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What’s new in What’s new in Subconjunctival Filtration Subconjunctival Filtration Surgery Surgery

• I have no financial disclosures

Financial Disclosure

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

• More c

re consistent nsistent supra-Tenons placement ement

• Bett

Better exp r exposure

• Flexible

le p placement ement

• No viscoel

No viscoelastic

• No c

No cornea rneal inc l incision sion

• Sc

Sclera ral exit point c l exit point certa rtain

• Inte

Internal exit rnal exit point uncert point uncertain

• No curlin

No curling

• Le

Less intr intra-op nee needling ng

• Conjunctiva

Conjunctival pe perfora rforation – ion – possible

• ssible le

leak ak

• Sel

Self-priming

• priming

Ab Ab externo externo vs.

• vs. Ab

Ab interno interno

• Inconsistent S-

consistent S-T T pla placement ement

• High c

gh cheekbones, eekbones, sunken or nken orbit bit

• Favors nasa

Favors nasal placem l placement ent

• Need viscoe

Need viscoelastic stic

• Two c
• cornea

rneal l inc incisions sions

• Sc

Sclera ral exit point unce l exit point uncertain rtain

• Inte

Internal exit rnal exit point cert point certain

• Curling, entra

Curling, entrapment in ment in Tenons Tenons

• More

More intra intra-op needl needling ng

• Conjunctiva

Conjunctival pe perfora rforation unlikely ion unlikely

• 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

• 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 – Replac Replace or e or add 2 add 2nd

nd XEN

XEN – Next surger Next surgery: y: Trab Trab? Tube? CPC? ? Tube? CPC?

It’s still a bleb, and blebs can fail It’s still a bleb, and blebs can fail

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
• utside of the tube.

4.5 mm 8.5 mm 350 micron 70 micron lumen

NOT FDA APPROVED

External: trab, trab-ExPress, tube

MicroShunt

2.7

NOT FDA APPROVED

MicroShunt

NOT FDA APPROVED

PreserFlo

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 84.8% 71.6%

Trab vs. Preserflo

• Prospective, randomized, controlled, single-masked

multicenter study

• Stand alone procedure
• 0.2 mg/ml MMC
• 12 month follow-up

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