European Glaucoma Society – A guide on surgical innovation for glaucoma
Authors: Abegao Pinto Luis , Sunaric Mégevand Gordana , Stalmans Ingeborg 
Published: December 2023

Prologue

Glaucoma surgery has been, for many decades now, dominated by the universal gold standard which is trabeculectomy augmented with antimetabolites. Tubes also came into the scene to complement what we use to call conventional or traditional glaucoma surgery. More recently we experienced a changing glaucoma surgery environment with the “advent” of what we have become used to calling Minimally Invasive Glaucoma Surgery (MIGS). What is the unmet need, what is the gap that these newcomers aim to fill?

Hippocrates taught us “bring benefit, not harm” and new glaucoma techniques and devices aim to provide safer surgery compared to conventional surgery. For the patient, but also for the clinician, safety is important. Is more safety achieved with new glaucoma surgery and, if so, is it associated with better, equivalent, or worse efficacy? Is new glaucoma surgery intended to replace conventional surgery or to complement it as an ‘add-on’ to what clinicians already have in their hands to manage glaucoma? Which surgery should be chosen for which patient? What are the options? Are they equivalent? These are too many questions for the clinician! What are the answers to the questions? What is the evidence to support answers? Do we need more evidence and how can we produce high-quality evidence? This EGS Guide explores the changing and challenging glaucoma surgery environment aiming to provide answers to these questions.

The EGS uses four words to highlight a continuum: Innovation, Education, Communication, and Implementation. Translating innovation to successful implementation is crucially important and requires high-quality evidence to ensure steps forward to a positive impact on health care when it comes to implementation.

The vision of EGS is to provide the best possible well-being and minimal glaucomainduced visual disability in individuals with glaucoma within an affordable healthcare system. In this regard, assessing the changes in glaucoma surgery is a pivotal contribution to better care. As mentioned, this Guide aims to provide answers to the crucial questions above. However, every clinician is aware that answers may differ for every person: an individualised approach is needed. Therefore, there will be no uniform answer for all situations and all patients. Clinicians would need, through the clinical method and possibly some algorithm, to reach answers and decisions at the individual level. In this regard, evidence is needed to support clinicians to make decisions. Of key importance in this Guide is to provide an overview of existing evidence on glaucoma surgery and specifically on recent innovations and novel devices, but also to set standards in surgical design and reporting for future studies on glaucoma surgical innovation. Designing studies in surgery is particularly challenging because of many subtle variations inherent to surgery and hence multiple factors involved in the outcome, but even more because one needs to define carefully outcomes relevant to the research question but also to the future translation into clinical practice. In addition this Guide aims to provide clinical recommendations on novel procedures already in use when insufficient evidence exists.

EGS has a long tradition to provide guidance to the ophthalmic community in Europe and worldwide through the EGS Guidelines (now in their 5th Edition). The EGS leadership recognized that the changing environment in glaucoma surgery currently represents a major challenge for the clinician, needing specific guidance. Therefore, the decision was made to issue this Guide on Glaucoma Surgery in order to help clinicians to make appropriate decisions for their patients and also to provide the framework and guidance for researchers to improve the quality of evidence in future studies. Ultimately this Guide will support better Glaucoma Care in accordance with EGS’s Vision and Mission.

Fotis Topouzis

EGS President

Contributors

All contributors have provided the appropriate COI visible in detail atwww.eugs.org/pages/guidesurgical/

This manuscript reflects the work and thoughts of the list of individuals recognized above, but importantly, it reflects EGS views on the subject matter. Its strength originates from a team effort, where a cohesive group of authors and reviewers have worked towards a common goal and now stand behind the text in its entirety. The EGS nevertheless wishes to thank the following external contributors for their additional expertise, which was particularly valuable to the development of this Surgical Guide: Amanda Bicket, Jonathan Bonnar, Catey Bunce, Kuan Hu, Sheffinea Koshy, Jimmy Le, Tianjing Li, Francisco Otarola, Riaz Qureshi, Anupa Shah, Richard Stead and Marta Toth. A particular appreciation goes to Ian Saldanha for drafting the introductory overview on Core Outcomes on chapter 8. Finally, EGS would like to acknowledge Augusto Azuara Blanco, Chair of the Scientific and Guidelines Committee, for his expertise and advisory role throughout the entire process.

