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Meta-Analysis
. 2023 Feb;261(2):477-501.
doi: 10.1007/s00417-022-05785-5. Epub 2022 Aug 8.

A systematic review and meta-analysis of randomised controlled trials in the management of neovascular glaucoma: absence of consensus and variability in practice

Saajan Ramji  1 , Gurnoor Nagi  1 , Abdus Samad Ansari  2   3 , Obeda Kailani  4   5
Affiliations
Meta-Analysis

A systematic review and meta-analysis of randomised controlled trials in the management of neovascular glaucoma: absence of consensus and variability in practice

Saajan Ramji et al. Graefes Arch Clin Exp Ophthalmol. 2023 Feb.

Abstract

Purpose: Neovascular glaucoma (NVG) is characterised by neovascularisation of the angle and therefore elevated intraocular pressure (IOP). This results in progressive optic neuropathy and loss of visual acuity. Treatment aims to reduce IOP in order to prevent optic nerve damage. A systematic review was completed synthesising results from randomised control trials (RCTs) comparing interventions for the management of NVG and their efficacy and safety.

Methods: Data was sourced from Web of Science, Embase and Medline after 1st January 2000. The primary outcome measures were mean IOP at follow-up and success rate. The secondary outcomes included mean IOP lowering medications and total complications. A meta-analysis was completed on comparative studies using Revman (version 5.4).

Results: For the two studies comparing Ahmed glaucoma valve (AGV) + pan-retinal photocoagulation (PRP) vs AGV + PRP + intra-vitreal bevacizumab (IVB), there was no difference in mean IOP or odds of success from the meta-analysis. From the 4 studies examining the utilisation of anti-vascular endothelial growth factor (anti-VEGF), one study showed lower mean IOP at 1 (p = 0.002) and 3 months (p = 0.033) for IVB vs sham injection. In the 2 studies studying transcleral diode laser (TDL), there were no significant findings. From the 4 studies looking at trabeculectomy (trab), lower mean IOP at 6 (p = 0.001), 9 (p = 0.01), 12 (p = 0.02) and 18 months (p = 0.004) was shown for intra-vitreal ranibizumab (IVR) + PRP + visco-trabeculectomy vs IVR + PRP + trab, and a significantly lower mean IOP was present in the Baerveldt group vs trab at 6 months (p = 0.03). In the 2 studies investigating the AGV, there was a lower mean IOP at 1 month (p = 0.01) in the AGV + triamcinolone (TCA) group. The risk of bias was low for 4 studies, high for 4 studies and 6 studies had some concerns.

Conclusion: This is the first meta-analysis of RCTs in the management of neovascular glaucoma. The lack of high-quality evidence contributes to the lack of consensus in managing NVG. Our results highlight modern treatment strategies and the need for better powered RCTs with long-term follow-up in order to establish optimal treatment modalities and true patient outcomes.

Keywords: Anti-VEGF; Meta-analysis; Neovascular glaucoma; Randomised controlled trial; Surgical; Systematic review.

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Conflict of interest statement

The authors declare no competing interests.

Figures

Fig1
Fig1
PRISMA flowchart of studies identified, screened and included
Fig. 2
Fig. 2
Meta-analysis of complete success rates at final follow-up. AGV, Ahmed glaucoma valve; PRP, pan-retinal photocoagulation; IVB, intra-vitreal bevacizumab; SD, standard deviation; CI, confidence interval
Fig. 3
Fig. 3
Meta-analysis of Mean IOP at 6-months follow-up. AGV, Ahmed glaucoma valve; PRP, pan-retinal photocoagulation; IVB, intra-vitreal bevacizumab; SD, standard deviation; CI, confidence interval
Fig. 4
Fig. 4
Meta-analysis of mean IOP at 12-months follow-up. AGV, Ahmed glaucoma valve; PRP, pan-retinal photocoagulation; IVB, intra-vitreal bevacizumab; SD, standard deviation; CI, confidence interval
See this image and copyright information in PMC

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