We conclude from our data that the XEN45 Gel Stent has an IOP-lowering potential and few side-effects. Pseudophakic eyes seem to have a better primary prognosis compared to combined surgery or surgery in phakic eyes.

The triple procedure is more effective in lowering intraocular pressure compared to phacoemulsification and trabecular aspiration alone in pseudoexfoliation glaucoma.

Introduction: We report a case of XEN45 Gel Stent removal 3 years after its implantation. The stent had degraded with a closed lumen, so a new stent was implanted. Case Report: A 63-year-old woman was scheduled for XEN45 Gel Stent implantation. Three years after the primary surgery and 2 years after a surgical revision, second revision surgery was required. The conjunctiva was opened, and the implanted XEN Gel Stent was stripped of the adhesive scar tissues. No aqueous humor flow was seen through the stent, and therefore, the stent was removed. The intrascleral and intracameral parts had degraded. The surface of the stent was irregular and cobbled. A part of the lumen in the middle of the stent had closed. Discussion: We detected changes in the stent after its removal during the surgical revision with conjunctival opening, which is our standard approach for failed XEN Gel Stents. Most surgeons advise needling of the stent in cases of failure. However, in cases of needling, changes in the stent might not have been detected. Thus, the number of patients with similar changes as this report might be higher than the publications suggest. No unique characteristics distinguished this patient from those who had a functional XEN Gel Stent. The stent, in this case, might have been of inferior quality as an exception, or all stents might degrade over time. Therefore, gonioscopy should be performed carefully to detect any changes in the stent. In cases of suspected stent degradation, we recommend a revision surgery with conjunctival opening and removal of the stent in cases of degradation.

This study shows that the combination of trabectome surgery and phacoemulsification leads to a clinically significant reduction of IOP over several years in patients with pseudoexfoliation glaucoma. The addition of trabecular aspiration as a triple procedure results in further lowering of IOP without causing more side effects. This finding might be biased by the higher medication score in the triple procedure group.

Purpose: This study investigates the long-term intraocular pressure (IOP) lowering potential, risk profile and success rate of a triple procedure comprising phacoemulsification, trabecular aspiration and trabectome (Microsurgical Technology, Redmond, WA, USA) for treating exfoliation glaucoma. Methods: A total of 117 eyes of 117 patients with exfoliation glaucoma underwent a combination of phacoemulsification, trabectome and trabecular aspiration. They were followed up for up to 7 years. The success rates were designated according to criteria based on the Tube versus Trabeculectomy Study and the World Glaucoma Association guidelines: A (no resurgery); B/C (IOP < 21/18 mmHg, no resurgery, IOP reduction > 20%); D (IOP ⩽ 15 mmHg, no resurgery, IOP reduction ⩾ 40%). Results: The mean follow-up period was 46 months. IOP showed a 38% reduction from 24.5 ± 6.1 to 15.2 ± 3.6 mmHg ( p < 0.0001). The Medication Score decreased by 23% from 2.2 ± 0.9 to 1.7 ±1.0 ( p < 0.0001). The success rates were 87, 76, 74 and 38% according to criteria A, B, C and D. In eyes with an initial IOP of >30 mmHg, a 57% reduction from 34.2 ± 4.4 to 14.8 ± 3.2 mmHg ( p < 0.0001) was observed, and the success rates were 91, 91, 82 and 59% for criteria A, B, C and D, respectively. Discussion: We conclude that the triple procedure may effectively lower IOP in patients with exfoliation glaucoma over a mean follow-up period of 46 months without significant side effects. Therefore, the triple procedure may serve as first-line surgery for patients with exfoliation and cataract, even with a high initial IOP.