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. 2025 Jul 14;17(7):e87872. doi: 10.7759/cureus.87872

Clinical Outcomes and Patient-Reported Outcomes of Minimally Invasive Glaucoma Surgery Techniques Over the Past Decade

Poonam Singh 1, Bharti Sharma 1, Nilutpal Sarma 1, Deb Sanjay Nag 2,✉, Abhishek Patnaik 1, Rashi Verma 1
Editors: Alexander Muacevic, John R Adler
PMCID: PMC12344473  PMID: 40809659

Abstract

Minimally invasive glaucoma surgery (MIGS) has revolutionized glaucoma management over the past decade by offering safer, more efficient alternatives to traditional surgeries such as trabeculectomy. This review synthesizes clinical and patient-reported outcomes from 40 studies published between 2014 and 2025. MIGS techniques, including trabecular meshwork bypass stents (e.g., iStent, Hydrus), suprachoroidal shunts (e.g., CyPass), and subconjunctival devices (e.g., Xen), achieve intraocular pressure (IOP) reductions of 15-50%, reduce medication dependence by 0.4-1.8 drugs, and exhibit low complication rates (e.g., hyphema: ≤20%; hypotony: ≤15.4%). Combined MIGS-cataract procedures outperform standalone MIGS, with superior IOP control (additional 2-2.8 mmHg reduction) and lower reoperation rates (3% vs. 24% at two years). Patient-reported outcomes, though understudied, indicate enhanced quality of life, visual function, and ocular surface health. Challenges include variability in device efficacy and limited long-term data. Future research should prioritize standardized patient-reported metrics and diverse populations.

Keywords: cataract, glaucoma, intraocular pressure, minimally invasive surgical procedures, patient-reported outcome measures

Introduction and background

Glaucoma, a leading cause of irreversible blindness globally, affects over 80 million people, with intraocular pressure (IOP) reduction as the primary treatment goal [1]. Traditional surgeries such as trabeculectomy, while effective, carry significant risks, including bleb leaks, infections, and prolonged recovery. Minimally invasive glaucoma surgery (MIGS) emerged in the early 2010s to bridge this gap, offering micro-scale devices that enhance aqueous outflow with minimal tissue disruption. MIGS targets mild-to-moderate glaucoma patients, prioritizing safety, rapid recovery, and reduced medication burden [2].

Over the past decade, minimally invasive glaucoma surgery (MIGS) has seen exponential innovation, with devices now grouped by their mechanisms. Trabecular bypass stents such as the iStent (Glaukos Corporation, Laguna Hills, CA, USA) and Hydrus improve fluid drainage by enhancing conventional outflow through Schlemm’s canal. Suprachoroidal shunts, such as the CyPass, redirect fluid to the suprachoroidal space to reduce IOP. For subconjunctival drainage, subconjunctival filtration devices (e.g., the Xen Gel Stent) create new pathways in the subconjunctival space. Lastly, canaloplasty devices such as OMNI focus on catheterizing and dilating Schlemm’s canal to optimize fluid dynamics [3]. Together, these advancements mark a transformative era in glaucoma care, offering tailored, minimally invasive solutions.

This review evaluates clinical outcomes (IOP reduction, medication use, safety) and patient-reported outcomes (quality of life, visual function) across 40 studies (2014-2025). We assess device-specific efficacy, procedural contexts (standalone vs. combined with cataract surgery), and identify evidence gaps for future research. Standalone MIGS procedures appear to incur higher reoperation rates (up to 24% at two years) compared to combined procedures [4]. Medication use declined by approximately 0.4 to 1.8 fewer medications, with some series reporting medication-free rates between 22.6% and 80% [5]. Across a variety of device types, most notably iStent (including iStent inject) and Hydrus, most studies report maintenance or improvement of best-corrected visual acuity (BCVA), minimal vision-related complications, and generally transient adverse events (including hyphema, hypotony, and IOP spikes). Although less frequently assessed, patient-reported outcomes indicate improvements in quality of life, visual function, and ocular surface comfort when MIGS is combined with cataract surgery. This article provides an overview of the clinical outcomes and patient-reported outcomes of MIGS techniques over the past decade.

