Conjunctival fibrosis remains the major impediment to the success of glaucoma filtration surgery. Anti-metabolites remain the gold standard for mitigating post-surgical fibrosis, but they are associated with high complication rates and surgical failure rates. Establishing a more targeted approach to attenuate conjunctival fibrosis may revolutionize the surgical approach to glaucoma. A new strategy is needed to prevent progressive tissue remodeling and formation of a fibrotic scar, subsequently increasing surgical success and reducing the prevalence of glaucoma-related vision loss. Advancements in our understanding of molecular signaling and biomechanical cues in the conjunctival tissue architecture are broadening the horizon for new therapies and biomaterials for the mitigation of fibrosis. This review aims to highlight the strategies and current state of promising future approaches for targeting fibrosis in glaucoma filtration surgery.

Introduction Despite the rise of micro-invasive glaucoma surgery (MIGS), glaucoma drainage device implantation continues to be a mainstay among glaucoma surgical treatment options. Anterior chamber tube placement, while effective in reducing intraocular pressure (IOP), poses corneal endothelial risks. Ciliary sulcus tube placement shows promise in reduced corneal endothelial cell loss, but proper sulcus placement can be challenging. Our study describes the initial safety and effectiveness results using a novel sulcus tube internal needle guidewire (STING) technique for glaucoma drainage device insertion into the ciliary sulcus. Methods We retrospectively reviewed the charts of all consecutive patients who underwent the STING technique using the Ahmed ClearPath, Ahmed Glaucoma Valve, or Baerveldt glaucoma implant with at least 6 months of follow-up. Demographic characteristics, type of glaucoma, previous medical and surgical treatment, pre- and postoperative IOP, pre- and postoperative medications, complications, and success rates were recorded. Results Out of nine eyes, seven resulted in qualified success (77.8%). Preoperative mean IOP was 23.8 ± 6.3 mmHg, and postoperative IOP decreased significantly to 14.9 ± 3.7 mmHg (p = 0.008). The average number of preoperative medications per patient was 4.4 ± 0.7, while the average number of postoperative medications per patient was reduced significantly to 3.6 ± 1.0 (p = 0.039). Conclusion The STING technique is a novel method for placing a glaucoma drainage device into the ciliary sulcus, leading to IOP lowering with minimal complications. The STING technique is designed to improve surgical ease and increase anatomical precision of sulcus tube placement. Video available for this article.

Purpose: To evaluate glaucoma surgeons’ practice patterns regarding glaucoma drainage device (GDD) tube shunt placement, assess their opinions on sulcus tube placement, and evaluate their receptiveness to technologies designed to improve sulcus tube placement. Patients and Methods: A 12-question survey was distributed electronically to American Glaucoma Society (AGS) members between November 6 and December 23, 2024. The survey assessed surgeons’ current tube-shunt placement practice patterns, factors influencing tube placement decisions, and receptiveness to proposed technologies designed for sulcus tube placement. Descriptive analysis was performed on 121 completed responses. Results: Most respondents (55%) reported a preference for placing tubes in the anterior chamber (AC) for the majority of their pseudophakic patients, with efficiency (62%), safety (62%), and familiarity (57%) reported as primary factors for this decision. Barriers to sulcus placement included concern for intraocular bleeding (67%), technical difficulty of sulcus placement (54%), the risk of vitreous loss and tube occlusion (53%), and iris complications (53%). However, if a sulcus tube insertion technology was available and assuming a randomized controlled trial (RCT) demonstrated the superiority of sulcus over AC placement in minimizing endothelial cell loss (ECL), 85% of respondents indicated they would be likely to routinely place tubes in the sulcus. Features deemed very important for such a technology included tube placement accuracy (87%), ease of use (86%), IOP-lowering effectiveness (73%), time-efficiency (71%), and affordability (67%). Conclusion: Currently, most glaucoma surgeons favor AC tube placement due to its familiarity, efficiency, and perceived safety, despite associated long-term risk of endothelial cell loss (ECL). Survey findings suggest strong interest in adopting sulcus placement, assuming a proven benefit on ECL and the availability of sulcus placement technologies designed to mitigate technical challenges. Development of robust data and reliable sulcus insertion technologies/techniques may change practice patterns.