Lens extraction for chronic angle‐closure glaucoma

Ariel Yuhan Ong; Sueko M Ng; S Swaroop Vedula; David S. Friedman

doi:10.1002/14651858.CD005555.pub3

Extracción del cristalino para el glaucoma crónico de ángulo cerrado

Appendices

Appendix 1. CENTRAL search strategy

#1   MeSH descriptor: [Glaucoma, Angle‐Closure] this term only
#2   angle* near/3 (occlud* or narrow* or width or close* or closure)
#3   glaucoma* near/3 (occlud* or narrow* or width or close* or closure)
#4   PAC or PACS or PACG or ACG
#5   #1 or #2 or #3 or #4
#6   MeSH descriptor: [Cataract] explode all trees
#7   MeSH descriptor: [Cataract Extraction] explode all trees
#8   MeSH descriptor: [Capsulorhexis] this term only
#9   MeSH descriptor: [Phacoemulsification] this term only
#10   pha?oemulsif*
#11   MeSH descriptor: [Aphakia, Postcataract] this term only
#12   MeSH descriptor: [Lenses, Intraocular] explode all trees
#13   MeSH descriptor: [Lens Implantation, Intraocular] this term only
#14   intraocular len* or IOL*
#15   lensectom* or capsulotom*
#16   cataract* or lens or lenses
#17   #6 or #7 or #8 o r#9 or #10 or #11 or #12 or #13 or #14 or #15 or #16
#18   #5 and #17

Appendix 2. MEDLINE Ovid search strategy

1. randomized controlled trial.pt.
2. (randomized or randomised).ab,ti.
3. placebo.ab,ti.
4. dt.fs.
5. randomly.ab,ti.
6. trial.ab,ti.
7. groups.ab,ti.
8. or/1‐7
9. exp animals/
10. exp humans/
11. 9 not (9 and 10)
12. 8 not 11
13. Glaucoma, Angle‐Closure/
14. (angle$ adj3 (occlud$ or narrow$ or width or close$ or closure)).tw.
15. (glaucoma$ adj3 (occlud$ or narrow$ or width or close$ or closure)).tw.
16. (PAC or PACS or PACG or ACG).tw.
17. or/13‐16
18. exp cataract/
19. exp cataract extraction/
20. capsulorhexis/
21. capsulorhexis.tw.
22. phacoemulsification/
23. pha?oemulsif$.tw.
24. aphakia, postcataract/
25. exp lenses intraocular/
26. lens implantation intraocular/
27. (intraocular lens or IOL$).tw.
28. (lensectom$ or capsulotom$).tw.
29. (cataract$ or lens or lense).tw.
30. or/18‐29
31. 17 and 30
32. 12 and 31

The search filter for trials at the beginning of the MEDLINE strategy is from the published paper by Glanville 2006.

Appendix 3. Embase Ovid search strategy

1. exp randomized controlled trial/
2. exp randomization/
3. exp double blind procedure/
4. exp single blind procedure/
5. random$.tw.
6. or/1‐5
7. (animal or animal experiment).sh.
8. human.sh.
9. 7 and 8
10. 7 not 9
11. 6 not 10
12. exp clinical trial/
13. (clin$ adj3 trial$).tw.
14. ((singl$ or doubl$ or trebl$ or tripl$) adj3 (blind$ or mask$)).tw.
15. exp placebo/
16. placebo$.tw.
17. random$.tw.
18. exp experimental design/
19. exp crossover procedure/
20. exp control group/
21. exp latin square design/
22. or/12‐21
23. 22 not 10
24. 23 not 11
25. exp comparative study/
26. exp evaluation/
27. exp prospective study/
28. (control$ or prospectiv$ or volunteer$).tw.
29. or/25‐28
30. 29 not 10
31. 30 not (11 or 23)
32. 11 or 24 or 31
33. closed angle glaucoma/
34. glaucomatous optic neuropathy/
35. neovascular glaucoma/
36. secondary glaucoma/
37. (angle$ adj3 (occlud$ or narrow$ or width or close$ or closure)).tw.
38. (glaucoma$ adj3 (occlud$ or narrow$ or width or close$ or closure)).tw.
39. (PAC or PACS or PACG or ACG).tw.
40. or/33‐39
41. exp cataract/
42. exp cataract extraction/
43. capsulorhexis/
44. capsulorhexis.tw.
45. phacoemulsification/
46. pha?oemulsif$.tw.
47. aphakia/
48. lens implant/
49. exp lens implantation/
50. (intraocular lens or IOL$).tw.
51. (lensectom$ or capsulotom$).tw.
52. (cataract$ or lens or lenses).tw.
53. or/41‐52
54. 40 and 53
55. 32 and 54

