46 EyeWorld Asia-Pacific | December 2024 GLAUCOMA Needling and hypotony were once more common obstacles with the XEN Gel Stent (AbbVie), however, after several years and lessons learned, many surgeons have adopted new approaches that have increased success rates and reduced the need for subsequent procedures. EyeWorld spoke with Ang Li, MD, and Jithin Yohannan, MD, to get their insights on the pearls they have gained using the stent, which originally received FDA approval in 2016. Dr. Li said she began using the XEN early in practice, shortly after its approval. Over the years, she’s found the ideal candidate to be the elderly, Caucasian patient who may be intolerant of drops with moderate to severe glaucoma, or patients in whom she is looking to avoid tube shunts or trabeculectomy. “It’s less invasive and postoperatively more tolerated by most patients compared to tubes or trabs. I do like to use it for surgically naïve patients because it has specific requirements for conjunctiva and Tenon’s tissue, so operated-on eyes generally don’t do as well, and they scar down more easily,” she said, noting that she is usually aiming to get pressures in the mid-teens with the XEN. Dr. Yohannan has similar criteria for XEN patient selection. He uses this stent on patients with uncontrolled glaucoma with more advanced damage whose IOPs are above target. He reserves the XEN for patients at higher risk for hypotony with a trab and those who are at less risk for bleb fibrosis. This includes older patients, high myopes, and patients who are not of African decent. by Liz Hillman, Editorial Co-Director Knocking Down XEN Obstacles Obstacle #1: Ab interno approach The XEN is approved for insertion in the subconjunctival space via an ab interno approach. However, Dr. Li and Dr. Yohannan—and many other glaucoma specialists—have adopted an ab externo approach for certain patients. “If you look at a random survey of glaucoma colleagues, it’s about 50/50 or even more ab externo for how physicians are using it,” Dr. Li said. Diffuse XEN bleb 2 years after ab interno implant approach with primary trimming and needling; IOP 9 mm Hg without drops. Source: Ang Li, MD
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