Review

Literature search and screening

A systematic search of the Semantic Scholar corpus, encompassing 126 million papers, was conducted using the query: “Clinical outcomes and patient-reported outcomes of MIGS techniques over the past decade.” This search yielded 500 potentially relevant publications. To ensure relevance and quality, the following strict inclusion criteria were applied: (1) studies involving adults (≥18 years) with any type of glaucoma; (2) interventions limited to MIGS alone or in combination with cataract surgery, excluding traditional glaucoma surgeries; (3) outcomes including clinical measures (e.g., IOP reduction, medication use), safety (e.g., complications), or patient-reported outcomes (e.g., quality of life); and (4) study designs restricted to randomized controlled trials (RCTs), cohort studies, systematic reviews, or case series with at least 10 participants. Following a holistic screening process, 40 studies met these criteria and were included for further analysis, as summarized in Table 1 [6-44]. The process of inclusion and exclusion is detailed in the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) flow diagram (Figure 1).

Table 1. Characteristics of the included studies.

MIGS: minimally invasive glaucoma surgery; MIMS: minimally invasive micro-sclerostomy; OMNI: OMNI® Surgical System; GATT: gonioscopy-assisted transluminal trabeculotomy; iStent: iStent trabecular micro-bypass system (Glaukos Corp., Laguna Hills, CA); XEN: XEN gel stent (AbbVie Inc., Chicago, IL, USA); ICE2: iStent combined with phacoemulsification and endocyclophotocoagulation; PMS: PreserFlo MicroShunt

Study Study design MIGS device type Patient population Follow-up duration Full text retrieved
Lee et al., 2017 [6] Systematic literature review iStent, iStent inject Open-angle glaucoma 6–18 months (randomized controlled trials) Yes
Ahmed et al., 2019 [7] Randomized controlled trial Hydrus, two iStents Open-angle glaucoma 12 months Yes
Pfeiffer et al., 2015 [8] Randomized controlled trial Hydrus Open-angle glaucoma with cataract 24 months Yes
Oo et al., 2024 [9] Systematic review/meta-analysis iStent, iStent inject, Hydrus, Kahook Dual Blade, Trabectome Normal-tension glaucoma 6–36 months Yes
Hu et al., 2022 [10] Systematic review/network meta-analysis Hydrus, iStent (first and second generation) Open-angle glaucoma End of follow-up (varied) Yes
Reiss et al., 2019 [11] Randomized controlled trial, prospective cohort CyPass Open-angle glaucoma with cataract 60 months Yes
Höh et al., 2014 [12] Prospective cohort CyPass Open-angle glaucoma with cataract 24 months Yes
Neuhann et al., 2024 [13] Retrospective review iStent Open-angle glaucoma, pseudoexfoliation glaucoma, ocular hypertension 10 years Yes
Ahmed et al., 2022 [14] Randomized controlled trial Hydrus Primary open-angle glaucoma with cataract 5 years Yes
Melo Araújo et al., 2020 [15] Randomized controlled trial iStent inject Primary open-angle glaucoma with cataract 24 months Yes
Voskanyan et al., 2024 [16] Prospective cohort MIMS Open-angle glaucoma, exfoliation glaucoma 52 weeks Yes
Riss, 2022 [17] Prospective cohort MicroShunt Primary open-angle glaucoma 2 years Yes
Salimi et al., 2021 [18] Prospective cohort iStent, iStent inject Primary angle-closure glaucoma with cataract 12 months Yes
