Faizan Naveed, Yusuf Ahmed, Cody Lo, Wei Sim, Irfan Kherani, Matthew B Schlenker, Jamie Beckman, Arsham Sheybani
BANG-containing procedures are associated with modest IOP and medication reductions, with a substantial but typically transient hyphema risk. However, the predominantly phaco-BANG evidence base cannot isolate the independent or clinically meaningful contribution of BANG. Small samples, substantial heterogeneity, limited washout IOP reporting, and low-certainty evidence, support cautious interpretation.
OBJECTIVE: To evaluate the effectiveness and safety of bent ab interno needle goniotomy (BANG) for glaucoma through systematic review and meta-analysis. BANG is a device-free trabecular meshwork-excisional, minimally invasive glaucoma surgery that may offer a lower-cost, more accessible alternative to device-based angle surgery, but its efficacy and safety profile have not been comprehensively consolidated.
METHODS: MEDLINE, Embase, Cochrane CENTRAL, Scopus, and Web of Science were searched until December 14, 2025. Eligible studies included ≥10 eyes undergoing stand-alone or combined phaco-BANG. Two reviewers independently screened and extracted data; risk of bias was assessed using ROBINS-I v2/RoB-2 and certainty using GRADE. Random-effects inverse-variance meta-analyses pooled intra-ocular pressure (IOP) change at 6 and 12 months and anti-glaucoma medication (AGM) reduction at 6 months; hyphema incidence was pooled using proportional meta-analysis. Leave-one-out and subgroup analyses were performed.
RESULTS: Fourteen studies met inclusion criteria. Across 10 cohorts (248 eyes), IOP decreased by 4.74 mm Hg (95% CI: 2.13-7.35; I² = 96.2%) at 6 months following BANG-containing procedures (predominantly phaco-BANG). Likewise, across 6 cohorts (140 eyes), 12-month IOP reduction was 4.88 mm Hg (0.44-9.31; I² = 98.0%). Across 6 cohorts (161 eyes), AGM burden decreased by 1.30 medications (0.86-1.74; I² = 85.7%). Across 11 cohorts (261 eyes), pooled hyphema incidence was 0.33 (0.14-0.55; I² = 93.3%). Leave-one-out and design-restricted analyses reduced heterogeneity and attenuated effect sizes, suggesting more conservative estimates of efficacy. Certainty of evidence was low.
CONCLUSIONS: BANG-containing procedures are associated with modest IOP and medication reductions, with a substantial but typically transient hyphema risk. However, the predominantly phaco-BANG evidence base cannot isolate the independent or clinically meaningful contribution of BANG. Small samples, substantial heterogeneity, limited washout IOP reporting, and low-certainty evidence, support cautious interpretation.