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What’s new in What’s new in Subconjunctival Filtration Subconjunctival Filtration Surgery Surgery Financial Disclosure • I have no financial disclosures

Subconjunctival Microstent (Xen) • Originally designed for subconjunctival bleb creation via ab-interno approach • 6 mm porcine gel material • 45 um in diameter • Becomes flexible and swells when implanted • “Hybrid” – Between a trab and tube – Between MIGS and non-traditional surgery Ab Ab externo externo vs. vs. Ab Ab interno interno • Inconsistent S- consistent S-T T pla placement ement • More c re consistent nsistent supra-Tenons placement ement • Bett Better exp r exposure • High c gh cheekbones, eekbones, sunken or nken orbit bit • Flexible le p placement ement • Favors nasa Favors nasal placem l placement ent • No viscoel No viscoelastic • Need viscoe Need viscoelastic stic • No c No cornea rneal inc l incision sion • Two c o cornea rneal l inc incisions sions • Sc Sclera ral exit point c l exit point certa rtain • Sc Sclera ral exit point unce l exit point uncertain rtain • Inte Internal exit rnal exit point uncert point uncertain • Inte Internal exit rnal exit point cert point certain • No curlin No curling • Curling, entra Curling, entrapment in ment in Tenons Tenons • Le Less intr intra-op nee needling ng • More More intra intra-op needl needling ng • Conjunctiva Conjunctival pe perfora rforation – ion – possible ossible le leak ak • Conjunctiva Conjunctival pe perfora rforation unlikely ion unlikely • Sel Self-priming -priming • Priming requi Priming required Less Less post-op needling rate? post-op needling rate?

XEN Post-op Manag XEN Post-op Management ment • Yes, this requires management to work! Yes, this requires management to work! • This is This is kinder, gentler bleb surgery kinder, gentler bleb surgery • It’s still It’s still a a bleb, but a better bleb, but a better bleb bleb

High IOP Early High IOP Early • Internal blockage – Internal blockage – DO DO Gonioscopy Gonioscopy – Not connected Not connected – Iri Iris, blood , blood, Descemets Descemets High IOP After 2 weeks High IOP After 2 weeks • Exte External blockage rnal blockage – Teno Tenons, enca ns, encapsula ulation, f ion, fibrosis brosis – Restart drops Restart drops – Needling Needling

XEN Needling It’s still a bleb, and blebs can fail It’s still a bleb, and blebs can fail • When to give up? (# of needlings) When to give up? (# of needlings) – Needling Needling in OR in OR – Open revisio Open revision in OR in OR nd XEN – Replac Replace or e or add 2 add 2 nd XEN – Next surger Next surgery: y: Trab Trab? Tube? CPC? ? Tube? CPC?

XEN Principles XEN Principles • Safer, more predictable, q Safer, more predictable, quicker recovery th ker recovery than trab an trab • It’s still a It’s still a bleb bleb • Good results possible with: Good results possible with: – Patient selection Patient selection – ab extern ab externo approac pproach – Prope Proper post post-o -op managem p management InnFocus Microshunt – now Preserflo  Make the device thin and soft to conform to the curvature of the eye.  Make the lumen sufficiently large to allow cells to pass yet small and long enough to prevent hypotony.  Add a fin to prevent migration and leakage around the outside of the tube. 350 micron 70 micron 8.5 mm lumen 4.5 mm NOT FDA APPROVED

External: trab, trab-ExPress, tube MicroShunt NOT FDA APPROVED 2.7

MicroShunt NOT FDA APPROVED Trab vs. Preserflo • Prospective, randomized, controlled, single-masked multicenter study • Stand alone procedure • 0.2 mg/ml MMC PreserFlo • 12 month follow-up NOT FDA APPROVED PRE-OP TRAB PRESERFL O IOP 21.1 mm Hg 11.2 mm Hg 14.2 mm Hg MEDS 3.0 0.3 0.6 NO MEDS 0 84.8% 71.6%

Ne w ve rsio n o f the Ahme d: No n Valve d Glauc o ma Shunts