Cantor et al., 2023 [19] Systematic review iStent, OMNI, GATT, Kahook Dual Blade, Hydrus, Xen, PreserFlo, iTrack Open-angle glaucoma 6–12 months (varied) Yes
Gillmann et al., 2020 [20] Systematic review/meta-analysis Multiple MIGS Open-angle glaucoma Varied Yes
Bicket et al., 2021 [21] Systematic review iStent, Hydrus, Trabectome, CyPass Open-angle glaucoma Short, medium, long-term Yes
Lavia et al., 2017 [22] Systematic review/meta-analysis Multiple MIGS Primary open-angle glaucoma, pseudoexfoliation, pigmentary glaucoma 12 months Yes
Nichani et al., 2020 [23] Systematic review iStent, Hydrus Mild-to-moderate open-angle glaucoma 1–2+ years Yes
Aref et al., 2022 [24] Systematic review iStent, CyPass, Hydrus Open-angle glaucoma with cataract 24 months Yes
Qidwai et al., 2022 [25] Retrospective review ICE2, PMS, XEN-45 Primary open-angle glaucoma, secondary open-angle glaucoma, normal-tension glaucoma, ocular hypertension, primary angle-closure glaucoma 24 months Yes
Jones et al., 2023 [26] Retrospective observational iStent inject, ICE2 Open-angle glaucoma 4 months Yes
Le et al., 2019 [27] Retrospective review iStent, Hydrus Open-angle glaucoma with cataract 24 months Yes
Yang et al., 2022 [28] Retrospective cohort   Glaucoma 2 years Yes
Malvankar-Mehta et al., 2015 [29] Systematic review/meta-analysis iStent Open-angle glaucoma with cataract Varied Yes
Turner et al., 2022 [30] Retrospective review iStent, XEN, Hydrus Glaucoma with cataract 12–18 months Yes
Oberfeld et al., 2024 [31] Retrospective review iStent, Kahook Dual Blade, Hydrus, combined MIGS Severe glaucoma with cataract 12 months Yes
Le and Saheb, 2014 [32] Systematic review iStent Open-angle glaucoma with cataract Varied Yes
Buffault et al., 2019 [33] Systematic review XEN Open-angle glaucoma, pseudoexfoliation glaucoma, pigmentary glaucoma 12 months Yes
Al-Mugheiry et al., 2017 [34] Prospective cohort Hydrus Open-angle glaucoma with cataract 16.8 months Yes
Gołaszewska et al., 2021 [35] Systematic review Canaloplasty, iStent Primary open-angle glaucoma 12–36 months Yes
Bartelt-Hofer et al., 2020 [36] Disease model/systematic review Trabecular micro-bypass stent, IS Primary open-angle glaucoma with cataract 1 year (model) Yes
Richter et al., 2023 [37] Systematic review Trabecular MIGS Open-angle glaucoma with cataract 2 years Yes
Voykov et al., 2025 [38] Systematic review Kahook Dual Blade, iStent inject, Hydrus Microshunt Glaucoma Not specified in the abstract Yes
Al Habash et al., 2020 [39] Cross-sectional Kahook Dual Blade, iStent, iStent inject, GATT Glaucoma with cataract Not specified in the abstract Yes
Kazerounian et al., 2020 [40] Retrospective cohort Ab interno canaloplasty Open-angle glaucoma (with or without cataract) 2 years Yes
Mbagwu et al., 2024 [41] Retrospective review OMNI, Hydrus, iStent inject Glaucoma with cataract 24 months Yes
Chang et al., 2021 [42] Retrospective review Endoscopic cyclophotocoagulation, iStent, Kahook Dual Blade, Trabectome Normal-tension glaucoma with cataract 2.5 years Yes
Khaimi et al., 2017 [43] Retrospective review Canaloplasty Open-angle glaucoma (with or without cataract) 3 years Yes
Mosaed, 2017 [44] Randomized controlled trial CyPass Mild-to-moderate glaucoma with cataract 2 years Yes
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Figure 1. Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) flow diagram.