Appendix 4. LILACS search strategy

glaucoma OR angle [Words] and occlud$ OR narrow$ OR width OR close$ OR closure [Words] and cataract OR lens OR lenses OR capsulorhexis OR phacoemulsification OR intraocular lens OR IOL OR lensectomy OR capsulotomy [Words]

Appendix 5. ClinicalTrials.gov search strategy

(cataract OR lens OR IOL OR phacoemulsification OR phacotrabeculectomy) | Glaucoma, Angle‐Closure

Appendix 6. WHO ICTRP search strategy

CONDITION = angle closure glaucoma AND INTERVENTION = cataract OR lens OR IOL OR phacoemulsification OR phacotrabeculectomy

Figure 1

Study flow diagram

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Figure 2

'Risk of bias' summary: review authors' judgements about each 'Risk of bias' item for each included study

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Analysis 1.1

Comparison 1: Phacoemulsification versus phaco‐viscogonioplasty (phaco‐VGP), Outcome 1: Mean IOP change from baseline

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Analysis 1.2

Comparison 1: Phacoemulsification versus phaco‐viscogonioplasty (phaco‐VGP), Outcome 2: Mean number of medications to control IOP

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Analysis 1.3

Comparison 1: Phacoemulsification versus phaco‐viscogonioplasty (phaco‐VGP), Outcome 3: Gonioscopic findings

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Analysis 1.4

Comparison 1: Phacoemulsification versus phaco‐viscogonioplasty (phaco‐VGP), Outcome 4: Mean visual acuity

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Analysis 2.1

Comparison 2: Phacoemulsification versus phacoemulsification with goniosynechialysis (phaco‐GSL), Outcome 1: Mean IOP change from baseline

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Analysis 2.2

Comparison 2: Phacoemulsification versus phacoemulsification with goniosynechialysis (phaco‐GSL), Outcome 2: Mean number of medications to control IOP

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Analysis 2.3

Comparison 2: Phacoemulsification versus phacoemulsification with goniosynechialysis (phaco‐GSL), Outcome 3: Gonioscopic findings

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Analysis 3.1

Comparison 3: Phacoemulsification versus combined phaco‐trabeculectomy, Outcome 1: Mean IOP

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Analysis 3.2

Comparison 3: Phacoemulsification versus combined phaco‐trabeculectomy, Outcome 2: Mean number of medications to control IOP

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Analysis 3.3

Comparison 3: Phacoemulsification versus combined phaco‐trabeculectomy, Outcome 3: Mean visual acuity

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Analysis 3.4

Comparison 3: Phacoemulsification versus combined phaco‐trabeculectomy, Outcome 4: Adverse effects

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Summary of findings 1. Phacoemulsification compared with laser peripheral iridotomy for primary angle‐closure glaucoma

