Xen Leakage Revision

For Glaucoma Physician's Surgical Pearls video series, Ang Li, MD, demonstrates a technique of revision to address leakage around an Xen gel stent (AbbVie). Transcript of the narration follows below:

This is Ang Li from the Cleveland Clinic. I’m showing a case of a Xen leakage revision. Fluorescein shows a brisk leak without signs of infection. The ischemic bleb is carefully dissected along the ring of steel that is surrounding the focally elevated and cystic bleb. A Weck-Cel [sponge] was used to test aqueous flow, which is functioning well.

A posterior relaxing incision is made in the superior fornix to allow forward mobility of the tissue and to minimize ptosis. The Tenon’s capsule is separated from the conjunctiva, and a limited tenonectomy is performed to ensure the survival of the new bleb, as I did not apply mitomycin-C given the leakage history. The conjunctiva is closed with 2 running wing sutures and a horizontal mattress [suture]. There is no leak at the end of the case.

In summary, when there is a late leak for an ab externo Xen, revision is required to prevent endophthalmitis. A posterior fornix-based relaxing incision can be helpful to mobilize the conjunctiva forward and to limit ptosis. GP

Ang Li, MD, is a glaucoma specialist at the Cole Eye Institute of Cleveland Clinic, in Cleveland, Ohio. She reports consulting and speaking fees from AbbVie. Reach Dr. Li at angli0505@gmail.com.

Mary Qiu, MD, the editor of this series, is a glaucoma and cataract surgeon who completed her glaucoma fellowship at the Cole Eye Institute at Cleveland Clinic and her ophthalmology residency training at the Wilmer Eye Institute at Johns Hopkins. Her special interests include neovascular glaucoma; tube revisions and exchanges; optimizing technique and outcomes for nonvalved tubes, goniotomy, and canaloplasty; surgical education for trainees; and creating and sharing her surgical videos.