Figure 1

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Data Extraction

Data from the 40 included studies were extracted using a large language model to ensure efficiency and accuracy. The extracted information encompassed: (1) study design, setting, and participant demographics; (2) types of MIGS devices used and procedural details; (3) quantitative clinical outcomes, such as IOP reduction, medication reduction, and success rates; (4) frequency and severity of complications; and (5) patient-reported outcomes, including metrics related to quality of life and visual function. This structured approach facilitated a comprehensive synthesis of the evidence, allowing for comparisons across studies and devices.

Results

Study Characteristics

The 40 studies exhibited diverse designs, including 17 systematic reviews, six RCTs, six prospective cohort studies, 11 retrospective studies, and one cross-sectional study. The most frequently studied MIGS devices were the iStent trabecular micro-bypass system (18 studies), Hydrus (15 studies), iStent inject (eight studies), Kahook Dual Blade (six studies), and CyPass (five studies). Populations primarily consisted of patients with open-angle glaucoma (20 studies), with 14 studies involving MIGS combined with cataract surgery and three focusing on normal-tension glaucoma. Follow-up durations varied, with seven studies reporting 12-month outcomes, eight studies spanning 13-24 months, and seven studies extending beyond 24 months, up to 10 years.

Clinical Outcomes: IOP Reduction

MIGS procedures demonstrated significant IOP reductions, ranging from 0.1 to 30.2 mmHg, corresponding to 4-56% reductions from baseline. Greater reductions were observed in patients with higher baseline IOP, such as those in the minimally invasive micro-sclerostomy study, which reported a mean reduction of 10.5 mmHg [16]. Success rates, defined as ≥20% IOP reduction or IOP ≤18 mmHg, ranged from 45% to 96%, with Hydrus outperforming single iStent implants (p < 0.001) [7]. Combined MIGS-cataract surgery yielded 2-2.8 mmHg greater IOP reductions compared to cataract surgery alone [8,15]. However, standalone MIGS procedures were associated with higher reoperation rates, reaching 24% at two years [4]. The findings are summarized in Table 2.

Table 2. Effects on intraocular pressure reduction.

MIGS: minimally invasive glaucoma surgery; MIMS: minimally invasive micro-sclerostomy; OMNI: OMNI® Surgical System; iStent: iStent trabecular micro-bypass system (Glaukos Corp., Laguna Hills, CA, USA); XEN: XEN gel stent (AbbVie Inc., Chicago, IL, USA); ICE2: iStent combined with phacoemulsification and endocyclophotocoagulation; PMS: PreserFlo MicroShunt

Study MIGS device Baseline intraocular pressure Mean intraocular pressure reduction Success rate
Lee et al., 2017 [6] iStent, iStent inject No mention found No mention found Relative risk = 1.38 (95% confidence interval = 1.18–1.63) for drop-free at 6–18 months
Ahmed et al., 2019 [7] Hydrus, two iStents 23–39 mmHg No mention found Hydrus showed higher surgical success (p < 0.001)
Pfeiffer et al., 2015 [8] Hydrus No mention found 2.3 mmHg lower at 24 months versus cataract surgery (p = 0.0093) 80%: 20% or more intraocular pressure reduction at 24 months
Oo et al., 2024 [9] Multiple No mention found 2.1–2.44 mmHg at 6–36 months No mention found
Hu et al., 2022 [10] Hydrus, two iStents No mention found Hydrus: 2.21 mmHg; two iStents: 1.88 mmHg No significant difference in medication-free status
Reiss et al., 2019 [11] CyPass No mention found No mention found 46% 20% intraocular pressure reduction at 60 months
