Angiographic biomarkers of filtering bleb function after XEN gel implantation for glaucoma: an optical coherence tomography-angiography study

Purpose: To evaluate, using optical coherence tomography-angiography (OCT-A), the vascular features of good bleb function after XEN gel implantation (XGI) for uncontrolled glaucoma. Methods: Forty-three patients (43 eyes), who underwent XGI, were enrolled. According to the intraocular pressure (IOP) reduction, patients were classified into Group 1 (21 eyes; success) and Group 2 (22 eyes; failure). Optical coherence tomography-angiography (OCT-A) was performed to image the vascularization of the conjunctival bleb-wall. The main outcomes were as follows: vessel displacement areas (VDAs), major vessel displacement area (MVDA; mm2), non-flow whole area (NFWA; mm2) and bleb-wall vessel density (BVD; %). Co-registered B-scans were also considered to evaluate the bleb-wall cyst-like structure density and area (BCSD, cysts/mm2; BCSA, mm2), and the bleb-wall thickness (BT, µm). Results: Mean postoperative follow-up was 7.5 ± 0.14 months; Group 1 and 2 IOP were 14.0 ± 2.5 and 25.3 ± 2.1 mmHg, respectively (p < 0.001). Greater VDA (p < 0.001), MVDA (p = 0.046) and NFWA (p = 0.001) values, and lower BVD (p < 0.001) was found in Group 1 compared to Group 2. Group 1 showed higher BSCD, BSCA and BT values compared to Group 2 (p < 0.001). Postoperative IOP positively correlated with BVD (r = 0.567; p = 0.003), but negatively with VDAs, MVDA (r = −0.581, p = 0.002; r = −0.619, p = 0.001, respectively), BCSD, BCSA (r = −0.580; p = 0.002; r = −0.664; p < 0.001) and BT (r = −0.627, p = 0.001). Conclusion: Successful filtration blebs after XGI present numerous and large areas of vessel displacement within the bleb-wall, along with a rarefied vascular network. These OCT-A features can be considered angiographic biomarkers of a good aqueous humour percolation through the bleb-wall layers.