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Malignant glaucoma after XEN45 implant
Glaucoma maligno tras implante XEN45
S. Montolío Marzo
, A. Lanzagorta Aresti, J.M. Davó Cabrera, E.A. Alfonso Muñóz, J.V. Piá Ludeña, E. Palacios Pozo
Corresponding author
FISABIO Oftalmología Médica, Valencia, Spain
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Montolío Marzo, A. Lanzagorta Aresti, J.M. Davó Cabrera, E.A. Alfonso Muñóz, J.V. Piá Ludeña, E. Palacios Pozo" "autores" => array:6 [ 0 => array:4 [ "nombre" => "S." "apellidos" => "Montolío Marzo" "email" => array:1 [ 0 => "s.montoliomarzo@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Lanzagorta Aresti" ] 2 => array:2 [ "nombre" => "J.M." "apellidos" => "Davó Cabrera" ] 3 => array:2 [ "nombre" => "E.A." "apellidos" => "Alfonso Muñóz" ] 4 => array:2 [ "nombre" => "J.V." "apellidos" => "Piá Ludeña" ] 5 => array:2 [ "nombre" => "E." "apellidos" => "Palacios Pozo" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "FISABIO Oftalmología Médica, Valencia, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Glaucoma maligno tras implante XEN45" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 493 "Ancho" => 1348 "Tamanyo" => 90040 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">AS-OCT (left) and anterior pole photograph (right): deeper anterior chamber after vitrectomy.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Glaucoma is one of the first causes of blindness in the world, with a prevalence exceeding 60 million individuals. Therapeutic approaches are a challenge for which a broad range of medical and surgical methodologies have been developed. Medical treatment involves the chronic installation of medication and eventually quality of life reductions due to consequential ocular surface alterations. Surgical intervention of glaucoma, filtrating surgery and valve devices entail a high rate of complications and investment of resources for follow-up.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Researchers have endeavored to develop surgical techniques to diminish chronic medical treatment, a first step prior to invasive surgical methods, as well as reduction in the post-surgery complications. This endeavor gave rise to the concept of minimally invasive glaucoma surgery with 3 alternative drainage pathways: suprachoroidal, uveoscleral and subconjunctival.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Within the subconjunctival pathway, the XEN gel stent implant (Allergan PLC, Dublin, Ireland) can be found. This implant is manufactured with cross-linked reinforced porcine collagen. This material is hydrophilic and malleable in contact with the aqueous humor. With a length of 6<span class="elsevierStyleHsp" style=""></span>mm and a diameter of 45 microns, it provides a theoretical filtration of 2–2.5<span class="elsevierStyleHsp" style=""></span>mL/min according to the Hagen Poiseuille equation.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The implant is marketed pre-charged with a 27 G automatic injector, which is introduced through a self-sealable corneal incision up to the superior nasal quadrant where it is injected in such a way that 2<span class="elsevierStyleHsp" style=""></span>mm of the implant must remain in the anterior chamber with the distal parts in the subconjunctival space. Adequate placement must be checked with gonio lens.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The majority of said devices require even more experience and evidence on results, cost effectiveness and complication rates.</p><p id="par0030" class="elsevierStylePara elsevierViewall">On the other hand, malign glaucoma is an infrequent but very severe complication in glaucoma surgery. Even though the physiopathology is not clear, anterograd pressure from the iris-crystalline lens or iris-lens diaphragm, secondary to the accumulation of aqueous behind said structures. It is understood as a multifactorial phenomenon that occurs in anatomically predisposed eyes. Said patients exhibit central and peripheral anterior chamber flattening and increased intraocular pressure with secondary angle closure.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinic case report</span><p id="par0035" class="elsevierStylePara elsevierViewall">Female, 72, with history of primary open angle glaucoma and cataracts. It was decided to perform combined surgery involving phacoemulsification, intraocular lens implant and XEN45 device. The patient visited for a postsurgical checkup in the reference hospital without evidencing alterations in examination.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Four days after surgery, the patient visited a reference hospital with intense ocular pain, nausea and vomit. Optical biomicroscopy showed grade 3 athalamia with slight corneal edema (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), a XEN45 device (Allergan PLC, Dublin, Ireland) implanted in the superior nasal quadrant with relative displacement to anterior chamber and anteriorization of the intraocular lens and iris. Intraocular pressure (IOP) measured with Goldmann applanation tonometer was 55<span class="elsevierStyleHsp" style=""></span>mmHg.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">At the Emergencies Dept. the patient was administered atropine, intravenous mannitol, beta blockers, prostaglandins, topical alpha antagonists and oral carbonic anhydrase inhibitors. After application of said treatment, IOP diminished to 30<span class="elsevierStyleHsp" style=""></span>mmHg although athalamia persisted without pupil reaction. Due to the difficulty in examining eye fundus, radiology was requested an ocular echography to discard suprachoroidal hemorrhage, which was found to be normal. Attempts were made to perform iridotomy-peripheral hyaloidotomy without success due to the close contact of the iris with the corneal endothelium.