Höh et al., 2014 [12] CyPass 21/<21 mmHg -37% (uncontrolled), 0% (controlled) at 24 months No mention found
Neuhann et al., 2024 [13] iStent 18.6 ± 4.4 mmHg 12.9–19.0% at 10 years 77.8% intraocular pressure 18 mmHg at 10 years
Ahmed et al., 2022 [14] Hydrus No mention found 16.8 ± 3.1 mmHg at 5 years 49.5% intraocular pressure 18 mmHg without medications
Melo Araújo et al., 2020 [15] iStent inject ~25 mmHg 7.0 mmHg (microstent), 5.4 mmHg (control) at 24 months 75.8% 20% intraocular pressure reduction (microstent)
Voskanyan et al., 2024 [16] MIMS 27.9 ± 3.7 mmHg 10.5 mmHg (38%) at 52 weeks 82.1% qualified, 70.5% complete success
Riss, 2022 [17] MicroShunt 25.7 ± 6.1 mmHg 9.9 mmHg at 1 year, 9.2 mmHg at 2 years 80.3% (1 year), 75.4% (2 years)
Salimi et al.,2021 [18] iStent, iStent inject 18.8/18.7 mmHg 21%/25% at 12 months 45%/64% at 12 months
Cantor et al., 2023 [19] Multiple No mention found -31% to -13.7% (6 months), -39% to -11.4% (1 year) No mention found
Gillmann et al., 2020 [20] Multiple No mention found 15.3–50% (device-dependent) No mention found
Bicket et al., 2021 [21] Hydrus, iStent, CyPass No mention found Hydrus: 2.0 mmHg greater at long-term Relative risk 1.6 (Hydrus), 1.4 (iStent), 1.3 (CyPass)
Lavia et al., 2017 [22] Multiple No mention found 3.4–4.1 mmHg (device-dependent) No mention found
Nichani et al., 2020 [23] iStent, Hydrus No mention found 8–12 mmHg post-surgery No mention found
Aref et al., 2022 [24] Multiple No mention found 20% unmedicated intraocular pressure lowering No mention found
Qidwai et al., 2022 [25] ICE2, PMS, XEN-45 18.5–20.5 mmHg 4.5–8.2 mmHg at 24 months No mention found
Jones et al., 2023 [26] iStent inject, ICE2 18.0 mmHg 4.0 mmHg at 4 months No mention found
Le et al., 2019 [27] iStent, Hydrus No mention found 0.1–1.6 mmHg at 24 months No mention found
Yang et al., 2022 [28] Multiple No mention found Decreased in all groups Reoperation: 3–24% at 2 years
Malvankar-Mehta et al., 2015 [29] iStent No mention found 4–27% (device-dependent) No mention found
Turner et al., 2022 [30] iStent, XEN, Hydrus 17.08 ± 4.23 mmHg 2.16 mmHg at 12–18 months No mention found
Oberfeld et al., 2024 [31] Multiple 16.7 ± 5.8 mmHg 3.2 mmHg at 12 months 47.5–87.5% (varied thresholds)
Le and Saheb, 2014 [32] iStent No mention found No mention found No mention found
Buffault et al., 2019 [33] XEN No mention found 25–56% (mean 42%) at 12 months No mention found
Al-Mugheiry et al., 2017 [34] Hydrus 18.1 ± 3.6 mmHg 2.8 mmHg at 16.8 months 80–96% (varied thresholds)
Gołaszewska et al., 2021 [35] Canaloplasty, iStent 45.0 ± 12.1 mmHg 29.9–30.2 mmHg at 3 years 47.2–81% (varied thresholds)
Bartelt-Hofer et al., 2020 [36] Multiple No mention found -2.05 to -4.85 mmHg at 1 year No mention found
Richter et al., 2023 [37] Trabecular MIGS No mention found 1.6–2.3 mmHg at 2 years No mention found
Voykov et al., 2025 [38] Multiple No mention found 1.8–1.9 mmHg (iStent inject, Hydrus) No mention found
Al Habash et al., 2020 [39] Multiple No mention found No mention found No mention found
Kazerounian et al., 2020 [40] Ab interno canaloplasty 20.24 ± 5.92 mmHg 6.57 mmHg at 2 years 80% off medication
Mbagwu et al., 2024 [41] OMNI, Hydrus, iStent inject No mention found -4.96 to -6.64 mmHg at 24 months No mention found
Chang et al., 2021 [42] Multiple 13.7 mmHg 1.4 mmHg at 2.5 years 5.4–67.2% (criteria dependent)
Khaimi et al., 2017 [43] Canaloplasty 19.7 mmHg 4.5–5.7 mmHg at 1–3 years 57.8–91.8% (varied thresholds)
Mosaed, 2017 [44] CyPass No mention found 7.4 mmHg at 2 years No mention found
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Clinical Outcomes: Medication Reduction

