Reducing Postoperative Needling in XEN63® Surgery with Adjunctive Cross-Linked Hyaluronic Acid Implant (Healaflow®): Early Evidence from Real-World Practice

Background: Open-angle glaucoma (OAG) is a leading cause of irreversible blindness. While trabeculectomy remains the surgical gold standard, bleb-forming minimally invasive procedures such as the XEN63 gel stent offer a safer alternative. However, early postoperative management remains critical, as needling is frequently required to preserve bleb function. Healaflow® (HF), a cross-linked hyaluronic acid gel, has been proposed as an adjunct in glaucoma surgery to maintain the subconjunctival space and modulate fibrosis. This study aimed to evaluate the outcomes of XEN63 implantation with or without HF in terms of IOP reduction, glaucoma medication use, surgical success, and postoperative intervention rates. Methods: This retrospective, comparative study included 20 pseudophakic eyes with medically uncontrolled OAG undergoing XEN63 implantation with mitomycin-C (MMC), either with (n = 10) or without (n = 10) adjunctive HF. Follow-up included IOP measurements, medication use, and the need for postoperative procedures up to 3 months. Results: At 3 months, both groups showed significant IOP reduction from baseline (−31.8% in XENhf vs. −38.8% in XENa, p > 0.05) with minimal medication use. Complete success was achieved in 90% of XENhf eyes and 80% of XENa eyes. Although the proportion of eyes requiring needling did not differ significantly, the total number of procedures was lower in the HF group (2 vs. 8; p = 0.004). Conclusions: Adjunctive HF use in XEN63 surgery may reduce the number of postoperative procedures while maintaining equivalent efficacy and safety, potentially easing the early management burden for both patients and clinicians.