| Objective:A systematic review and network meta-analysis was conducted to evaluate the effectiveness and safety of the six surgical interventions for neovascular glaucoma,in order to help ophthalmologist in making treatment strategies for patients with neovascular glaucoma.Methods:Based on the inclusion criteria and exclusion criteria,PubMed,Cochrane Library,Embase and Web of Science were searched for clinical comparative studies,including both randomized controlled trials and non-randomized controlled trials.Quality assessment of the included trials was conducted by using the Cochrane Risk of Bias Tool,the Newcastle-Ottawa scale（NOS）,GRADE and CINeMA,to assess the certainty of evidence for the outcomes from the network meta-analysis.A network meta-analysis for all included studies was carried out by using STATA 15.0,ranking according to the surface under cumulative ranking（SUCRA）for different endpoints.Main outcome measures:The main outcome measures were the weighted mean differences（WMDs）for intraocular pressure reduction,odds ratios（ORs）for success rate.Outcome measures were reported with a 95% confidence interval（CI）and P< 0.05 was considered statistically significant.Results:Twenty-three trials with a total of 1303 patients were included and the sample size between 20 to 170 cases,in which four studies were randomized controlled trials and nineteen were cohort studies.The all included literature involved six surgical interventions:（1）Ahmed glaucoma valve implant surgery,AGV;（2）Ahmed glaucoma valve implant surgery combined with intravitreal anti-vascular endothelial growth factor,AGV+IVAV;（3）Cyclophotocoagulation,CPC;（4）Cyclocryotherapy,CCT;（5）Trabeculectomy with mitomycin,Trab（MMC）;（6）Trabeculectomy with mitomycin combined with intravitreal anti-vascular endothelial growth factor,Trab（MMC）+IVAV;The main results of network analysis were shown as follow:1.The network results showed that compared with AGV,AGV+IVAV（MD=4.74,95%[1.04,8.45]）and Trab（MMC）+IVAV（MD=6.19,95%[0.99,11.40]）showed a favorable effect in intraocular pressure reduction 6 months after surgery;While there were no significant difference between AGV+IVAV（MD=-1.45,95%[-5.93,3.03]）and Trab（MMC）+IVAV.In addition,there were no significant difference among the other interventions.The order of efficacy ranked as follows: Trab（MMC）+IVAV（SUCRA=88.1）> AGV+IVAV（SUCRA=68.9）> Trab（MMC）（SUCRA=58.8）> CCT（SUCRA=39.6）> CPC（SUCRA=30.1）> AGV（SUCRA=14.5）.2.In the outcome of intraocular pressure reduction 12 months after surgery,no significant difference was found among the six surgical interventions.The order of efficacy ranked as follows: CPC（SUCRA=81.9）> AGV+IVAV（SUCRA=79.9）> AGV（SUCRA=48.2）> Trab（MMC）+IVAV（SUCRA=43.6）> Trab（MMC）（SUCRA=28.2）>CCT（SUCRA=18.2）.3.In the outcome of surgical success rate,AGV（OR=-0.17,95%[-0.53,-0.05]）,AGV+IVAV（OR=-0.10,95%[-3.48,-1.19]）,CPC（OR=-0.12,95%[-0.53,-0.05]）,Trab（MMC）（OR=3.54,95%[1.15,10.91]）,Trab（MMC）+IVAV（OR=5.78,95%[2.29,14.61]）showed a superior impact compared with CCT.Besides,AGV+IVAV presented with a significantly higher success rate than that in AGV（OR=1.71,95%[1.12,2.61]）and Trab（MMC）（OR=-0.34,95%[-0.78,-0.15]）;however,no significant difference was found between AGV（OR=-0.59,95%[-1.33,-0.26]）and Trab（MMC）.At the same time,no significant difference was found among the other interventions.The order of efficacy ranked as follows: AGV+IVAV（SUCRA=92.7）> CPC（SUCRA=73.7）> AGV（SUCRA=54.3）> Trab（MMC）+IVAV（SUCRA=53.9）> Trab（MMC）（SUCRA=25）>CCT（SUCRA=0.4）.Conclusion:According to the cluster analyses in intraocular pressure reduction 6 months after surgery,intraocular pressure reduction 12 months after surgery and surgical success rate,AGV+IVAV and CPC demonstrated a superior effect to other treatments in the long-term clinical efficacy,and the effectiveness of CCT was the worst in the treatment of neovascular glaucoma.Additionally,AGV+IVAV is superior to CPC concerning the success rate in the long-term treatment.However,considering the limitations of this study,due to the low quality of included studies were low and insufficient data of the other outcome measurement,the credibility of the evidence reduced.Therefore,more high-quality,large sample and multi-center randomized controlled trials,especially those surgical interventions not mentioned in this review,should be carried out in the future so as to further confirm the current conclusions. |
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