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Editors Selection IGR 19-4

Surgical Treatment: XEN Gel: with or without Phaco?

Comment by Sameh Mosaed on:

75591 Prospective Evaluation of Standalone XEN Gel Implant and Combined Phacoemulsification-XEN Gel Implant Surgery: 1-Year Results, Mansouri K; Guidotti J; Rao HL et al., Journal of Glaucoma, 2018; 27: 140-147

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The study by Kaweh Mansouri and colleagues compared XEN alone (40 eyes) vs. XEN + cataract surgery (109 eyes) in a predominantly white population with mostly mild to moderate openangle glaucoma. All patients received XEN with 45-micron internal diameter, and mitomycin was applied intraoperatively in all cases. The primary outcome was IOP reduction greater or equal to 20% at one year post-op. Overall, 62.1% of the patients achieved this goal, with the mean IOP decreased from 20.0 ± 7.1 mmHg to 13.9 ± 4.3 mmHg. At one year, the median IOP reduction was 40% in the XEN alone group and 22.9% in the XEN+ CE group, although this difference was not statistically significant. There was no difference between the XEN-alone and XEN+CE in terms of success rate, regardless of whether that success was defined as complete or qualified. These success rates ranged in the upper 50s for complete success, and low 70s for qualified success. The adverse event rates in this study were in the < 5% range which was somewhat lower than most of the other available studies.

This study confirmed what had been shown in other smaller studies, that:

1. XEN stent can lower IOP to a slightly greater extent than what had been seen in some of the MIGS devices at one-year postop; and
2. concomitant cataract surgery does not seem to confer significant additional IOP reduction than what the XEN stent alone could accomplish.

XEN [...] seems to work a bit better than most MIGS, but that comes at the price of a bleb-reliant procedure with more involved postoperative care

This study had a few limitations. Firstly, it did not specify how patients were divided into the XEN alone vs. XEN + cataract surgery. This decision did not seem to stem from visual acuity, since the preoperative best corrected visual acuity was similar between the groups. Secondly, needling was not considered an adverse event, even though this necessitated another trip the OR. Thirdly, the preoperative IOP was not washed out, which made the results difficult to compare with other studies that used washed-out IOP for baseline. Nevertheless, this study demonstrated that XEN occupies a unique space in the glaucoma surgical armamentarium. It seems to work a bit better than most MIGS, but that comes at the price of a bleb-reliant procedure with more involved postoperative care.

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