Medication burden decreased significantly post-MIGS, with reductions ranging from 0.4 to 1.8 fewer drugs. The highest medication-free rate (73%) was observed with Hydrus combined with cataract surgery [9]. Long-term data showed that iStent maintained a 33.3% medication-free rate at 10 years [13]. Multi-stent approaches, such as Hydrus or two iStents, consistently outperformed single-implant strategies in reducing medication use [7,10]. Table 3 summarizes the effect on the reduction in medications.

Table 3. Reduction in medications.

MIGS: minimally invasive glaucoma surgery; MIMS: minimally invasive micro-sclerostomy; OMNI: OMNI® Surgical System; iStent: iStent trabecular micro-bypass system (Glaukos Corp., Laguna Hills, CA, USA); ICE2: iStent combined with phacoemulsification and endocyclophotocoagulation; PMS: PreserFlo MicroShunt

Study MIGS device Baseline medications Medication reduction Medication-free rate
Lee et al., 2017 [6] iStent, iStent inject No mention found Mean difference = -0.42 (95% confidence interval = -0.60 to -0.23) No mention found
Ahmed et al., 2019 [7] Hydrus, two iStents No mention found -0.6 (Hydrus) at 12 months 22.6% more Hydrus subjects medication-free
Pfeiffer et al., 2015 [8] Hydrus No mention found 0.5 ± 1.0 (Hydrus + cataract surgery), 1.0 ± 1.0 (cataract surgery) at 24 months No mention found
Oo et al., 2024 [9] Multiple No mention found 0.87–1.26 at 6–36 months 73% (Hydrus + cataract surgery), 38% (cataract surgery) at 24 months
Hu et al., 2022 [10] Hydrus, two iStents No mention found No explicit quantitative value No significant difference
Reiss et al., 2019 [11] CyPass No mention found No mention found No mention found
Höh et al., 2014 [12] CyPass No mention found 1.0–1.1 at 24 months No mention found
Neuhann et al., 2024 [13] iStent 1.83 ± 1.03 37.8–51.4% at 10 years 33.3% at 10 years
Ahmed et al., 2022 [14] Hydrus No mention found 0.5 ± 0.9 (Hydrus), 0.9 ± 0.9 (cataract surgery) at 5 years No mention found
Melo Araújo et al., 2020 [15] iStent inject No mention found -0.4 versus control at 24 months 66% (Hydrus), 46% (cataract surgery) at 5 years
Voskanyan et al., 2024 [16] MIMS 1.8 ± 0.8 0.27 ± 0.7 at 52 weeks No mention found
Riss, 2022 [17] Micro Shunt 2.9 ± 1.1 0.6 ± 1.0 (1 year), 1.0 ± 1.3 (2 years) No mention found
Salimi et al.,2021 [18] iStent, iStent inject No mention found 52%/50% at 12 months No mention found
Cantor et al., 2023 [19] Multiple No mention found No mention found No mention found
Gillmann et al., 2020 [20] Multiple No mention found No mention found No mention found
Bicket et al., 2021 [21] Multiple No mention found No mention found No mention found
Lavia et al., 2017 [22] iStent, Hydrus No mention found No mention found No mention found
Aref et al., 2022 [24] Multiple No mention found No mention found No mention found
Qidwai et al., 2022 [25] ICE2, PMS, XEN-45 2.0–2.9 0.5–2.0 at 24 months No mention found
Jones et al., 2023 [26] iStent inject, ICE2 1.8 ± 0.8 1.1 ± 0.9 at 4 months No mention found
Le et al., 2019 [27] iStent, Hydrus 2.1–2.6 0.3–1.1 at 6 months No mention found
Yang et al., 2022 [28] Multiple No mention found No mention found No mention found
Malvankar-Mehta et al., 2015 [29] iStent No mention found 1.01–1.33 No mention found
Turner et al., 2022 [30] iStent, XEN, Hydrus 2.68 ± 1.06 1.46 ± 1.32 at 12–18 months No mention found
Oberfeld et al., 2024 [31] Multiple 2.3 ± 1.9 1.8 ± 1.7 at 12 months No mention found
Le and Saheb, 2014 [32] iStent No mention found No mention found No mention found
Buffault et al., 2019 [33] XEN No mention found Reduction in all studies No mention found
Al-Mugheiry et al., 2017 [34] Hydrus 1.96 ± 0.96 0.04 ± 0.20 at 16.8 months No mention found
Gołaszewska et al., 2021 [35] Canaloplasty, iStent No mention found Significant reduction No mention found
Bartelt-Hofer et al., 2020 [36] Multiple No mention found No mention found No mention found
Richter et al., 2023 [37] Trabecular MIGS No mention found No mention found No mention found
Voykov et al., 2025 [38] Multiple No mention found No mention found No mention found
Al Habash et al., 2020 [39] Multiple No mention found Significant reduction (p < 0.001) No mention found
Kazerounian et al., 2020 [40] Mbagwu et al., 2024 Ab interno canaloplasty OMNI, Hydrus, iStent inject 1.92 ± 1.04 0.05 ± 0.23 at 2 years
Chang et al., 2021 [42] Multiple 2 1.1 at 1.5 years No mention found
Khaimi et al., 2017 [43] Canaloplasty 2.1 0.4–0.6 at 1–3 years No mention found
Mosaed, 2017 [44] CyPass No mention found No mention found No mention found
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Safety Outcomes

Common complications included hyphema (≤20%), hypotony (8.8-15.4%), IOP spikes (≤32.7%), and stent obstruction (≤8.8%) [10,12,22]. Most complications were transient, with sight-threatening events, such as endophthalmitis, being rare (one case reported [26]). Surgical reoperations, often for stent malposition, were noted in nine studies [6,33]; however, overall, MIGS demonstrated a favorable safety profile compared to traditional glaucoma surgeries. The reported complications are presented in Table 4.

Table 4. Types of Complication.

