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Editors Selection IGR 14-1
Surgical Treatment: SIBS microshunt, gel stent, or trabeculectomy: which wins?
Comment by Pradeep Ramulu on:
127174 Glaucoma Surgery Comparison: SIBS Microshunt Versus Gelatin 45 µm Microstent Versus Trabeculectomy as Primary Surgical Interventions, Armstrong JJ; De Francesco T; De Francesco T; Beckers HJ et al., American Journal of Ophthalmology, 2025; 277: 169-183
Armstrong et. al. performed a large, 12-month retrospective case series comparing surgical outcomes for the SIBS microshunt, gel 45 µM stent (implanted ab interno), and trabeculectomy. Strengths of the study are the significant numbers of eyes (577 total – at least 125 in each group), and pooling of data from centers spanning 6 countries. As might be expected, the patients/eyes chosen for each surgical group differed, with SIBS microshunt eyes having a slightly lower preop IOP (20 mmHg vs. 22 for the gel stent and trabeculectomy groups) while on fewer preop medications. There were racial differences between groups as well, with gel microstent patients more frequently White.
The SIBS microshunt group demonstrated the best postoperative outcomes, with 69% achieving complete surgical success (medication-free IOP of 17 or less with no visually significant hypotony and reduction in IOP of at least 20%) as compared to 58% and 46% for the trabeculectomy and gel stent groups, respectively. Better outcomes were likewise observed in the SIBS microshunt group when assessing qualified success (IOP goals met with or without medications), and outcomes assessing different IOP thresholds as success (21 or 14 mmHg). The SIBS microshunt group also demonstrated the lowest rate of postoperative complications (27% vs. 39% and 54% for the gel stent and trabeculectomy, respectively), and the lowest rates of needling (12% vs. 30% and 22% for the gel stent and trabeculectomy, respectively).
The authors acknowledge that patterns in patient selection might account for the observed outcome differences across surgical group. They also attempt to reconcile their real-world findings with prior randomized trials which show conflicting results (SIBS microshunt inferiority to trabeculectomy, gel stent equivalence to trabeculectomy), speculating these differences may arise from differences in mitomycin-C concentrations, patient characteristics, or differences/improvements in surgical technique. Further study is needed before definitive conclusions can be made regarding the efficacy of the SIBS microshunt in glaucoma as compared to other bleb-forming procedures.
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