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Considering the angle closure secondary glaucoma with “posterior push” mechanism, 3 possible diagnostics were considered: pupil blockage, suprachoroidal hemorrhage or malign glaucoma. Pupil blockage was discarded due to the arrangement of the intraocular lens which was tilted in a way that maintained communications between the pre-and retro-iridian space, in addition to the absence of peripheral as well as central anterior chamber. Even though the time elapsed until the emergence of the condition did not suggest supra choroidalhemorrhage, echography was taken 4 days after surgery to discard its presence. Accordingly, malign glaucoma remained as exclusion diagnostic.</p><p id="par0055" class="elsevierStylePara elsevierViewall">After the episode at the Emergency Dept. the patient was referred to the reference hospital for assessing surgical treatment, and 2 days later she visited our hospital with an examination similar to that of the Emergency Dept. episode, with intense pain and without having recovered the chamber or diminished IOP by means of GAT (70<span class="elsevierStyleHsp" style=""></span>mmHg). After complete pars plana vitrectomy it was possible to increase anterior chamber depth which was maintained with viscoelastic. During surgery and as a result of the rapid IOP reduction produced by vitrectomy, hemorrhagic choroidal detachment areas were observed and drained by means of sclerectomy.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In the immediate postop, the chamber was deep though IOP remained high (25<span class="elsevierStyleHsp" style=""></span>mmHg with maximum oral and topical treatment) with persistence of 360° gonio synechiae, for which reason it was decided to implant a retroiridian superior temporal Ahmed valve.</p><p id="par0065" class="elsevierStylePara elsevierViewall">After one month follow-up, the patient was free of pain, the anterior chamber was deep (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), IOP was controlled at 16<span class="elsevierStyleHsp" style=""></span>mmHg with a fixed combination of beta blocker and carbonic anhydrase inhibitor. However, progressive corneal decompensation presented, and visual acuity is “projection of light” which (barring improvement) will be susceptible to endothelial transplant. Biomicroscopy shows both devices, i.e., the temporal superior Ahmed valve and the nasal superior XEN45 device (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">Minimally invasive glaucoma surgery (MIGS) which comprises the XEN45 device implant could have less ambitious objectives for reducing intraocular pressure, although it initially substitutes said sacrifice by diminishing complications inherent to said surgery. The complication rates found in published references are highly variable, with hypotony (Graver et al., 24.6%. 11.9% Schlenker et al.) and the necessity of <span class="elsevierStyleItalic">needling</span> due to the failure of the filtration bleb (Graver et al., 32.3%. Schlenker et al., 43.2%) being most frequent.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> In contrast, in other publications the hypotony rate is virtually nonexistent (Pérez-Torregrosa et al., 0%. Gregorio et al., 2.4%).<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Subconjunctival bleeding, hyphema, implant displacement, uveitis, formation of synechiae or bleb losses are occasional complications.</p><p id="par0080" class="elsevierStylePara elsevierViewall">To date, the experience with said surgery type is presumably insufficient, and it would be recommendable to initiate a prospective study with a larger cohort of patients to assess the actual complications of said techniques.</p><p id="par0085" class="elsevierStylePara elsevierViewall">In what concerns malign glaucoma, the complication encountered in the present case was not discussed in any published study with the exception of Schlenker et al. (2017), who reported an incidence of 2.2% in a series of 187 patients with XEN45 implant and application of mitomycin between 0.05 and 0.2<span class="elsevierStyleHsp" style=""></span>mL.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">It is surprising that the appearance of said complication could have devastating consequences involving a departure of the “minimally invasive” philosophy discussed above. Malign glaucoma could lead to endothelial decompensation, poor IOP control and the necessity of secondary surgeries such as pars plana vitrectomy or the use of drainage devices for controlling intraocular pressure.</p><p id="par0095" class="elsevierStylePara elsevierViewall">The least invasive technique for malign glaucoma is peripheral iridotomy, hyaloidotomy, emphasizing the need of disrupting the anterior hyaloids to slow down the mechanism that anteriorizes the iris-lens/crystalline lens diaphragm. As in the present case, the technique could be influenced by the absence of chamber or corneal opacification derived from the increased pressure and contents of the endothelium with other structures.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Vitrectomy appears as the most effective technique for resolving the condition with success rates of 65–90% in pseudophakic patients in whom the withdrawal of the anterior hyaloids it easier. This involves the need of posterior pole surgery specialist for resolving the complication.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">In the case reported herein, the patient finally needed valve surgery, additionally involving the failure of the intention to delay invasive glaucoma surgeries. The fact of limiting the possible range of surgical techniques (due to the presence of 360° gonio synechiae) and the execution of surgery in poor conditions (on controlled IOP and conjunctiva with previous retina surgery) is undoubtedly food for thought.