Phacoemulsification compared with laser peripheral iridotomy for primary angle‐closure glaucoma
Patient or population: participants with primary angle‐closure glaucoma Settings: 30 hospital eye services in Australia (1), mainland China (1), Hong Kong (2), Malaysia (2), Singapore (2), and the UK (22) Intervention: phacoemulsification Comparison: laser peripheral iridotomy (LPI)
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of eyes (studies)	Certainty of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	laser peripheral iridotomy	phacoemulsification
Progression of visual field loss (worsening of one or more stages, according to the Glaucoma Staging System‐2) (at 12 months)	165 per 1000	65 per 1000 (25 to 152 per 1000)	OR 0.35 (0.13 to 0.91)	216 (one study)	⊕⊕⊕⊝ moderate^a	‐
Mean IOP change from baseline to 12 months (mmHg)	The mean change in IOP in the control group was ‐6.48 mmHg	The mean change in IOP in the intervention group was 0.03 mmHg higher (95% CI ‐2.34 mmHg to 2.32 mmHg)	‐	257 (one study)	⊕⊕⊕⊝ moderate^a	‐
Mean number of medications to control IOP (at 12 months)	On average, the number of medications in the control group was 0.98	On average, the number of medications in the intervention group was 0.70 lower (95% CI ‐0.89 to ‐0.51)	‐	263 (one study)	⊕⊕⊕⊝ moderate^a	‐
Gonioscopic findings (Degree of angle closure) (at 12 months or later)	The mean angle closure in the control group was 203°	The mean angle closure in the intervention group was 84.93° less (95% CI 38.61° to 131.25°)		106 (one study)	⊕⊕⊕⊝ moderate^a	‐
Visual acuity (ETDRS letter chart) (at 12 months)	The mean visual acuity in the control group was 77.4	The mean visual acuity in the intervention group was 2.03 letters greater (95% CI ‐0.77 to 4.84)	‐	242 (one study)	⊕⊕⊕⊝ moderate^a	‐
Adverse effects	No data available		‐	‐	‐	‐
Quality of life measures (measured on the EQ‐5D; higher = better) (at 12 months)	The average score on the EQ‐5D in the control group was 2.88	The average score on the EQ‐5D in the intervention group was 0.04 higher (95% CI ‐0.16 to 0.24)	‐	254 (one study)	⊕⊕⊕⊝ moderate^a	‐
The assumed risk* is based on the estimate in the control group. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; IOP: intraocular pressure; MD: mean difference; OR: odds ratio; EQ‐5D: European Quality of Life‐5 Dimension
GRADE Working Group grades of evidence High certainty. Further research is very unlikely to change our confidence in the estimate of effect. Moderate certainty. Further research is likely to have an important impact on our confidence in the estimate of effect, and may change the estimate. Low certainty. Further research is very likely to have an important impact on our confidence in the estimate of effect, and is likely to change the estimate. Very low certainty. We are very uncertain about the estimate.
^aDowngraded one level for imprecision because sample size was not adequately powered (original study was powered to investigate participants with both primary angle closure (PAC) and primary angle‐closure glaucoma (PACG), whereas only participants with PACG were included in this analysis).

Summary of findings 1. Phacoemulsification compared with laser peripheral iridotomy for primary angle‐closure glaucoma

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Summary of findings 2. Phacoemulsification versus phacoemulsification plus viscogonioplasty for primary angle‐closure glaucoma

Phacoemulsification versus phacoemulsification plus viscogonioplasty for primary angle‐closure glaucoma
Patient or population: participants with primary angle‐closure glaucoma Settings: university hospital in Iran Intervention: phacoemulsification Comparison: phacoemulsification plus viscogonioplasty (phaco‐VGP)
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Certainty of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	phacoemulsification plus viscogonioplasty	phacoemulsification
Progression of visual field loss	No data available for this outcome		‐	‐	‐	‐
Mean IOP change from baseline to 12 months (mmHg)	The mean change in IOP in the control group was ‐8.8 mmHg	The mean change in IOP in the intervention group was ‐8.3 mmHg; on average, 0.50 mmHg higher (95% CI ‐2.64 to 3.64)	‐	91 eyes (one study)	⊕⊕⊝⊝ low^a^,b	‐
Mean number of medications to control IOP (at 12 months)	The mean number of medications to control IOP in the control group was 0.4	The mean number of medications to control IOP in the intervention groups was 0.1; on average, 0.30 fewer (95% CI ‐0.55 to ‐0.05)	‐	91 eyes (one study)	⊕⊕⊝⊝ low^a^,b	at 6 months: MD ‐0.30 (95% CI ‐0.56 to ‐0.04; 1 study, 91 eyes)
Gonioscopic findings (Spaeth grading system) (at 12 months or later)	The mean change of angle grading in the control group was 2.0	The mean change of angle grading in the intervention group was 1.4; on average, 0.60 less (95% CI ‐0.91 to ‐0.29)	‐	91 eyes (one study)	⊕⊕⊝⊝ low^a^,b	‐
Gonioscopic findings (TISA500) (at 12 months)	The mean TISA500 in the control group was 0.054	The mean TISA500 in the intervention group was 0.020; on average, 0.03 less (95% CI ‐0.06 to ‐0.01)	‐	91 eyes (one study)	⊕⊕⊝⊝ low^a^,b	‐
Gonioscopic findings (TISA750) (at 12 months)	The mean TISA750 in the control group was 0.119	The mean TISA750 in the intervention group was 0.084; on average, 0.03 less (95% CI ‐0.06 to ‐0.01)	‐	91 eyes (one study)	⊕⊕⊝⊝ low^a^,b	‐
Visual acuity (log MAR units) (postoperatively)	The mean best corrected visual acuity in the control group was 0.28	The mean best corrected visual acuity in the intervention group was 0.27; on average, 0.01 less (95% CI ‐0.10 to 0.08)	‐	91 eyes (one study)	⊕⊕⊝⊝ low^a^,b	‐
Adverse effects (at 12 months)	hyphema (3 eyes), postoperative fibrin reaction (4 eyes)	postoperative fibrin reaction (2 eyes)	‐	‐	‐
Quality of life measures	No data available for this outcome		‐	‐	‐	‐
The assumed risk* is based on the estimate in the control group. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; IOP: Intraocular pressure; TISA: trabecular iris space area
GRADE Working Group grades of evidence High certainty. Further research is very unlikely to change our confidence in the estimate of effect. Moderate certainty. Further research is likely to have an important impact on our confidence in the estimate of effect, and may change the estimate. Low certainty. Further research is very likely to have an important impact on our confidence in the estimate of effect, and is likely to change the estimate. Very low certainty. We are very uncertain about the estimate.
^aDowngraded for high risk of attrition bias ^bDowngraded one level for imprecision due to wide confidence intervals