Luis Abegao Pinto, Centro Hospitalar Universitário Lisboa Norte

Editor

Gordana Sunaric Mégevand, Eye Research Centre, Adolphe de Rothschild Hospital, Geneva, Switzerland and Centre Ophtalmologique de Florissant, Geneva, Switzerland

Editor

Ingeborg Stalmans, Ingeborg Stalmans, University Hospitals UZ Leuven, Catholic University KU Leuven

Editor

Luis Abegao Pinto, Centro Hospitalar Universitário Lisboa Norte

Hana Abouzeid, Clinical Eye Research Centre Adolph de Rothschild, AZ Ophthalmologie

Eleftherios Anastasopoulos, Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki, Greece

Augusto Azuara Blanco, Centre for Public Health, Queen’s University Belfast

Luca Bagnasco, Clinica Oculistica, DiNOGMI University of Genoa

Alessandro Bagnis, Clinica Oculistica, IRCCS Ospedale Policlinico San Martino

Joao Barbosa Breda, Faculty of Medicine of the University of Porto, Porto, Portugal. Centro Hospitalar e Universitário São João, Porto, Portugal. KULeuven, Belgium

Keith Barton, University College London, Moorfields Eye Hospital

Amanda Bicket, University of Michigan (Ann Arbor, MI, USA)

Jonathan Bonnar, Belfast Health and Social Care Trust

Chiara Bonzano, Clinica Oculistica, IRCCS Ospedale Policlinico San Martino

Rupert Bourne, Cambridge University Hospital

Alain Bron, University Hospital Dijon

Catey Bunce, King’s College London

Carlo Cutolo, Clinica Oculistica, DiNOGMI University of Genoa, and IRCCS Ospedale Policlinico San Martino

Barbara Cvenkel, University Medical Centre Ljubljana Faculty of Medicine, University of Ljubljana

Antonio Fea, University of Turin

Theodoros Filippopoulos, Athens Vision Eye Institute

Panayiota Founti, Moorfields Eye Hospital NHS Foundation Trust

Stefano Gandolfi, U.O.C. Oculistica, University of Parma

Julian Garcia Feijoo, Hospital Clinico San Carlos, Universidad Complutense, Madrid

Gerhard Garhoefer, Medical University of Vienna, Austria

David Garway Heath, Moorfields Eye Hospital NHS Foundation Trust, London. Institute of Ophthalmology, University College London.

Gus Gazzard, Moorfields Eye Hospital NHS Foundation Trust, London. Institute of Ophthalmology, University College London.

Stylianos Georgoulas, Addenbrooke’s, Cambridge University Hospitals

Dimitrios Giannoulis, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece

Franz Grehn, University Hospitals Wuerzburg

Kuang Hu, NIHR Moorfields Biomedical Research Centre, London – Institute of Ophthalmology – University College London

Michele Iester, Clinica Oculistica, DiNOGMI University of Genoa, and IRCCS Ospedale Policlinico San Martino

Hari Jayaram, Moorfields Eye Hospital

Gauti Johannesson, Umea University

Stylianos Kandarakis, National and Kapodistrian University of Athens, G. Gennimatas Hospital, Athens, Greece.

