
Comparison 3 Trabeculectomy (Trab) + AMT (amniotic membrane) versus Trabeculectomy (Trab), Outcome 2 Postoperative IOP at one day.
3.3
3.3. Analysis
Comparison 3 Trabeculectomy (Trab) + AMT (amniotic membrane) versus Trabeculectomy (Trab), Outcome 3 Postoperative IOP at one week.
3.4
3.4. Analysis
Comparison 3 Trabeculectomy (Trab) + AMT (amniotic membrane) versus Trabeculectomy (Trab), Outcome 4 Postoperative IOP at one month.
3.5
3.5. Analysis
Comparison 3 Trabeculectomy (Trab) + AMT (amniotic membrane) versus Trabeculectomy (Trab), Outcome 5 Postoperative IOP at three months.
3.6
3.6. Analysis
Comparison 3 Trabeculectomy (Trab) + AMT (amniotic membrane) versus Trabeculectomy (Trab), Outcome 6 Postoperative IOP at six months.
3.7
3.7. Analysis
Comparison 3 Trabeculectomy (Trab) + AMT (amniotic membrane) versus Trabeculectomy (Trab), Outcome 7 Postoperative IOP at two years.
3.8
3.8. Analysis
Comparison 3 Trabeculectomy (Trab) + AMT (amniotic membrane) versus Trabeculectomy (Trab), Outcome 8 Complications.
4.1
4.1. Analysis
Comparison 4 Trabeculectomy (Trab) + E‐PTFE versus Trabeculectomy (Trab), Outcome 1 Postoperative IOP at one year.
4.2
4.2. Analysis
Comparison 4 Trabeculectomy (Trab) + E‐PTFE versus Trabeculectomy (Trab), Outcome 2 Hypotony at 24 months.
4.3
4.3. Analysis
Comparison 4 Trabeculectomy (Trab) + E‐PTFE versus Trabeculectomy (Trab), Outcome 3 Hyphaema at 24 months.
4.4
4.4. Analysis
Comparison 4 Trabeculectomy (Trab) + E‐PTFE versus Trabeculectomy (Trab), Outcome 4 Inflammation at 24 months.
4.5
4.5. Analysis
Comparison 4 Trabeculectomy (Trab) + E‐PTFE versus Trabeculectomy (Trab), Outcome 5 Shallow anterior chamber at 24 months.
4.6
4.6. Analysis
Comparison 4 Trabeculectomy (Trab) + E‐PTFE versus Trabeculectomy (Trab), Outcome 6 Flat anterior chamber at 24 months.
4.7
4.7. Analysis
Comparison 4 Trabeculectomy (Trab) + E‐PTFE versus Trabeculectomy (Trab), Outcome 7 Choroidal detachment at 24 months.
See this image and copyright information in PMC

References

References to studies included in this review

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Yan 2004 {published data only}
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References to studies excluded from this review

Cao 2004 {published data only}
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Jin 2006 {published data only}
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Lau 2008 {published data only}
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Li 2003 {published data only}
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Li 2008 {published data only}
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Liu 2003 {published data only}
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Liu 2004 {published data only}
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Mahdy 2010 {published data only}
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NCT00472810 {unpublished data only}
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NCT00597181 {unpublished data only}
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Sugiyama 2011 {published data only}
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Wang 2010 {published data only}
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Zhang 2008 {published data only}
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References to ongoing studies

JPRN‐UMIN000008391 {unpublished data only}
    1. JPRN‐UMIN000008391. Comparison between Ex‐PRESS shunt surgery and trabeculectomy for refractory glaucoma. apps.who.int/trialsearch/Trial2.aspx?TrialID=JPRN‐UMIN000008391 (accessed 22 February 2015).
JPRN‐UMIN000008981 {unpublished data only}
    1. JPRN‐UMIN000008981. Prospective comparative study of the Ex‐PRESS mini glaucoma shunt with standard trabeculectomy. apps.who.int/trialsearch/Trial2.aspx?TrialID=JPRN‐UMIN000008981 (accessed 22 February 2015).
NCT00449098 {unpublished data only}
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NCT00524758 {unpublished data only}
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NCT01440751 {unpublished data only}
    1. NCT01440751. Comparative study of the safety and effectiveness of Ologen collagen matrix versus mitomycin‐C in glaucoma filtering surgery. clinicaltrials.gov/ct2/show/NCT01440751 (accessed 22 February 2015).

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References to other published versions of this review

Wang 2013b
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