Summary of findings 2. Phacoemulsification versus phacoemulsification plus viscogonioplasty for primary angle‐closure glaucoma

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Summary of findings 3. Phacoemulsification versus phacoemulsification plus goniosynechialysis for primary angle‐closure glaucoma

Phacoemulsification versus phacoemulsification plus goniosynechialysis for primary angle‐closure glaucoma
Patient or population: participants with primary angle closure glaucoma Settings: tertiary eye care center and university hospital in Vietnam, Thailand, and Hong Kong Intervention: phacoemulsification Comparison: phacoemulsification plus goniosynechialysis (phaco‐GSL)
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Certainty of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	phacoemulsification plus goniosynechialysis	phacoemulsification
Progression of visual field loss	No data available for this outcome		‐	‐	‐	‐
Mean IOP change from baseline (mmHg) (at 12 months)	The mean change in IOP in the control group was ‐6.47 mmHg	The mean change in IOP in the intervention group was ‐6.59; on average, 0.12 lower (95% CI ‐4.72 to 4.48)	‐	32 eyes (one study)	⊕⊕⊕⊝ moderate^a	at 6 months: MD ‐0.04 mmHg (95% CI ‐0.93 to 0.85; 1 study, 64 eyes)
Mean number of medications to control IOP (at 12 months)	The mean number of medications to control IOP in the control group was 0.94	The mean number of medications to control IOP in the intervention groups was 0.56; on average, 0.38 fewer (95% CI ‐1.23 to 0.47)	‐	32 eyes (one study)	⊕⊕⊕⊝ moderate^a	at 6 months: MD ‐0.35 (95% CI ‐0.63 to ‐0.07; 1 study, 64 eyes)
Gonioscopic findings (Anterior segment optical coherence tomography parameters) (at 6 months)	See comments	See comments	‐	64 eyes (one study)	‐	AOD500: MD ‐0.04° (95% CI ‐0.27 to 0.19) AOD750: MD 0.01° (95% CI ‐0.27 to 0.29) TISA500: MD ‐0.02° (95% CI ‐0.06 to 0.02) TISA750: MD ‐0.03° (95% CI ‐0.17 to 0.11) SSA: MD ‐1.59° (95% CI ‐6.75 to 3.57)
Visual acuity (log MAR units)	No data available for this outcome		‐	‐	‐	‐
Adverse effects (at 6 months)	hyphema (3 eyes)	none reported	‐	‐	‐
Quality of life measures	No data available for this outcome		‐	‐	‐	‐
The assumed risk* is based on the estimate in the control group. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). AOD: angle opening distance;CI: confidence interval; IOP: intraocular pressure; MD: mean difference; SSA: scleral spur angle; TISA: trabecular iris space area
GRADE Working Group grades of evidence High certainty. Further research is very unlikely to change our confidence in the estimate of effect. Moderate certainty. Further research is likely to have an important impact on our confidence in the estimate of effect, and may change the estimate. Low certainty. Further research is very likely to have an important impact on our confidence in the estimate of effect, and is likely to change the estimate. Very low certainty. We are very uncertain about the estimate.
^aDowngraded one level for imprecision due to wide confidence intervals

