Efficacy and safety of goniotomy and gonioscopy-assisted transluminal trabeculotomy for exfoliation glaucoma: a systematic review and single-arm meta-analysis

Objective To assess the efficacy and safety of goniotomy (GT) and gonioscopy-assisted transluminal trabeculotomy (GATT) with or without phacoemulsification (PEI) for exfoliation glaucoma (XFG). Methods Searches were conducted in PubMed, Scopus, Embase, Ovid, and the Web of Science. Two independent reviewers performed study selection, data extraction, and quality assessment. The primary outcomes were the reduction in intraocular pressure (IOP) and the number of antiglaucoma medications (AGMs) at 1, 6, and 12 months postoperatively. Safety was assessed by the incidence of complications. Results Fourteen studies involving 624 eyes were included. The GATT ± PEI group showed significant IOP reductions of 1.96 mmHg ( p < 0.01), 2.17 mmHg ( p < 0.001), and 2.07 mmHg ( p < 0.001) at 1, 6, and 12 months, respectively, with corresponding AGM reductions of 3.28 ( p < 0.001), 2.87 ( p = 0.003), and 2.54 ( p = 0.011). The GT + PEI group demonstrated IOP reductions of 1.95 ( p < 0.001), 2.00 ( p = 0.040), and 2.13 mmHg ( p = 0.013), with AGM reductions of 1.07, 0.96, and 0.96 (all p < 0.001). For standalone procedures, GT significantly reduced AGMs at all timepoints (all p < 0.001) and IOP at 1 and 6 months (both p = 0.002), while standalone GATT significantly reduced IOP only at 1 month (2.39 mmHg, p < 0.001) and AGMs at 6 and 12 months (both p < 0.001). The most common complications were anterior chamber hemorrhage (47.6%) and IOP spike (17.0%). Conclusion This meta-analysis demonstrates that GT and GATT, particularly when combined with phacoemulsification, are safe and effective in reducing IOP and medication burden in patients with XFG. The evidence for sustained IOP lowering with standalone GATT remains limited, suggesting that combined surgery may offer more reliable long-term pressure control, especially for patients with concurrent cataract. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD420251072295 , identifier CRD420251072295.