New Possibilities for Minimally Invasive Bleb Surgery in Glaucoma Care

Overview

Minimally invasive bleb surgery (MIBS) is emerging as a promising approach to bridge the gap between the efficacy of traditional filtering surgeries and the safety of angle-based MIGS. Several investigational devices and techniques are under development that may expand treatment options beyond the operating room and into clinical settings.

Background

Glaucoma treatment often involves a tradeoff between efficacy and safety. Traditional filtering surgeries like trabeculectomy and tube shunts provide durable intraocular pressure (IOP) reduction but carry higher risks and require prolonged postoperative care. Angle-based minimally invasive glaucoma surgeries (MIGS) offer improved safety and faster recovery but generally do not achieve robust IOP lowering, limiting their use in advanced disease. Minimally invasive bleb surgery (MIBS) aims to combine the efficacy of traditional filtering surgery with enhanced safety and quicker recovery.

Data Highlights

Several MIBS devices are in various stages of development and clinical evaluation: the Xen 45 gel stent is currently used in the US with sustained IOP reduction but outcomes below trabeculectomy; the Xen 63 variant may offer incremental benefits but is not yet available in the US; the PreserFlo MicroShunt is undergoing pivotal US trials; the Calibreye titratable shunt has shown encouraging 12-month data internationally; the VisiPlate aqueous shunt is enrolling patients in the US SAPPHIRE trial; and nonimplant approaches like Aqualumin and Hexiris’ Obi Ex are also in development.

Key Findings

• MIBS aims to achieve IOP reduction approaching traditional filtering surgeries with better safety and faster recovery.
• The Xen 45 gel stent is the most familiar MIBS device in the US but has not matched trabeculectomy outcomes.
• The PreserFlo MicroShunt, used internationally, is in US pivotal trials and may become available soon.
• New devices such as the Calibreye titratable shunt and VisiPlate aqueous shunt show promising early data.
• Nonimplant MIBS approaches like Aqualumin and Hexiris’ Obi Ex are being developed for office-based procedures.
• MIBS could expand glaucoma treatment options beyond the operating room, potentially improving care for patients at high risk of vision loss.

Clinical Implications

MIBS technologies may offer clinicians new tools to provide stronger IOP lowering with fewer risks and faster recovery compared to traditional filtering surgeries. The development of office-based and less invasive procedures could streamline glaucoma management and improve patient outcomes, especially for those with advanced disease who require effective pressure control. Awareness of emerging devices and ongoing clinical trials is important for future treatment planning.

Conclusion

Minimally invasive bleb surgery represents a promising evolution in glaucoma care, potentially bridging the gap between efficacy and safety. Continued development and clinical validation of MIBS devices may soon expand therapeutic options and improve patient outcomes.

References

1. Pitha IF, AGS 2026 -- New Possibilities for Minimally Invasive Bleb Surgery