Large Study Identifies Predictors of Surgical Success in Goniotomy

Researchers argue that goniotomy may benefit patient groups not typically considered first-line candidates for the procedure, such as those with pseudoexfoliation, low-tension or severe glaucoma subtypes, all of which conferred higher rates of surgical success. These charts from the study show mean IOP up to 36 months post-surgery in (A) goniotomy combined with cataract surgery and (B) goniotomy as a standalone procedure.  Photo: Joo JH, et al. Ophthalmol Glaucoma. February 2, 2026. Click image to enlarge. Despite goniotomy being one of the fastest-growing minimally invasive glaucoma surgeries, data remains limited regarding which clinical and demographic factors are associated with better outcomes. To help clarify, a recent study in Ophthalmology Glaucoma reviewed data from the IRIS Registry and identified several factors associated with lower intraocular pressure (IOP) at three years post-op, including higher baseline IOP, more severe glaucoma and a diagnosis of pseudoexfoliation or low-tension glaucoma.The retrospective clinical cohort study analyzed 48,098 eyes that underwent goniotomy in the United States between 2013 and 2022. The median age at surgery was 73 years and 55% were female. If both eyes had surgery, the first operated eye was analyzed. Patients with prior trabeculectomy or tube shunt procedures were excluded. Short-term success and long-term failure were defined as follows:Short-term success: Between one and six months post-op, the eye met the following criteria for at least two consecutive visits after the first post‑op month: IOP ≤21mm Hg, ≥20% reduction from baseline IOP, no hypotony (IOP <6mm Hg) and no additional glaucoma surgery. Note that medication data was excluded from this study.Long-term failure: This was indicated at the first visit the above success criteria were no longer met.At six months, 52% of eyes achieved short-term success. Among patients who underwent phaco-goniotomy (n=31,861), mean IOP fell from 16.8mm Hg to 15.06mm Hg (-10.4%) at 36 months postoperatively; in stand-alone goniotomy (n=3,776), IOP decreased from 21.28mm Hg to 15.26mm Hg (-28.3%) over the same time period.The analysis revealed several factors that were independently associated with higher odds of short-term success and lower risk of long-term failure, including higher baseline IOP, older age, male sex, severe glaucoma, concurrent cataract surgery, pseudoexfoliation glaucoma and low-tension glaucoma. Pilocarpine use within two weeks of surgery also conferred greater short-term success but subsequently increased the risk of delayed failure.When discussing these findings in their paper, the researchers pointed out that most of these factors have previously been linked to better IOP-lowering outcomes in goniotomy—but not all. Something they found particularly surprising was the greater likelihood of surgical success observed in patients with severe glaucoma. They explained that “some prior analyses from registry-based studies [have shown] better outcomes in eyes with more advanced disease,” while “other studies have shown that goniotomy procedures may have limited efficacy or unpredictable success in severe stages of POAG.” Another unexpected finding was the link between low-tension glaucoma and greater goniotomy success, “particularly considering that higher baseline IOP was also associated with success in the multivariable analysis.” According to the authors, “this implies that within low-tension glaucoma cases, those with higher baseline IOP were more likely to succeed, whereas in cases with the same baseline IOP, those with low-tension glaucoma were more likely to succeed than those with primary open-angle glaucoma.”The researchers highlighted several limitations of their study, including its retrospective nature and the exclusion of data on medication burden, angle anatomy and diagnostic information such as visual field and OCT retinal nerve fiber layer scans. Integrating this data in future studies may help clarify patient selection for goniotomy and other MIGS procedures, they noted.It’s also important to note that this study’s definition of surgical success may differ from prior analyses. As the authors explained, “It is plausible that some eyes with apparent IOP reduction maintained surgical success through adjunctive pharmacotherapy, particularly in low-tension, pseudoexfoliation and severe glaucoma subgroups.” Alternatively, they noted, “some eyes may have undergone goniotomy with the goal of reducing medication burden while maintaining adequate IOP control,” which may have been considered successful by those doctors and patients but not in the present study. Based on the results of this large, real-world analysis, the authors suggested that “goniotomy may benefit patient groups not traditionally prioritized for MIGS.” Identifying which eyes are likely to respond best to goniotomy “can help physicians in choosing the most appropriate surgical treatment for different patient profiles,” they concluded.Click here for the journal source. Joo JH, Xiao H, Rothman AL, et al. Factors associated with goniotomy outcomes in the United States: an IRIS® Registry analysis. Ophthalmol Glaucoma. February 2, 2026. [Epub ahead of print]. This article was developed by the editorial staff in conjunction with experts in the field. In the process, AI may have been among the editorial tools used to meet the goals of human editors, who approved all content.