Bleb Needling for Reviving a Failed Filter

Restoring function while preserving future surgical options.

Oluwatosin Smith, MD, and Matthew E. Emanuel, MD

Glaucoma Today

Key Takeaways Bleb needling is a safe, repeatable, and highly effective method for restoring function after the failure of traditional subconjunctival filtration surgery, including trabeculectomy and Ex-Press shunt placement. A careful assessment of bleb morphology, the thoughtful selection of surgical approach, the appropriate use of antifibrotic and antiinflammatory adjuncts, and meticulous postoperative management can produce durable reductions in IOP while delaying or avoiding the implantation of a glaucoma drainage device. Before proceeding to additional glaucoma surgery, bleb needling merits consideration whenever a previously functioning filtration procedure can be salvaged. Bleb needling, or revision, is an age-old technique for restoring function when subconjunctival filtration surgery fails. A colleague once jokingly remarked, “Why don’t we just perform primary trabeculectomies, let them fail, and then needle them, since the outcomes after needling seem better than the primary surgery?” Although said in jest, this comment highlights that bleb needling is an effective method of revitalizing a previously functional filtration procedure while preserving future surgical options. For that reason, bleb needling has become our preferred intervention before proceeding to the implantation of a glaucoma drainage device. This article focuses on bleb needling after traditional subconjunctival filtration procedures, including trabeculectomy and Ex-Press glaucoma filtration device (Alcon) surgery. FACTORS INFLUENCING SUCCESS Successful bleb needling depends on several important considerations: Bleb appearance and configuration; Choice of needling technique (ab interno vs ab externo); Use of antifibrotic agents and corticosteroids intra- and postoperatively; Use of a spacer such as an OVD; Selection of the appropriate setting (slit lamp vs OR); and Postoperative management and patient expectations. How much time has passed since the original filtration surgery may also influence outcomes. The biology of wound healing changes over time.

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Jacob Lang, OD, FAAO

Modern Optometry

The Bright Side of AI

Alan Ruby, MD

Retina Today

In April 2026, we ran an excellent article detailing how owners and administrators can use data monitoring to improve their practices. Tonya LaRue, MBA, explained why it’s important to track profit and loss statements, accounts receivable and collections, balance sheets, scheduling, and other metrics. While this is all very important data to monitor, the proposed monthly tracking with a spreadsheet and even (gasp!) some manual input may be a difficult ask for some practices. Isn’t there an app for that? For this issue, we asked data guru Bill James, MHA, COE, chief financial officer at Talley Eye Institute in Indiana, to discuss ways to automate some that data collection and analysis. During the 2025 ASRS Business of Retina meeting, he presented on his practice’s AI program, which uses automated “scrubbers” to review their patient management and electronic health record databases and identify potential workflow, coding, and billing issues. In his article, Using Data to Catch Problems Early, he shares how the system flagged a change in the allowable reimbursement for an anti-VEGF medication, ensuring the practice had time to minimize any financial ramifications. It’s a great example of how a carefully implemented AI system led to significant savings and efficiency without much ongoing work for staff. The key to its success isn’t necessarily the programming itself, but the collaboration with staff to identify stress points that needed automated monitoring. FURTHER READING Using Data Monitoring to Drive Practice Success By Tonya LaRue, MBA Once you have your data under control, we have several other important articles to help boost your practice management acumen.