Efthymios Karmiris, Hellenic Air Force General Hospital & National and Kapodistrian University of Athens, G. Gennimatas Hospital, Athens

Alan Kastner, Clinica Oftalmologica Pasteur, Santiago, Chile

Andreas Katsanos, University of Ioannina, Greece

Christina Keskini, Aristotle University of Thessaloniki, AHEPA Hospital

Anthony Khawaja, Moorfields Eye Hospital and UCL Institute of Ophthalmology

Anthony King, Nottingham University Hospitals NHS Trust

James Kirwan, Portsmouth hospitals university NHS trust

Miriam Kolko, University of Copenhagen, Copenhagen University Hospital Rigshospitalet

Sheffinea Koshy, University of Galway

Antoine Labbe, Quinze-Vingts ­National Ophthalmology Hospital

Jimmy Le, Johns Hopkins Bloomberg School of Public Health, Baltimore

Sanna Leinonen, Tays Eye Centre, Tampere University Hospital

Sophie Lemmens, University Hospitals UZ Leuven

Tianjing Li, School of Medicine, University of Colorado Anschutz Medical Campus

Giorgio Marchini, Clinica Oculistica, University Hospital, AOUI, Verona, Italy

José Martinez De La Casa, Hospital Clinico San Carlos. Universidad Complutense

Andy McNaught, Gloucestershire Eye Unit

Frances Meier Gibbons, Eye Center Rapperswil, Switzerland

Karl Mercieca, University Hospitals Eye Clinic, Bonn, Germany

Manuele Michelessi, IRCCS – Fondazione Bietti

Stefano Miglior, University of Milan Bicocca

Eleni Nikita, Moorfields Eye Hospital NHS Foundation Trust

Francesco Oddone, IRCCS ­Fondazione Bietti

Francisco Otarola, Universidad de La Frontera

Marta Pazos, Institute of Ophthalmology. Hospital Clínic Barcelona. Researcher at Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)

Norbert Pfeiffer, Mainz University Medical Center

Verena Prokosh, University of Cologne, Center for ophthalmology.

Riaz Qureshi, Johns Hopkins Medicine, Baltimore

Gokulan Ratnarajan, Queen Victoria Hospital, East Grinstead, UK

Herbert Reitsamer, University Clinic Salzburg / SALK

Luca Rossetti, University of Milan, ASST Santi Paolo e Carlo, Milano, Italy

Ian Saldanha, Johns Hopkins Bloomberg School of Public Health, Baltimore

Cedric Schweitzer, CHU Bordeaux, Univ. Bordeaux, ISPED, INSERM, U1219 – Bordeaux Population Health Research Centre, France

Andrew Scott, Moorfields Eye Hospital London

Riccardo Scotto, Clinica Oculistica, DiNOGMI University of Genoa

Anupa Shah, Queen’s University Belfast

George Spaeth, Wills Eye Hospital/Sidney Kimmel Medical College/Thomas Jefferson University

Richard Stead,Nottingham University Hospitals NHS Trust

Francesco Stringa, University Hospital Southampton NHS FT

Gordana Sunaric, Centre Ophtalmologique de Florissant, Centre de Recherche Clinique en Ophtalmologie Mémorial Adolphe de Rothschild

Andrew Tatham, University of Edinburgh, Princess Alexandra Eye Pavilion

Mark Toeteberg, University Hospital Zurich

Fotis Topouzis, Aristotle University of Thessaloniki, AHEPA Hospital

Marta Toth, Moorfields Eye Hospital NHS Foundation Trust

Carlo Traverso, Clinica Oculistica, DiNOGMI University of Genoa, and IRCCS Ospedale Policlinico San Martino

Anja Tuulonen, Tays Eye Centre, Tampere University Hospital

Clemens Vass, Medical University of Vienna

Ananth Viswanathan, Moorfields Eye Hospital NHSFT and UCL Institute of Ophthalmology

Richard Wormald, UCL Institute of Ophthalmology

External Reviewers

American Glaucoma Society

Asia-Pacific Glaucoma Society

Middle East Africa Glaucoma Society

World Glaucoma Societywww.eugs.org/pages/externalreviewers

The team of Clinica Oculistica of the University of Genoa for medical editing and illustration

Luca Bagnasco

Alessandro Bagnis

Chiara Bonzano

Carlo Cutolo

Michele Iester

Riccardo Scotto

Carlo Traverso