Needling After Subconjunctival Stent Implantation With Mitomycin C
Success depends on appropriate patient selection, early recognition of subconjunctival fibrosis, meticulous technique, and aggressive modulation of wound healing.
David S. Jin, and Irfan N. Kherani, MD, FRCSC
Glaucoma Today 
Key Takeaways Bleb needling is an integral component of subconjunctival glaucoma surgery, not just a rescue procedure. Success depends on appropriate patient selection, early recognition of subconjunctival fibrosis, meticulous technique, and aggressive modulation of wound healing. Performed thoughtfully, needling can restore filtration, prolong bleb function, and reduce the need for additional surgery. Needling is an essential component of management after subconjunctival glaucoma surgery. Postoperative fibrosis is an expected aspect of wound healing, and timely needling can improve IOP, restore aqueous outflow, prolong bleb function, and reduce the need for additional surgery. Needling tends to be most successful during the active phase of wound remodeling, before dense collagen maturation. Both the Xen Gel Stent (AbbVie) and the Preserflo MicroShunt (Santen/Glaukos) depend on a functioning subconjunctival bleb; when subconjunctival or sub-Tenon fibrosis limits posterior flow, needling with an antimetabolite can restore filtration and may delay or avoid the necessity of bleb revision or further glaucoma surgery. INDICATIONS The decision to perform needling is not based on the bleb’s appearance alone. Needling merits consideration when the IOP is above target, the patient’s medication burden is increasing, and the bleb shows reduced filtration, such as increased vascularity, thickening, localization, encapsulation, flattening, or a loss of microcysts. Before needling, the surgeon should confirm via gonioscopy that the implant is patent and correctly positioned, without occlusion by iris tissue, pigment, or vitreous.1-5 TIMING There is no universally accepted single time point for optimal needling.
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