Trabeculectomy Augmented With Anti-VEGF Improves Surgical Outcomes in Glaucoma: A Systematic Review and Meta-Analysis

Abstract

Purpose: Trabeculectomy has long been established as the "gold standard" surgical procedure in the management of glaucoma when medical and laser options are deemed to be inadequate but has variable success due to fibrosis and scarring at the surgical site. Antivascular endothelial growth factor (anti-VEGF) agents have been investigated as adjuncts to improve surgical outcomes. The aim of this systematic review and meta-analysis was to compare trabeculectomy augmented with anti-VEGF and trabeculectomy without anti-VEGF for the treatment of glaucoma in an adult population. Specifically, this systematic review and meta-analysis evaluated the efficacy of anti-VEGF agents in enhancing trabeculectomy success, intraocular pressure (IOP) reduction, and medication reduction.

Design: Systematic Review and Meta-analysis METHODS: This systematic review and meta-analysis was prospectively registered on PROSPERO (CRD42025636060). A systematic search was conducted in Medline, EMBASE, and Web of Science for randomized controlled trials comparing trabeculectomy with and without anti-VEGF agents in glaucoma. Primary outcomes included complete and qualified success rates as well as mean IOP reduction and reduction in IOP-lowering medications. Follow-up periods were 6, 12, and 24 months. Meta-analyses were conducted using Review Manager (version 5.4).

Results: Sixteen studies comprising 1002 patients were included in the analysis. At 12 months, trabeculectomy with adjunctive mitomycin C (MMC) and anti-VEGF demonstrated significantly higher odds of achieving complete success (OR = 1.90, 95% CI [1.16, 3.10], P = .01). Specifically, intracameral or intravitreal bevacizumab was associated with improved odds of complete success at 12 months, with the 1.25 mg dose yielding a notable benefit (OR = 1.58, 95% CI [1.06, 2.36], P = .03). Additionally, trabeculectomy with MMC and bevacizumab significantly reduced the requirement for IOP-lowering medications (MD = 0.34, 95% CI [0.09, 0.60], P = .008). A risk-of-bias assessment classified 11 studies as low risk and 5 with some concerns.

Conclusion: Anti-VEGF agents improve trabeculectomy outcomes when used with Mitomycin-C, enhancing complete success rates and reducing medication needs. This analysis underscores the potential of anti-VEGF therapy as a valuable adjunct, though further research with standardized protocols is essential to strengthen these findings.