Nonpenetrating Deep Sclerectomy versus Conventional Surgery in Primary Congenital Glaucoma: a Systematic Review and...

Primary congenital glaucoma (PCG) is a leading cause of irreversible childhood blindness, with elevated prevalence in consanguineous populations of the Middle East and Central Asia. Nonpenetrating deep sclerectomy (NPDS) is theoretically safer than conventional penetrating surgery, yet comparative evidence lacks systematic synthesis.

We systematically searched seven databases through December 2025. Eligible studies compared NPDS with conventional surgery in children with PCG aged under 4 years with ≥ 6 months follow-up. Two reviewers independently screened and extracted data; risk of bias was assessed with ROBINS-I and RoB 2.0. A random-effects meta-analysis [REML with Hartung-Knapp-Sidik-Jonkman (HKSJ) correction] was performed.

Five studies [seven arms, 356 eyes; one randomized controlled trial (RCT), four observational] were included. Mean intraocular pressure (IOP) reduction was 10.34 mmHg (HKSJ 95% CI 7.54-13.14; 95% PI: 2.25-18.43 mmHg; I² = 97.2%, indicating substantial between-study variability driven primarily by differences in baseline IOP [β = +0.61 mmHg; P = 0.004], adjuvant use, and surgical technique; P < 0.001). Surgical success was achieved in 77.1% of eyes (95% CI 65.3-85.8%). Visual acuity improved by 0.329 LogMAR (approximately three Snellen lines; 95% CI 0.220-0.438; P = 0.001). The composite complication rate was 13.2% (95% CI 8.7-19.4%), with I² = 0% for hypotony, shallow anterior chamber, and hyphema. NPDS resulted in significantly fewer reinterventions (7.4% versus 14.1%; P = 0.046) and better corneal clarity preservation (92.4% versus 83.4%; P = 0.013) than non-NPDS procedures.

Evidence comparing NPDS and conventional surgery in PCG remains limited. Surgery achieved a mean IOP reduction of 10.34 mmHg (HKSJ 95% CI 7.54-13.14), though estimates showed substantial heterogeneity (I² = 97.2%). While NPDS may be associated with lower reintervention rates and improved corneal clarity, no definitive differences in primary efficacy were observed. These findings require confirmation in well-designed prospective studies.

PROSPERO registration: CRD420251121650.