Novel Ripcord Suture Technique To Reduce Postoperative Hypotony In Xen63 Gel Stent Implantation For Refractory Glaucoma: A Retrospective Cohort Study

Although minimally invasive bleb surgery (MIBS) devices such as the XEN63 Gel Stent implant are regarded as having a lower risk profile than traditional surgical glaucoma procedures, post-operative hypotony (IOP <5 mmHg) is a common complication with incidence reported as high as 37% in the literature. To prevent post-operative hypotony, this study investigates a novel ripcord technique involving cannulation of the XEN63 lumen with a 10-0 nylon suture at the time of surgery, with the non-cannulated end of the suture incarcerated in a clear corneal incision. Later, this suture can be safely removed at slit lamp as needed to modulate patient’s intraocular pressure (IOP).

This single centre, retrospective cohort study was conducted at The Ottawa Hospital - Eye Institute, Department of Ophthalmology, University of Ottawa, Ottawa, Ontario, Canada.

Retrospective chart review was conducted to include glaucoma patients who underwent ‘non-ripcord’ (NRC) and ‘ripcord’ (RC)-modified XEN63 implantation surgery by a single surgeon between October 2022 and October 2025. In addition to patient demographics, data collection included pre- and post-operative slit lamp findings, visual acuity, IOP measurements, post-surgical complications, and additional interventions required. Primary outcomes compared post-operative IOP (day 1, day 7, month 3), rate of hypotony (IOP <5 mmHg), and hypotony-associated complications (e.g., decreased visual acuity, Descemet’s folds, choroidal folds, etc.) between RC and NRC groups, and the safety of ripcord removal. Data is presented as mean ± standard deviation.

Fifty-seven eyes (27 RC; 30 NRC) were included. At post-operative day 1, mean IOP was significantly lower (p<0.0001) in the NRC group (4.5 ± 2.4 mmHg) as compared to RC group (12.5 ± 4.7 mmHg). Proportion of patients with hypotony (<5 mmHg) were significantly higher (p<0.0001) in the NRC (51.7%) versus RC (3.7%) group. The rate of hypotony-associated post-operative complications was significantly higher (p=0.0288) in the NRC group (26.7%) versus RC group (3.7%). Ripcord was removed in 74.1% of the patients in RC group without complication within 3 months, with mean IOP reduction of 7.1 ± 4.9 mmHg post-removal. Mean IOP was not statistically different between the NRC (8.8 ± 4.3 mmHg) and RC group (9.8 ± 4.3 mmHg) at post-operative month 3.

This study demonstrates a novel ripcord cannulation technique for the XEN63 Gel Stent implant to prevent post-operative hypotony. Despite the small sample size, current findings demonstrate marked reduction in immediate post-operative hypotony and hypotony-associated complications with the ripcord technique, highlighting its efficacy. Removal of ripcord at the slit lamp without complications in nearly 75% of RC eyes further demonstrates its safety and utility in providing additional IOP lowering post-operatively. While limited by its retrospective nature, the current work highlights that XEN63 ripcord cannulation may offer a promising modification to improve IOP outcomes in a highly prevalent surgical glaucoma procedure.