GLAUCOMA XEN implant device versus trabeculectomy, either alone or in combination with phacoemulsification, in open-angle glaucoma patients María Teresa Marcos Parra 1 & Javier Alejandro Salinas López 1 & Noelia Soledad López Grau 1 & Ana María Ceausescu 1 & Juan José Pérez Santonja 1 Received: 17 January 2019 /Revised: 23 April 2019 /Accepted: 26 April 2019 # Springer-Verlag GmbH Germany, part of Springer Nature 2019 Abstract Purpose To compare the efficacy and safety of the XEN45 implant with that of trabeculectomy (TRAB), either alone or in combination with phacoemulsification (PHACO), in patients with open-angle glaucoma (OAG). Methods Retrospective, single-center and comparative study conducted on OAG patients. Patients were divided into four groups: group 1 (XEN alone); group 2 (XEN+PHACO); group 3 (TRAB alone); group 4 (TRAB+PHACO). For statistical purposes, groups 1 and 2 were combined (XEN implant), while groups 3 and 4 were also combined (TRAB surgery). The main outcome measure was intraocular pressure (IOP). Results Ninety-one patients (121 eyes; 65 XEN and 56 TRAB) were included. IOP reduction was - 6.7 (- 10.4 to - 3.0) mmHg, p = 0.0013; - 3.5 (- 5.0 to - 2.0) mmHg, p < 0.0001; - 8.1 (- 10.4 to - 5.9) mmHg, p < 0.0001l; and - 7.3 (- 9.3 to - 5.3) mmHg, p < 0.0001 in the XEN alone, XEN+PHACO, TRAB alone, and TRAB+PHACO, respectively. At month 12, an IOP ≥ 6 and ≤ 16 mm without treatment was achieved by 44 (67.7%) and 43 (76.8%), p = 0.2687 in the XEN implant and the TRAB surgery groups, respectively. The mean number of antiglaucoma medications was significantly reduced in all the study groups (p < 0.0001 each). Needling occurred in 20.0% (13/65) of eyes in the XEN implant group, while hyphema occurred in 30.4% (17/56) of eyes in the TRAB group. Conclusions XEN implant, either alone or in combination with phacoemulsification, significantly reduces both IOP and the number of antiglaucoma medications to a similar rate than trabeculectomy, but with a better safety profile. Keywords Open-angle glaucoma . Glaucoma . XEN implant . Trabeculectomy . Intraocular pressure Introduction In glaucoma patients, the main treatment for preventing pro- gressive damage consists in lowering intraocular pressure (IOP) [1]. Although the first ocular hypotensive approach is usually the topical medication, many patients did not achieve a good glaucoma control due to different causes including poor ad- herence, side effects, or lack of maintained efficacy [2–5]. When topical antiglaucoma treatment does not adequately control the disease, surgery becomes an option [6, 7]. Trabeculectomy and tube shunt drainage devices are still considered as the gold standard [8, 9]. However, they may lead to potential vision-threatening complications [10]. Recently, less invasive glaucoma procedures, collectively termed minimally invasive glaucoma surgery (MIGS), have been developed to avoid or reduce the complications arising from conventional surgical procedures [11–15]. Due to its high safety profile, MIGS can be considered in milder diseases instead of more invasive procedures [16, 17]. MIGS devices have three main aqueous outflow pathways: Schlemm’ s canal improving trabecular outflow, the suprachoroidal space im- proving the uveoscleral outflow, and the subconjunctival space creating an alternative outflow pathway [16–18]. Among the different MIGS devices, the ab interno gel Implant XEN® (Allergan, Dublin, Ireland) is the only one that * María Teresa Marcos Parra mayte-mp@hotmail.com 1 Ophthalmology Department, Hospital General Universitario de Alicante, Alicante, Pintor Baeza, 11, 03010 Alicante, Spain Graefe's Archive for Clinical and Experimental Ophthalmology https://doi.org/10.1007/s00417-019-04341-y