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Failed trabeculectomy: is the Xen stent an option?

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First Author: A.Karimi UK

Co Author(s):    D. Lindfield                    

Abstract Details

Purpose:

Trabeculectomy remains the gold standard for the surgical management of glaucoma. For refractory glaucoma, multiple surgeries may be required and a large diameter tube with an equatorial plate is often utilised should trabeculectomy fail. The number of Minimally Invasive Glaucoma Surgical (MIGS) procedures is rising and Xen (Allergan Inc.) has shown a better safety profile than trabeculectomy, but what if it was used for a failed trabeculectomy? Xen is relatively contraindicated in eyes with previous conjunctival procedures, but trabeculectomy blebs are superior and Xen is placed superonasally, so the stent can be considered if the target quadrant is not scarred.

Setting:

Retrospective notes review of 17 Xen surgeries performed following failed trabeculectomies across five centres in England, UK.

Methods:

All cases of had careful clinical conjunctival assessment in the area of intended implantation. Unimpaired conjunctival mobility, lack of fibrosis and lack of active inflammation were required for implant surgery. All procedures were performed by consultant ophthalmic surgeons with a subspecialty interest in glaucoma. Implantation was augmented with 0.1 ml of 0.2mg/ml of Mitomycin C.

Results:

IOP reduced from 21.5 (±2.4) preoperatively to 13.6 (±3.4) at Month 12 (p<0.05). Medications reduced from 2.8 (±0.6) preop to 1.0 (±1.3) at Month 12 (p<0.05). 4 cases had an IOP <6mmHg without choroidal effusions or maculopathy, which typically resolved by week 1. A postoperative IOP spike of ≥30 mmHg occurred in 2 cases; one managed with glaucoma drops and one required bleb revision surgery. 9 of the 17 cases required either needling or an antimetabolite injection postoperatively. Implant failure requiring Baerveldt tubes due to uncontrolled IOPs occurred in 2 cases (11.8%) at 9 or 12 months.

Conclusions:

In cases of failed trabeculectomy, the Xen stent may be a viable option as it can offer a safer, less invasive and more predictable reduction in IOP compared to other shunt devices. However, careful preoperative assessment, targeted stent placement and frequent proactive bleb management is required for Xen to achieve circa 15mmHg outcomes.

Financial Disclosure:

... receives consulting fees, retainer, or contract payments from a company producing, developing or supplying the product or procedure presented, ... travel has been funded, fully or partially, by a company producing, developing or supplying the product or procedure presented