Summary of findings 3. Phacoemulsification versus phacoemulsification plus goniosynechialysis for primary angle‐closure glaucoma

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Summary of findings 4. Phacoemulsification versus phacoemulsification plus trabeculectomy for primary angle‐closure glaucoma

Phacoemulsification versus phacoemulsification plus trabeculectomy for primary angle‐closure glaucoma
Patient or population: participants with primary angle‐closure glaucoma Settings: university hospital in Egypt Intervention: phacoemulsification Comparison: phacoemulsification plus trabeculectomy
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Certainty of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Phacoemulsification combined with trabeculectomy	Phacoemulsification
Progression of visual field loss (at 12 months)	No data available for this outcome		‐	‐	‐
Mean IOP change from baseline to 12 months (mmHg)	The mean IOP in the control group was 13.2 mmHg	The mean IOP in the intervention group was 12.6 mmHg; on average, 0.60 mmHg lower (95% CI ‐1.99 to 0.79)	‐	63 eyes (one study)	⊕⊕⊝⊝ low^a^,b
Mean number of medications to control IOP (at 12 months)	The mean number of medications to control IOP in the control group was 0.5	The mean number of medications to control IOP in the intervention group was 0.5; on average, there was no difference (95% CI ‐0.42 to 0.42)	‐	63 eyes (one study)	⊕⊕⊝⊝ low^a^,b	‐
Gonioscopic findings	No data available for this outcome		‐	‐	‐	‐
Mean best corrected visual acuity (on Snellen chart) (at final follow‐up)	The mean best corrected visual acuity in the control group was 0.38	The mean best corrected visual acuity in the intervention group was 0.35: on average, 0.03 lower (95% CI ‐0.18 to 0.12)		63 eyes (one study)	⊕⊕⊝⊝ low^a^,b	‐
Adverse effects (up to 12 months)	Intraoperative and postoperative complications		RR 0.59 (0.34 to 1.04)	63 eyes (one study)	⊕⊕⊝⊝ low^a^,b
	580.6 per 1000	343.8 per 1000	RR 0.59 (0.34 to 1.04)
	Additional IOP‐lowering procedures required		RR 5.81 (1.41 to 23.88)
	64.5 per 1000	375 per 1000	RR 5.81 (1.41 to 23.88)
Quality of life measures (at 12 months)	No data available for this outcome		‐	‐	‐	‐
The assumed risk* (e.g. the median control group risk across studies) is based on the estimate in the control group. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; IOP: intraocular pressure; RR: risk ratio
GRADE Working Group grades of evidence High certainty. Further research is very unlikely to change our confidence in the estimate of effect. Moderate certainty. Further research is likely to have an important impact on our confidence in the estimate of effect, and may change the estimate. Low certainty. Further research is very likely to have an important impact on our confidence in the estimate of effect, and is likely to change the estimate. Very low certainty. We are very uncertain about the estimate.
^aDowngraded for high risk of attrition bias ^bDowngraded one level for imprecision due to wide confidence intervals

Summary of findings 4. Phacoemulsification versus phacoemulsification plus trabeculectomy for primary angle‐closure glaucoma

