Modified Superior Angle Access Using a Direct Goniolens for Ab Interno Needling Bleb Revisions

Direct visualization of the superior angle during ab interno bleb revision can be achieved by rotating the globe with traction sutures, allowing surgeons to use a standard direct goniolens rather than an indirect gonioprism. In this series of 13 eyes with failed or failing trabeculectomy blebs, globe rotation permitted consistent identification of the trabeculectomy ostium, and facilitated effective needling with the Grover-Fellman spatula without intraoperative perforations or bleb leaks. This simple modification may broaden the adoption of ab interno bleb revision and improve access to the superior angle for a range of MIGS procedures.We describe a novel technique of globe rotation that facilitates direct gonioscopic visualization of the superior angle during ab interno bleb revision and evaluate its outcomes. A retrospective review of 13 eyes undergoing revision with the Grover-Fellman biplanar sclerostomy spatula was performed. The superior angle was visualized using a direct goniolens after globe rotation with limbal traction sutures and optimal patient and microscope positioning. All cases achieved successful access to the trabeculectomy ostium. Mean intraocular pressure decreased from 25.7 ± 13 mm Hg preoperatively to 10.5 ± 4.2 mm Hg at 6 months ( P = 0.005), and the median number of medications reduced from 4 (IQR: 2-4) to 0 (IQR: 0-2) ( P = 0.005). Three eyes required antiglaucoma medications, and 1 required an aqueous drainage implant postoperatively. No bleb leaks or conjunctival perforations occurred, and the technique was also combined with other MIGS procedures in select patients. Globe rotation provides a simple means to achieve direct visualization of the superior angle and enables ab interno bleb revision with a direct goniolens. This approach may serve as a practical alternative to indirect gonioscopy and facilitate broader adoption of ab interno techniques.