Title: Safety and Efficacy of Ripasudil after Trabeculectomy: A Systematic Review and Single-Arm Meta-analysis.

Background: The use of conventional glaucoma medication after the trabeculectomy can have negative impact on postoperative outcome due to disuse atrophy of the trabecular meshwork. The use of ripasudil may not have that negative impact because of direct action on trabecular meshwork.

Objective: This systematic review and meta-analysis aims to evaluate the efficacy and safety of using ripasudil as a maintenance therapy after trabeculectomy.   

Methods: PubMed, Embase, Scopus, and Cochrane Library were systematically searched from inception to October 28, 2025. Pooled proportions and incidence rates with 95% confidence intervals (CIs), as well as mean differences for continuous outcomes, were calculated using a random-effects model. Heterogeneity was assessed using the I² statistic. All analyses were conducted using the “metaprop” and “metamean” functions in R Studio (version 4.4.3).

Results: This meta-analysis included 150 patients with an average age of 67.9 years receiving ripasudil following trabeculectomy. Ripasudil was associated with a significant reduction in intraocular pressure (IOP), with pooled mean differences of −7.09 mmHg at 3 months (95% CI −11.69 to −2.49; I² = 92.6%), −9.0 mmHg at 12 months (95% CI −11.72 to −6.28; I² = 88.0%), and −9.11 mmHg at 24 months (95% CI −13.16 to −5.06; I² = 81.9%). The incidence of hyphema was 27% (95% CI 17%–36%; I² = 18.1%), and transient IOP elevation occurred in 27% (95% CI 18%–36%; I² = 0%).

Conclusion: Ripasudil provides meaningful and sustained IOP reduction after trabeculectomy with an acceptable safety profile, supporting its potential use as a postoperative maintenance therapy. However, small sample sizes and heterogeneity in some outcomes underscore the need for larger, high-quality studies to confirm these findings.