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Table 1. Summary table

Intervention	Phacoemulsification	Phacoemulsification	Phacoemulsification	Phacoemulsification	Phacoemulsification
Comparison	Laser peripheral iridotomy (LPI)	Phacoemulsification plus viscogonioplasty	Phacoemulsification plus goniosynechialysis (phaco‐GSL)	Phacoemulsification plus trabeculectomy	Trabeculectomy
Study ID	Azuara‐Blanco 2016	Moghimi 2015	Angmo 2019; Husain 2019	El Sayed 2019 (Data not presented for Tham 2008; Tham 2009)	Tham 2013
Progression of visual field loss	OR 0.49 (95% CI 0.24 to 0.92) at 6 months; OR 0.35 (95% CI 0.13 to 0.91) at 12 months; OR 0.37 (95% CI 0.17 to 0.82) at 24 months; OR 0.42 (95% CI 0.20 to 0.87) at 36 months	NR	NR	Unable to complete analysis to compare between groups	Unable to complete analysis to compare between groups
Mean change in IOP (in mmHg)	MD ‐0.65 mmHg (95% CI ‐3.12 to 1.82) at 6 months; MD ‐0.03 mmHg (95% CI ‐2.34 to 2.32) at 12 months; MD 0.74 mmHg (95% CI ‐1.66 to 3.13) at 24 months; MD 1.04 mmHg (95% CI ‐1.22 to 3.31) at 36 months	MD 0.50 mmHg (95% CI ‐2.64 to 3.64; 91 eyes) at 12 months	MD ‐0.04 mmHg (95% CI ‐0.93 to 0.85; 1 study, 64 eyes) at 6 months; MD ‐0.12 mmHg (95% CI ‐4.72 to 4.48; 1 study, 32 eyes) at 12 months	MD 0.50 mmHg (95% CI ‐1.95 to 2.95) at 1 month; MD 0.00 mmHg (95% CI ‐2.36 to 2.36) at 3 months; MD ‐0.30 mmHg (95% CI ‐1.89 to 1.29) at 6 months; MD ‐0.60 mmHg (95% CI ‐1.99 to 0.79) at 12 months	Unable to complete analysis to compare between groups
Mean change in anterior chamber depth	NR	NR	NR	NR	NR
Number of medications used to control IOP	MD ‐0.65 (95% CI ‐0.85 to ‐0.45) at 6 months; MD ‐0.70 (95% CI ‐0.89 to ‐0.51) at 12 months; MD ‐0.73 (95% CI ‐0.94 to ‐0.52) at 24 months; MD ‐0.65 (95% CI ‐0.87 to ‐0.43) at 36 months	MD ‐0.30 (95% CI ‐0.56 to ‐0.04; 91 eyes) at 6 months; MD ‐0.30 (95% CI ‐0.55 to ‐0.05; 91 eyes) at 12 months	MD ‐0.35 (95% CI ‐0.63 to ‐0.07; 1 study, 64 eyes) at 6 months; MD ‐0.38 (95% CI ‐1.23 to 0.47; 1 study, 32 eyes) at 12 months	MD 0.30 (95% CI 0.01 to 0.59) at 1 month; MD 0.40 (95% CI 0.06 to 0.74) at 3 months; MD 0.20 (95% CI ‐0.15 to 0.55) at 6 months; MD 0.00 (95% CI ‐0.42 to 0.42) at 12 months	Unable to complete analysis to compare between groups
Gonioscopic findings (measured in degrees)	Appositional angle closure MD ‐84.93° (95% CI ‐131.25 to ‐38.61) at 12 months; MD ‐74.16° (95% CI ‐121.34 to ‐26.98) at 36 months Synechial angle closure MD ‐69.63° (95% CI, ‐104.34 to ‐16.92) at 12 months; MD 1.12 (95% CI, ‐42.37 to 44.62) at 36 months	Angle width MD ‐0.60 (95% CI ‐0.91 to ‐0.29; 91 eyes) at 12 months or later; TISA500 MD ‐0.03 (95% CI ‐0.06 to ‐0.01; 91 eyes) at 12 months; TISA750 MD ‐0.03 (95% CI ‐0.06 to ‐0.01; 91 eyes) at 12 months	AOD500 MD ‐0.04 (95% CI ‐0.27 to 0.19; 1 study, 64 eyes); at 6 months; AOD750 MD 0.01 (95% CI ‐0.27 to 0.29; 1 study, 64 eyes) at 6 months; TISA500 MD ‐0.02 (95% CI ‐0.06 to 0.02; 1 study, 64 eyes) at 6 months; TISA750 MD ‐0.03 (95% CI ‐0.17 to 0.11; 1 study, 64 eyes) at 6 months; SSA MD ‐1.59 (95% CI ‐6.75 to 3.57; 1 study, 64 eyes) at 6 months	Unable to complete analysis to compare between groups	Unable to complete analysis to compare between groups
Best corrected visual acuity	MD 2.03 (95% CI ‐0.77 to 4.84) at 12 months; MD 4.30 (95% CI 0.74 to 7.87) at 36 months	MD ‐0.01 (95% CI ‐0.10 to 0.08; 91 eyes) postoperatively	NR	MD ‐0.03 (95% CI ‐0.18 to 0.12; 1 study, 63 eyes)	Unable to complete analysis to compare between groups
Adverse effects	Phacoemulsification group: malignant glaucoma (1 eye); irreversible loss of vision of more than 10 ETDRS letters (1 eye); other related adverse events (1 eye). LPI group: lost ten or more ETDRS letters irreversibly (3 eyes); other related adverse events (10 eyes).		Phaco‐GSL group hyphema (3 eyes)	Less risk of: Intra‐ and post‐operative complications (RR 0.59, 95% CI 0.34 to 1.04); additional IOP‐lowering procedures (RR 5.81, 95% CI 1.41 to 23.88) in the phacoemulsification group	none
Quality of life measures (European Quality of Life‐5 Dimension)	MD 0.03 (95% CI ‐0.16 to 0.22) at 6 months; MD 0.04 (95% CI ‐0.16 to 0.24) at 12 months; MD 0.005 (95% CI ‐0.19 to 0.20) at 24 months; MD ‐0.04 (95% CI ‐0.24 to 0.16) at 36 months	NR	NR	NR	NR
AOD: angle opening distance; CI: confidence interval; IOP: Intraocular pressure; NR: not reported; MD: mean difference; OR: odds ratio; RR: risk ratio; SSA: scleral spur angle; TISA: trabecular iris space area

