Infective Necrotizing Scleritis After XEN Gel Stent With Mitomycin-C

Abstract

The purpose of this study was to report a case of infective necrotizing scleritis following XEN Gel Stent with mitomycin-C.Methods: Case report. This is a case report of a 68-year-old woman.Results: XEN Gel Stent glaucoma surgery enhanced with mitomycin-C 0.04% and combined with cataract surgery was performed at a regional center to manage the patient's primary open-angle glaucoma. Past medical history was significant for rheumatoid arthritis requiring treatment with methotrexate and adalimumab. Periocular pain and swelling developed 14 months after the initial operation, followed by a rapid deterioration of visual acuity to 20/60, intraocular pressure of 4 mm Hg, and worsening pain 5 months later. On initial presentation to Sydney Eye Hospital, 180 degrees of scleral necrosis was evident with a moderate anterior segment inflammatory reaction and a large temporal choroidal effusion due to hypotony. Empirical hourly topical ofloxacin and cephalothin 5% drops, with oral moxifloxacin, were initiated. Conjunctival swab grew Staphylococcus aureus and Staphylococcus lugdunensis. Significant clinical improvement occurred, but the XEN Gel Stent became exposed after 9 days of treatment with worsening hypotony. Urgent surgical revision was performed to remove the XEN Gel Stent and apply a tutoplast plug with overlying amniotic membrane graft. Intraocular pressure gradually improved over 6 weeks to 15 mm Hg with reversal of hypotonous changes, and visual acuity stabilized at 20/40.Conclusions: To our knowledge, this is the first reported case of necrotizing scleritis following XEN Gel Stent insertion. It is a reminder that infection should always be the primary differential diagnosis in patients with surgical-induced necrotizing scleritis.

Complications of XEN gel stent implantation for the treatment of glaucoma: a systematic review

“…Potential mechanisms for the initial conjunctival erosions include: (1) the administration of the anti-metabolite MMC; (2) the ab interno approach; (3) the subconjunctival position; (4) prolonged use of topical anti-glaucoma medications; as well as (5) mechanical stress, for instance, from elderly patients rubbing their eyes with their hands. The use of anti-metabolites can enhance the success rate of filtering surgery by mitigating the wound-healing process, yet it may increase the risk of bleb-related complications, like a thin-walled cystic bleb or surgically induced necrotizing scleritis ( 57 , 58 , 103 ). Since the XEN gel stent is implanted using the ab interno approach without the need for conjunctival dissection or sutures, there is a risk of malposition of the distal end of the implant.…”

A case of mitomycin C toxicity after XEN gel stent implantation with the XEN air technique in a glaucoma patient

“…During surgery, mitomycin C (MMC) is used to reduce post-operative subconjunctival fibrosis and scar formation in the filtering bleb, which is an essential aspect of glaucoma filtration surgery. However, the “anti-metabolite” filtration surgery may result in major complications and side effects, such as thin-walled cystic blebs, late bleb leaks, bleb infections, endophthalmitis, chronic hypotony, and persistent corneal epithelial defects [ 2 – 4 ]. Here, we present a case of MMC toxicity that occurred after XEN gel stent implantation using the XEN air technique, presumably due to ophthalmic viscosurgical device (OVD) usage.…”