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    Xen Resuscitation 101

    AAO2021 Video Program

    The Xen45 Gel Stent is now a useful tool in today's armamentarium of minimally invasive glaucoma surgery. However, subconjunctival scarring and encapsulation may cause failure of this bleb-forming procedure. This video demonstrates the surgical technique of bleb needling and revision, which is critical to ensuring good long-term outcomes. Bleb needling should be considered when the target IOP is not reached and the Xen45 is immobile, the bleb is flat or when there is encapsulation. Needling may be performed at the slit lamp or in the operating theater. However, care must be taken not to transect the Xen45. One should visualize a straight and mobile Xen45 at the end of the needling. If the IOP remains suboptimal despite multiple needling attempts, open conjunctival revision should be considered. A fibrotic sock is often found encasing the Xen45, and this requires careful dissection and removal. The internal lumen of the Xen45 should be examined intraoperatively. Patency of the Xen45 may be ensured by various means before closing the conjunctiva. Both bleb needling and open conjunctival revision should be augmented by antimetabolite therapy.