Table 1. Summary table

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Comparison 1. Phacoemulsification versus phaco‐viscogonioplasty (phaco‐VGP)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1.1 Mean IOP change from baseline Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

1.1.1 at 12 months	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.2 Mean number of medications to control IOP Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

1.2.1 at 6 months	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.2.2 at 12 months	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.3 Gonioscopic findings Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

1.3.1 Change of angle grading at 12 months or later	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.3.2 TISA500	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.3.3 TISA750	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.4 Mean visual acuity Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

1.4.1 at baseline	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.4.2 postoperatively	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

Comparison 1. Phacoemulsification versus phaco‐viscogonioplasty (phaco‐VGP)

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Comparison 2. Phacoemulsification versus phacoemulsification with goniosynechialysis (phaco‐GSL)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
2.1 Mean IOP change from baseline Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

2.1.1 at 6 months	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
2.1.2 at 12 months	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
2.2 Mean number of medications to control IOP Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

2.2.1 at 6 months	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
2.2.2 at 12 months	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
2.3 Gonioscopic findings Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

2.3.1 AOD500	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
2.3.2 AOD750	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
2.3.3 TISA500	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
2.3.4 TISA750	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
2.3.5 SSA	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

Comparison 2. Phacoemulsification versus phacoemulsification with goniosynechialysis (phaco‐GSL)

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Comparison 3. Phacoemulsification versus combined phaco‐trabeculectomy

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
3.1 Mean IOP Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

3.1.1 at baseline	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
3.1.2 at 1 month	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
3.1.3 at 3 months	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
3.1.4 at 6 months	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
3.1.5 at 12 months	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
3.2 Mean number of medications to control IOP Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

3.2.1 at baseline	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
3.2.2 at 1 month	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
3.2.3 at 3 months	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
3.2.4 at 6 months	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
3.2.5 at 12 months	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
3.3 Mean visual acuity Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

3.3.1 preoperatively	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
3.3.2 at the final follow‐up	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
3.4 Adverse effects Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

3.4.1 Intra‐ and post‐operative complications	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
3.4.2 Additional IOP‐lowering procedures	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 3. Phacoemulsification versus combined phaco‐trabeculectomy

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Extracción del cristalino para el glaucoma crónico de ángulo cerrado

Appendices

Appendix 1. CENTRAL search strategy

Appendix 2. MEDLINE Ovid search strategy

Appendix 3. Embase Ovid search strategy

Appendix 4. LILACS search strategy

Appendix 5. ClinicalTrials.gov search strategy

Appendix 6. WHO ICTRP search strategy

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Appendices

Appendix 1. CENTRAL search strategy

Appendix 2. MEDLINE Ovid search strategy

Appendix 3. Embase Ovid search strategy

Appendix 4. LILACS search strategy

Appendix 5. ClinicalTrials.gov search strategy

Appendix 6. WHO ICTRP search strategy

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