Study Complications Frequency Severity Required
Lee et al., 2017 [6] Stent malposition/obstruction, intraocular pressure rise, hyphema, hypotony No mention found Transient, not vision-threatening No mention found
Ahmed et al., 2019 [7] Secondary glaucoma surgery, best-corrected visual acuity loss 2 lines 3.9% (two iStents), 2 eyes (Hydrus), 1 eye (two iStents) No mention found No mention found
Pfeiffer et al., 2015 [8] Peripheral anterior synechiae, inflammation, Descemet membrane folds, iris erosion Peripheral anterior synechiae: 9 Minor, transient 3 glaucoma surgeries for intraocular pressure
Oo et al., 2024 [9] No mention found – – –
Hu et al., 2022 [10] Device malposition/obstruction, peripheral anterior synechiae, hyphema, uveitis, macular edema Peripheral anterior synechiae: 15.3% (Hydrus), others <6% Generally not sight-threatening No mention found
Reiss et al., 2019 [11] Sight-threatening events, best-corrected visual acuity loss, visual field mean deviation worsening 3 events (2 Micro-Stent, 1 control) Serious, but few No mention found
Höh et al., 2014 [12] Hypotony, micro-stent obstruction Hypotony: 15.4%, obstruction: 8.8% Transient, not sight-threatening 11% required surgery
Neuhann et al., 2024 [13] Secondary glaucoma surgeries, age-related macular degeneration, optic atrophy 9 surgeries, 5 age-related macular degeneration/atrophy No sight-threatening/device-related Surgery as needed
Ahmed et al., 2022 [14] Endothelial cell loss, peripheral anterior synechiae, device malposition No mention found Peripheral anterior synechiae not affecting intraocular pressure No mention found
Melo Araújo et al., 2020 [15] No mention found – – –
Voskanyan et al., 2024 [16] Iris plugging, intraocular pressure spikes, others rare Iris plugging: 18, intraocular pressure spikes: 15 Mild-to-moderate Pilocarpine, laser, viscoelastic removal
Riss, 2022 [17] Increased intraocular pressure, hyphema No mention found No mention found 4 reoperations
Salimi et al.,2021 [18] No mention found – – –
Cantor et al., 2023 [19] No mention found – Most transient, non-serious –
Gillmann et al., 2020 [20] No mention found – – –
Bicket et al., 2021 [21] Vision loss (CyPass) No mention found – –
Lavia et al., 2017 [22] Intraocular pressure spikes 0–32.7% Generally minimal Additional surgery
Nichani et al., 2020 [23] Stent obstruction, inflammation No mention found No mention found No mention found
Aref et al., 2022 [24] No mention found – – –
Qidwai et al., 2022 [25] Buttonhole, cystoid macular edema, inflammation, keratitis, branch retinal vein occlusion No mention found Transient Nonsteroidal anti-inflammatory drugs, steroids
Jones et al., 2023 [26] Endophthalmitis, hypotony, choroidal detachment 1 endophthalmitis Transient No mention found
Le et al., 2019 [27] Bleeding, hyphema, stent repositioning, intraocular pressure spikes Intraocular pressure spikes: 3.9–17% Generally transient Repositioning, trabeculectomy
Yang et al., 2022 [28] No mention found 1–2% No mention found No mention found
Malvankar-Mehta et al., 2015 [29] No mention found – – –
Turner et al., 2022 [30] No mention found – – –
Oberfeld et al., 2024 [31] No mention found – – –
Le and Saheb, 2014 [32] Stent obstruction/malposition Infrequent Transient Observation, secondary procedures
Buffault et al., 2019 [33] Hypotony, choroidal detachment, hyphema, bleb leak, malignant glaucoma Hypotony: 3%, others <2% Transient, some severe Needling (32%), repeat surgery (5.7%)
Gołaszewska et al., 2021 [35] Micro-hyphema, Descemet membrane detachment, intraocular pressure, stent issues Micro-hyphema common, Descemet membrane detachment 3.3% Generally transient No mention found
Mbagwu et al., 2024 [41] No mention found – – –
Chang et al., 2021 [42] Inflammation, hypotony, hyphema, edema, cystoid macular edema See table Transient No mention found
Khaimi et al., 2017 [43] Hyphema, cataract, intraocular pressure spikes, hypotony No mention found Low, no serious events No mention found
Mosaed, 2017 [44] No mention found – – No vision-threatening events
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Patient-Reported Outcomes

Patient-reported outcomes highlighted the benefits of MIGS beyond clinical metrics. BCVA was maintained or improved in 97.5% of cases, with BCVA loss being rare (1.2-2.5%) and unrelated to the devices [7,8,26]. Quality of life improved for 79% of patients post-MIGS, with significant gains in glaucoma-specific metrics, such as reduced photophobia and improved mobility, as reported by Jones et al. [26,39]. Reduced medication use correlated with improved ocular surface health, alleviating symptoms such as dryness and redness [26,39].