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Beyond the surgical aspects, we must be aware that in many cases the implantation of MIGS devices is associated to cataract surgery in patients who otherwise would not have undergone glaucoma surgery on its own. In these cases, it is particularly important to emphasize that risks could be lower to those of other surgeries but not entirely absent or of a benign nature, as reported in the present case.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0115" class="elsevierStylePara elsevierViewall">The objective of minimally invasive glaucoma surgery is to reduce the human need for medication, improve a patient's quality of life and delay invasive filtrating surgery, achieving a better preserved conjunctiva.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Lower complication rates have popularized said surgery among ophthalmologists, mainly in light glaucoma cases associated to cataract surgery. However, it is not without potentially severe complications such as the malign glaucoma case presented herein. Accordingly, said techniques should be performed by glaucoma surgeons able to recognize eventual complications and preempt devastating consequences for patients who in general exhibited a good baseline.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflict of interests</span><p id="par0125" class="elsevierStylePara elsevierViewall">No conflict of interests was declared by the authors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1157250" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1084471" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1157251" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1084472" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinic case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-08-06" "fechaAceptado" => "2018-10-24" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1084471" "palabras" => array:3 [ 0 => "Malignant glaucoma" 1 => "Minimally invasive glaucoma surgery" 2 => "XEN implant" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1084472" "palabras" => array:3 [ 0 => "Glaucoma maligno" 1 => "Cirugía microinvasiva de glaucoma" 2 => "Implante XEN" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Minimally invasive glaucoma surgery for chronic open-angle glaucoma treatment tries to reduce the amount of chronic topical drug treatment, delaying invasive glaucoma surgery and diminishing the number of surgical complications. XEN45 uses subconjunctival drainage in order to reduce intraocular pressure.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The report is presented of a patient following phacoemulsification, intraocular lens implantation and XEN45 implant. After four days acute malignant glaucoma was observed, with stage 3 athalamia requiring pars plana vitrectomy and secondary Ahmed valve implantation.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The lower rate of complications due to minimally invasive glaucoma surgery has increased its use. Nevertheless, it is not free of severe adverse events, even requiring a multidisciplinary approach as in our malignant glaucoma report.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">En el tratamiento del glaucoma de ángulo abierto ha surgido el concepto de cirugía mínimamente invasiva intentando reducir el tratamiento tópico crónico, retrasar cirugía más invasiva y disminuir el número de complicaciones. El XEN45 utiliza la vía de drenaje subconjuntival para reducir la presión intraocular.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Presentamos el caso de una paciente que fue sometida a cirugía de facoemulsificación, implante de lente intraocular y dispositivo XEN45. Cuatro días después presentó episodio agudo de glaucoma maligno con atalamia grado 3 que requirió vitrectomía pars plana e implante secundario de válvula de Ahmed.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La menor tasa de complicaciones de la cirugía mínimamente invasiva de glaucoma ha incrementado su uso. Sin embargo, no está exenta de complicaciones graves requiriendo incluso un abordaje multidisciplinar como en el caso del glaucoma maligno que presentamos.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Montolío Marzo S, Lanzagorta Aresti A, Davó Cabrera JM, Alfonso Muñóz EA, Piá Ludeña JV, Palacios Pozo E. Glaucoma maligno tras implante XEN45. Arch Soc Esp Oftalmol. 2019;94:134–137.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 452 "Ancho" => 780 "Tamanyo" => 36717 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Anterior segment optical coherence tomography (AS-OCT): athalamia grade 3, four days after XEN45 implantation.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 493 "Ancho" => 1348 "Tamanyo" => 90040 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">AS-OCT (left) and anterior pole photograph (right): deeper anterior chamber after vitrectomy.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 446 "Ancho" => 1348 "Tamanyo" => 73776 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">anterior pole photograph: Ahmed valve reservoir in superior temporal quadrant (*) and XEN45 device in superior nasal quadrant (+) (left). AS-OCT: cross-section of pre-iridian Ahmed valve tube lumen (*) and longitudinal section of the XEN45 device (+) (right).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "An update on implants for Minimally Invasive Glaucoma Surgery (MIGS)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "E. 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