To compare efficacies and safeties of combined phacoemulsification–microinvasive glaucoma surgeries (MIGS) to phacoemulsification only in eyes with open-angle glaucoma.

Systematic review and meta-analysis.

A multidatabase literature search was conducted to capture MIGS articles published before April 19, 2024. Key exclusion criteria were inadequate follow-up, significant loss to follow-up, standalone MIGS surgery, or unreported primary outcomes. MIGS were grouped according to mechanisms of action: (1) trabecular meshwork (TM) bypass that improves aqueous drainage into Schlemm's canal, (2) non–gonioscopy-assisted transluminal trabeculotomy (non-GATT) goniotomies that remove TM with varying devices, and (3) GATT that removes TM with a catheter or suture placed into Schlemm's canal. Efficacy was measured by reductions in intraocular pressure (IOP) and medications, whereas safety was compared using incidence of sight-threatening and other adverse events.

A total of 95 studies were included, accounting for 9733 eyes followed up at 1-year. The control group had a baseline IOP of 16.9 (95% CI: 15.9-17.9) mm Hg on 1.43 (1.19-1.68) medications and a postoperative IOP of 15.2 (14.4-15.9) mm Hg on 0.80 (0.54-1.00) medications. The TM bypass baseline IOP was 18.2 (17.6-18.7) mm Hg on 1.89 (1.78-2.01) medications that lowered to an IOP of 14.8 (14.5-15.1) mm Hg on 0.80 (0.65-0.95) medications at 1 year after operation. The non-GATT goniotomy baseline IOP was 20.0 (19.2-20.8) mm Hg on 2.30 (2.09-2.53) medications, and at 1-year follow-up, the IOP was 14.6 (14.3-15.0) mm Hg on 1.41 (1.22-1.62) medications. Lastly, the GATT baseline IOP of 21.8 (19.5-24.1) mm Hg on 2.90 (2.36-3.44) medications was reduced to an IOP of 12.5 (10.0-15.0) mm Hg on 0.73 (0.37-1.09) medications at 1-year after operation. All MIGS groups had equal or lower rates of sight-threatening events and secondary glaucoma surgery when compared with control. GATT had the highest hyphema rate at 27.7% (13.5%-44.5%) followed by non-GATT goniotomy with 15.5% (7.8%-25.0%). These were both significantly higher than TM bypass and control groups, with hyphema rates of 3.5% (1.6%-5.9%) and 4% (only 1 study reporting hyphema rate), respectively.

Based on current peer-reviewed articles, there is strong evidence that when compared with phacoemulsification alone, combined phacoemulsification-MIGS is beneficial for patients with open-angle glaucoma and does not increase the incidence of vision-threatening events. Key limitations of our review stem from heterogeneities in protocol design or outcome reporting and a limited number of high-quality studies with long-term follow-up.