Comparative Device Performance

Hydrus and multi-stent devices demonstrated superior IOP reduction (2.21 mmHg) and medication-free rates (22.6-80%) compared to single iStent implants (1.88 mmHg) [7,10]. Standalone MIGS had higher reoperation rates (24% at two years [4]) compared to combined procedures (3% [14]). Long-term efficacy was notable with iStent combined with cataract surgery, achieving a 77.8% success rate at 10 years [13].

Discussion

Clinical Implications

MIGS has emerged as a significant advancement in glaucoma management, offering a less invasive approach compared to traditional surgeries while effectively lowering IOP and reducing the dependence on medications [1]. The combination of MIGS with cataract surgery demonstrates synergistic benefits, offering enhanced efficacy compared to either procedure alone, which optimizes the outcome for patients with both conditions [8,15]. Specific MIGS devices, such as Hydrus and multi-stent approaches, have shown superior IOP control, while others, such as XEN gel stent (AbbVie Inc., Chicago, IL, USA) (Xen), are more suitable for refractory cases [7,10]. The low complication profile of MIGS makes it a valuable option for a wide range of glaucoma patients. The reported improvement in quality of life indicates that MIGS can enhance patient comfort and overall well-being, contributing to a more positive patient experience [26,39].

Limitations

We acknowledge several limitations that affect the overall interpretation and generalizability of the findings. Heterogeneity in the definition of “success,” particularly concerning IOP thresholds, makes it challenging to compare outcomes across different studies, potentially skewing overall efficacy assessments [26,32,39]. The limited reporting of patient-reported outcomes constrains the evaluation of the full impact of MIGS on patients’ lives, with only a few studies addressing quality of life and visual function [26,32,39]. The presence of industry-funded trials introduces a potential bias, as such trials may be more likely to report favorable outcomes, potentially overstating the efficacy of specific devices [8,14]. There is a need for longer-term data, particularly for newer MIGS devices such as Hydrus and OMNI, to establish their durability and long-term effectiveness [18]. The limited studies exploring MIGS in specific glaucoma types, such as angle-closure glaucoma, underscore the need for more targeted research in diverse glaucoma populations [18].

Future Directions

To advance the field and address current limitations, several key areas for future research are highlighted. Standardizing patient-reported outcome metrics is crucial to better capture the holistic impact of MIGS on patients’ lives. Using validated tools such as the National Eye Institute Visual Functioning Questionnaire 25 would enable more consistent and comparable data across studies [18]. Gathering long-term data (more than five years) for newer devices such as Hydrus and OMNI® Surgical System (OMNI) is essential to understand their long-term efficacy and safety profiles [18]. Addressing the gap in knowledge regarding the efficacy of MIGS in diverse populations, such as those with angle-closure glaucoma, is needed to tailor treatment strategies and improve outcomes in these groups [18]. Future studies should focus on exploring the effectiveness of MIGS in various stages of glaucoma, including advanced cases, to better define the role of MIGS in the spectrum of glaucoma management.

Conclusions

MIGS has established itself as a safe, effective, and patient-friendly option for managing glaucoma, particularly in those with mild-to-moderate disease and coexisting cataract. Clinical outcomes demonstrate meaningful IOP and medication reductions while maintaining visual acuity and minimizing serious complications. Combined procedures with cataract surgery offer the most favorable profiles in terms of efficacy and safety. Although data on patient-reported outcomes are still emerging, preliminary findings suggest improvements in visual function and quality of life. Further high-quality, long-term studies focusing on diverse populations and standardized quality of life metrics are warranted to better inform clinical practice and health policy.

Disclosures

Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following:

Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work.

Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.

Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Author Contributions

Concept and design:  Deb Sanjay Nag, Poonam Singh, Bharti Sharma, Nilutpal Sarma, Abhishek Patnaik, Rashi Verma

Acquisition, analysis, or interpretation of data:  Deb Sanjay Nag, Poonam Singh, Bharti Sharma, Nilutpal Sarma, Abhishek Patnaik, Rashi Verma

Drafting of the manuscript:  Deb Sanjay Nag, Poonam Singh, Bharti Sharma, Nilutpal Sarma, Abhishek Patnaik, Rashi Verma

Critical review of the manuscript for important intellectual content:  Deb Sanjay Nag, Poonam Singh, Bharti Sharma, Nilutpal Sarma, Abhishek Patnaik, Rashi Verma

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