Like many of my colleagues, the last month or so of my life has been highlighted by the arrival of Allergan’s Xen45 subconjunctival micro-stent, the latest of the big three microincisional glaucoma surgery (MIGS) implants.
The Glaukos iStent trabecular microbypass stent arrived in 2012, beginning the MIGS era. Glaucoma surgeons refreshed their intraoperative gonioscopy skills and learned the delicate technique of bypassing the trabecular meshwork from an ab interno approach at the time of cataract extraction. An important subsequent development was the availability of a few other angle surgeries that could be uncoupled from the cataract operation. These include goniotomy with the Kahook Dual Blade (New World Medical), as well as Visco360 and Trab360 (Sight Sciences).
To me, it is important to have glaucoma surgical procedures that are minimally invasive and uncoupled from cataract surgery, so that we may treat our pseudophakic patients or phakic patients not yet requiring cataract extraction. In the fall of 2016, Alcon’s CyPass Micro-Stent superaciliary micro-shunt became available in conjunction with cataract surgery. This elegant procedure offers an entirely new way to reduce the intraocular pressure through the supraciliary space and uveal scleral outflow pathway.
It is perhaps fitting that round 1 of the MIGS revolution should finish with the arrival of the Xen implant. The Xen45 Gel Stent combines the power of trabeculectomy with the light footprint of a MIGS procedure. Techniques for enhancing the surgery, such as antifibrosis chemotherapy and needle revision, are very familiar and comfortable to surgeons. Also uncoupled from cataract surgery, the procedure offers versatility and may be offered at many stages of the disease. I know from speaking to my colleagues that my initial, positive experience with this treatment is indeed very typical.
We are indeed fortunate to be practicing at a time with so many options to treat glaucoma.
Dr. Nathan M. Radcliffe is the director of the glaucoma service and a clinical assistant professor at New York Univeristy Langone Ophthalmology Associates and is a cataract and glaucoma surgeon at the New York Eye Surgery Center.