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

PrologueGlaucoma 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 TopouzisEGS PresidentContributorsAll 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 NorteEditorGordana Sunaric Mégevand, Eye Research Centre, Adolphe de Rothschild Hospital, Geneva, Switzerland and Centre Ophtalmologique de Florissant, Geneva, SwitzerlandEditorIngeborg Stalmans, Ingeborg Stalmans, University Hospitals UZ Leuven, Catholic University KU LeuvenEditorLuis Abegao Pinto, Centro Hospitalar Universitário Lisboa NorteHana Abouzeid, Clinical Eye Research Centre Adolph de Rothschild, AZ OphthalmologieEleftherios Anastasopoulos, Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki, GreeceAugusto Azuara Blanco, Centre for Public Health, Queen’s University BelfastLuca Bagnasco, Clinica Oculistica, DiNOGMI University of GenoaAlessandro Bagnis, Clinica Oculistica, IRCCS Ospedale Policlinico San MartinoJoao Barbosa Breda, Faculty of Medicine of the University of Porto, Porto, Portugal. Centro Hospitalar e Universitário São João, Porto, Portugal. KULeuven, BelgiumKeith Barton, University College London, Moorfields Eye HospitalAmanda Bicket, University of Michigan (Ann Arbor, MI, USA)Jonathan Bonnar, Belfast Health and Social Care TrustChiara Bonzano, Clinica Oculistica, IRCCS Ospedale Policlinico San MartinoRupert Bourne, Cambridge University HospitalAlain Bron, University Hospital DijonCatey Bunce, King’s College LondonCarlo Cutolo, Clinica Oculistica, DiNOGMI University of Genoa, and IRCCS Ospedale Policlinico San MartinoBarbara Cvenkel, University Medical Centre Ljubljana Faculty of Medicine, University of LjubljanaAntonio Fea, University of TurinTheodoros Filippopoulos, Athens Vision Eye InstitutePanayiota Founti, Moorfields Eye Hospital NHS Foundation TrustStefano Gandolfi, U.O.C. Oculistica, University of ParmaJulian Garcia Feijoo, Hospital Clinico San Carlos, Universidad Complutense, MadridGerhard Garhoefer, Medical University of Vienna, AustriaDavid 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 HospitalsDimitrios Giannoulis, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, GreeceFranz Grehn, University Hospitals WuerzburgKuang Hu, NIHR Moorfields Biomedical Research Centre, London – Institute of Ophthalmology – University College LondonMichele Iester, Clinica Oculistica, DiNOGMI University of Genoa, and IRCCS Ospedale Policlinico San MartinoHari Jayaram, Moorfields Eye HospitalGauti Johannesson, Umea UniversityStylianos 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, AthensAlan Kastner, Clinica Oftalmologica Pasteur, Santiago, ChileAndreas Katsanos, University of Ioannina, GreeceChristina Keskini, Aristotle University of Thessaloniki, AHEPA HospitalAnthony Khawaja, Moorfields Eye Hospital and UCL Institute of OphthalmologyAnthony King, Nottingham University Hospitals NHS TrustJames Kirwan, Portsmouth hospitals university NHS trustMiriam Kolko, University of Copenhagen, Copenhagen University Hospital RigshospitaletSheffinea Koshy, University of GalwayAntoine Labbe, Quinze-Vingts ­National Ophthalmology HospitalJimmy Le, Johns Hopkins Bloomberg School of Public Health, BaltimoreSanna Leinonen, Tays Eye Centre, Tampere University HospitalSophie Lemmens, University Hospitals UZ LeuvenTianjing Li, School of Medicine, University of Colorado Anschutz Medical CampusGiorgio Marchini, Clinica Oculistica, University Hospital, AOUI, Verona, ItalyJosé Martinez De La Casa, Hospital Clinico San Carlos. Universidad ComplutenseAndy McNaught, Gloucestershire Eye UnitFrances Meier Gibbons, Eye Center Rapperswil, SwitzerlandKarl Mercieca, University Hospitals Eye Clinic, Bonn, GermanyManuele Michelessi, IRCCS – Fondazione BiettiStefano Miglior, University of Milan BicoccaEleni Nikita, Moorfields Eye Hospital NHS Foundation TrustFrancesco Oddone, IRCCS ­Fondazione BiettiFrancisco Otarola, Universidad de La FronteraMarta Pazos, Institute of Ophthalmology. Hospital Clínic Barcelona. Researcher at Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)Norbert Pfeiffer, Mainz University Medical CenterVerena Prokosh, University of Cologne, Center for ophthalmology.Riaz Qureshi, Johns Hopkins Medicine, BaltimoreGokulan Ratnarajan, Queen Victoria Hospital, East Grinstead, UKHerbert Reitsamer, University Clinic Salzburg / SALKLuca Rossetti, University of Milan, ASST Santi Paolo e Carlo, Milano, ItalyIan Saldanha, Johns Hopkins Bloomberg School of Public Health, BaltimoreCedric Schweitzer, CHU Bordeaux, Univ. Bordeaux, ISPED, INSERM, U1219 – Bordeaux Population Health Research Centre, FranceAndrew Scott, Moorfields Eye Hospital LondonRiccardo Scotto, Clinica Oculistica, DiNOGMI University of GenoaAnupa Shah, Queen’s University BelfastGeorge Spaeth, Wills Eye Hospital/Sidney Kimmel Medical College/Thomas Jefferson UniversityRichard Stead,Nottingham University Hospitals NHS TrustFrancesco Stringa, University Hospital Southampton NHS FTGordana Sunaric, Centre Ophtalmologique de Florissant, Centre de Recherche Clinique en Ophtalmologie Mémorial Adolphe de RothschildAndrew Tatham, University of Edinburgh, Princess Alexandra Eye PavilionMark Toeteberg, University Hospital ZurichFotis Topouzis, Aristotle University of Thessaloniki, AHEPA HospitalMarta Toth, Moorfields Eye Hospital NHS Foundation TrustCarlo Traverso, Clinica Oculistica, DiNOGMI University of Genoa, and IRCCS Ospedale Policlinico San MartinoAnja Tuulonen, Tays Eye Centre, Tampere University HospitalClemens Vass, Medical University of ViennaAnanth Viswanathan, Moorfields Eye Hospital NHSFT and UCL Institute of OphthalmologyRichard Wormald, UCL Institute of OphthalmologyExternal ReviewersAmerican Glaucoma SocietyAsia-Pacific Glaucoma SocietyMiddle East Africa Glaucoma SocietyWorld Glaucoma Societywww.eugs.org/pages/externalreviewersThe team of Clinica Oculistica of the University of Genoa for medical editing and illustrationLuca BagnascoAlessandro BagnisChiara BonzanoCarlo CutoloMichele IesterRiccardo ScottoCarlo Traverso