Speaker- Luís Abegão Pinto

In recent years, glaucoma treatment has evolved rapidly with a surge in implants and interventions, leading to more questions than answers. Key concerns include whether minimally invasive glaucoma surgery (MIGS) is effective as a standalone procedure, the best angle surgery technique, the role of micro shunts versus trabeculectomy, and treatment algorithms for patients with both glaucoma and cataracts. Traditionally, answers were sought from colleagues or mentors, but this isn't always evidence-based. While surgery is an art, there's also a science behind it. With over 30,000 results on PubMed for "glaucoma surgery," it's crucial to digest this evidence and audit personal data. The highest quality of evidence comes from systematic reviews and randomized controlled trials.

Surgical outcomes in glaucoma are not always straightforward to evaluate through randomized clinical trials (RCTs), largely due to the ongoing evolution of techniques and the need for adjustments during real-world practice. The Ideal framework was developed to offer a structured approach to surgical innovation. It outlines stages from initial innovation to long-term follow-up, encouraging the use of prospective case series early on and shifting to RCTs when possible while also leveraging real-world data through registries. However, even with this framework, not all data is of high quality, and clinicians often face uncertainties. Critical evaluation is needed to understand what constitutes reliable evidence, how long outcomes should be tracked, and where the gaps lie. In the absence of robust trial data, consensus-based recommendations can be a practical alternative. To help address these challenges, the European Glaucoma Society’s Surgery Task Force focuses on generating evidence-based recommendations. This includes reviewing existing data, making recommendations where evidence is limited, and providing practical guidance for new surgeons. They use the Grade system to rate the strength of recommendations, aiming to offer clearer insights and support for decision-making in glaucoma surgery.

In March 2021, a consensus initiative was launched involving 50 surgeons from across Europe, aimed at identifying the top 10 clinical questions surrounding preoperative, intraoperative, and postoperative care in glaucoma surgery. Of the 50 surgeons, 30 from 18 different countries participated, contributing over 200 questions. The process included three rounds of discussion: the first involved data review, agreement, and initial voting; the second round focused on refining consensus, and the third finalized the recommendations. Additionally, a "Choosing Wisely" section outlined key do's and don’ts for surgeons. The results, compiled in a guide available on the European Glaucoma Society website, cover key innovations in surgical approaches, particularly in MIGS. The guide highlights trabecular stenting devices, trabecular dilation, and disrupting surgeries, which are considered non-bleb filtering internal MIGS procedures. It also includes suprachoroidal devices under MIGS, as well as less invasive subconjunctival bleb-forming surgeries like the Xen Gel Stent and Preserflo MicroShunt, distinguishing them as either ab interno or ab externo procedures. The guide offers a structured approach to the latest techniques in glaucoma surgery.

The consensus guide outlines key recommendations for glaucoma devices and surgical approaches, particularly MIGS. MIGS is intended to reduce drug burden and is often combined with cataract surgery, but its effectiveness as a standalone option is uncertain. It is not suitable for patients with progressing or advanced glaucoma. While MIGS is generally safe, long-term outcomes are still being evaluated. Recommendations vary in strength. Weak recommendations include using higher concentrations of mitomycin in Preserflo compared to trabeculectomy. Stronger recommendations support similar steroid treatment strategies for bleb-forming devices as for trabeculectomy. Important considerations include verifying an open angle prior to MIGS or bleb-forming procedures, careful use of antifibrotics, and auditing surgical results. Cost factors should also be taken into account. Surgeons are advised against using MIGS in shallow chambers, targeting very low pressures, or performing angle surgery without adequate experience in gonioscopy, as visualization is critical for successful outcomes.

The consensus initiative identified ten critical questions in glaucoma surgery, focusing on optimal antifibrotic treatments, steroid frequency, and timing for needling procedures. Each question includes associated recommendations and clinical comments. The guide also outlines reporting standards for research, emphasizing the need to define complications and safety clearly, distinguishing between early and late complications. A checklist is provided to assist in measuring and reporting data accurately. The glaucoma surgery is a rapidly advancing field, with some areas lacking robust evidence. While many practices currently rely on an eminence-based approach, frameworks such as ideal and consensus methods facilitate the generation of high-quality data. The European Glaucoma Society’s Surgical Guide of Innovation seeks to compile insights from experienced surgeons across Europe, offering guidance for future research and benchmarking for stakeholders. 

42nd Congress of the European Society of Cataract and Refractive Surgeons, 6 – 10 September 2024, Fira de Barcelona, Spain.