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

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 one 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.