Kahook Dual Blade Goniotomy Versus iStent Implantation Combined With Phacoemulsification: A Systematic Review and Meta-Analysis

Précis: In this meta-analysis, Kahook dual blade (KDB) goniotomy achieved higher rates of surgical success compared with iStent/iStent inject implantation combined with phacoemulsification. KDB goniotomy demonstrated better intraocular pressure (IOP) reduction at month 6 compared with the stent group. Objective: To compare the outcomes of phacoemulsification combined with either KDB goniotomy (phaco-KDB) or trabecular microbypass stent (iStent and iStent inject) implantation (phaco-Stent). Methods: A literature search was performed on PubMed, Embase, Web of Science, and Cochrane Library from inception to April 2024. Randomized clinical trials and observational studies that compared KDB goniotomy to the first or second-generation iStent combined with phacoemulsification were included. The main outcome measures were surgical success, mean change in IOP and medication number, and complication rates. Mean differences (MDs) and pooled odds ratios were used to analyze continuous and binary outcomes, respectively. Results: Fourteen studies were included with a total of 1959 eyes (958 phaco-KDB, and 1000 phaco-Stent including 753 phaco-iStent and 207 phaco-iStent inject). The combined findings showed significantly higher rates of surgical success in the phaco-KDB group versus the phaco-Stent group (odds ratio: 0.68; 95% CI: 0.50 to 0.92; P = 0.01; I 2 = 40%), and greater IOP reduction in the phaco-KDB group versus the phaco-Stent group at month 6 (MD: 1.13 mm Hg; 95% CI: 0.43 to 1.83; P = 0.002; I 2 = 51%). By month 12, both groups demonstrated similar IOP reduction. Subgroup analysis at month 12 showed greater IOP reduction in the phaco-KDB group versus the phaco-iStent group (MD: 1.69 mm Hg; 95% CI: 0.44 to 2.95; P = 0.008; I 2 = 74%). However, compared with the phaco-iStent inject group, there was no significant difference in IOP reduction (MD: −0.72 mm Hg; 95% CI: −3.69 to 2.24; P = 0.63; I 2 = 64%). Medication reduction and the incidence of adverse events were comparable between groups. Conclusion: KDB goniotomy may offer better surgical success compared with Stent implantation when used in combination with phacoemulsification. KDB goniotomy demonstrated better IOP reduction at month 12 compared with iStent. However, iStent inject showed a similar IOP reduction to KDB.