OBJECTIVES: To perform an adjusted indirect treatment comparison (ITC) of minimally invasive glaucoma surgeries (MIGS) on top of phacoemulsification (PHACO) in patients with primary open-angle glaucoma (POAG).

METHODS: For the study of any type of MIGS on top of PHACO in patients with POAG, we identified five eligible randomized clinical trials (RCT) with a common control arm (PHACO) from a 2017 published systematic literature review. We performed an ITC using the methods described by Bucher and collaborators. We defined our main endpoint of interest as the one year mean change from baseline in intraocular pressure (IOP). For comparisons with more than one RCT, we pooled effects using a meta-analysis with validated software. We tested a number of alternative scenarios to reinforce our findings.

RESULTS: Estimated absolute IOP reductions (mmHg units and 95% CI) for PHACO alone, and when combined with one trabecular micro-bypass stent (TMBS), two TMBS, suprachoroidal microstent and intracanalicular scaffold were -2.05(-3.38 to -0.72), -3.15(-5.66 to -0.64), -4.85(-7.71 to -1.99), -3.75(-5.68 to -1.64) and -2.25(-4.87 to 0.37) respectively. Following high observed heterogeneity in the evidence, we prioritized random-effect models. We removed outlying results from one RCT when estimating a pooled PHACO effect (suprachoroidal microstent study). Sensitivity analyses showed similar trends in the outcomes.

CONCLUSIONS: When compared to PHACO alone, selected combined MIGS showed mostly a statistical significant improvement in reducing the IOP. Present heterogeneity between RCTs could be an important bias. Studies comparing the mean change in IOP vs modern cataract surgery (PHACO) alone are up to date the best common criteria to perform ITCs for MIGS in POAG patients, but scarce evidence is available.