Several techniques have emerged as complement or replacement for trabeculectomy, the standard surgery for glaucoma. Device-modified trabeculectomy is a recently developed technique whose results compared to the classical technique have not been fully defined. To answer this question, we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We identified eight systematic reviews including 34 studies overall. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. We concluded device-modified trabeculectomy probably leads to greater overall success rate and may decrease intraocular pressure more than classical surgery. In addition, this technique would probably have a better safety profile than standard trabeculectomy.
Glaucoma is the second leading cause of blindness worldwide according to the World Health Organization. Among the known risk factors for the development of this disease is the increase in intraocular pressure (IOP). Trabeculectomy is the standard surgery for patients with uncontrolled glaucoma despite medical treatment. The use of devices has been recently added to the classical surgical technique, in order t promote the flow of aqueous humor from the anterior chamber and to avoid the post-trabeculectomy scaring by maintaining a continuous drainage of aqueous humor. In this line, the use of devices has been proposed as a technique that could improve surgical success and decrease the associated complication rate.
To answer the question, we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others, to identify systematic reviews and their included primary studies. We extracted data from the identified reviews and reanalyzed data from primary studies included in those reviews. With this information, we generated a structured summary using a pre-established format, which includes key messages, a summary of the body of evidence (presented as an evidence matrix in Epistemonikos), meta-analysis of the total of studies, a summary of findings table following the GRADE approach and a table of other considerations for decision-making.
Key messages
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What is the evidence. |
We found eight systematic reviews [1],[2],[3],[4],[5],[6],[7],[8] that include 48 primary studies reported in 54 references [9],[10],[11],[12],[13],[14],[15],[16],[17],[18], |
What types of patients were included* |
The characteristics of included patients were: Regarding the type of glaucoma, 14 trials included patients with open angle glaucoma [12],[18],[19],[21],[25],[34], Regarding the severity of glaucoma, 21 trials included patients with glaucoma refractory to medical treatment. [13],[14],[15],[16],[18],[19],[21],[32],[36],[37],[38],[39], |
What types of interventions were included* |
Regarding the type of intervention, 18 trials used amniotic membrane [12],[13],[14],[25],[31],[32],[34],[36],[37], Regarding the use of mitomycin C (MMC), 15 trials did not use MMC in any of their arms [13],[14],[19],[21],[25], All trials compared versus standard treatment (trabeculectomy). |
What types of outcomes |
The systematic reviews grouped the outcomes as follows:
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* The information about primary studies is extracted from the systematic reviews identified, unless otherwise specified.
The information on the effects of device-modified trabeculectomy is based on 34 randomized trials including 1540 eyes.
Twenty-five trials measured absolute decrease in intraocular pressure (1164 eyes) [13],[14],[15],[16],[18],[21],[25],[31],[32],[34],[36],[37],[39],[42],[45],[48],[52],[53],[56],[57],[58],[59],[60],[61],[62], three trials assessed complete success (151 eyes) [18],[21],[56], six trials measured the need for reintervention (258 eyes) [18],[21],[39],[45],[49],[56], 14 trials measured hypotonia (695 eyes) [15],[18],[21],[34],[37],[42],[43],[45],[48],[49],[50],[52],[56],[62], 10 trials measured bleb filtration (521 eyes) [14],[16],[18],[21],[43],[48],[50],[52],[56],[62], 23 trials measured narrow chamber (1199 eyes) [14],[15],[18],[21],[25],[31],[32],[34],[36],[39],[42],[43],[48],[49],[50],[52],[56],[57],[58],[59],[60],[61],[62], 16 trials measured hyphema (818 eyes) [13],[14],[15],[16],[18],[21],[39],[43],[45],[49],[50],[52],[53],[56],[58],[60] and 3 trials measured the need for cataract surgery (264 eyes) [21],[43],[56].
The summary of findings is as follows:
To whom this evidence does and does not apply |
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About the outcomes included in this summary |
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Balance between benefits and risks, and certainty of the evidence |
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Resource considerations |
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What would patients and their doctors think about this intervention |
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Differences between this summary and other sources |
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Could this evidence change in the future? |
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Using automated and collaborative means, we compiled all the relevant evidence for the question of interest and we present it as a matrix of evidence.
Follow the link to access the interactive version: Device modified trabeculectomy in glaucoma
The upper portion of the matrix of evidence will display a warning of “new evidence” if new systematic reviews are published after the publication of this summary. Even though the project considers the periodical update of these summaries, users are invited to comment in Medwave or to contact the authors through email if they find new evidence and the summary should be updated earlier. After creating an account in Epistemonikos, users will be able to save the matrices and to receive automated notifications any time new evidence potentially relevant for the question appears.
The details about the methods used to produce these summaries are described here http://dx.doi.org/10.5867/medwave.2014.06.5997.
Epistemonikos foundation is a non-for-profit organization aiming to bring information closer to health decision-makers with technology. Its main development is Epistemonikos database (www.epistemonikos.org).
These summaries follow a rigorous process of internal peer review.
Conflicts of interest
The authors do not have relevant interests to declare.
En los últimos años, diversas técnicas han surgido como complemento o reemplazo para la trabeculectomía, cirugía estándar en el manejo del glaucoma. La trabeculectomía modificada con dispositivo es una técnica reciente cuyos resultados en comparación con la técnica clásica aún no han sido del todo definidos. Para responder esta pregunta utilizamos Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante búsquedas en múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Identificamos ocho revisiones sistemáticas que en conjunto incluyen 34 estudios aleatorizados. Extrajimos los datos desde las revisiones identificadas, reanalizamos los datos de los estudios primarios, realizamos un metanálisis y preparamos tablas de resumen de los resultados utilizando el método GRADE. Concluimos que la trabeculectomía modificada con dispositivo probablemente se asocia a un mayor éxito completo y que podría disminuir la presión intraocular más que la cirugía clásica. Además, está técnica probablemente tendría un mejor perfil de seguridad que la terapia estándar.
Citation: Pimentel E, Schmidt J. Is device-modified trabeculectomy better than classic surgery for treatment of glaucoma?. Medwave 2017; 17(Suppl3):e7018 doi: 10.5867/medwave.2017.7018
Submission date: 7/7/2017
Acceptance date: 1/8/2017
Publication date: 31/8/2017
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