Rescue of Failed XEN-45 Gel Implant by Nd:YAG Shock Wave to Anterior Chamber Tip to Dislodge Hidden Intraluminal Occlusion

Fellman, Ronald L.; Grover, Davinder S.; Smith, Oliver J.; Kornmann, Helen L.

doi:10.1097/ijg.0000000000001847

Cited by 9 publications

(8 citation statements)

References 13 publications

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“…Fellman et al suggested hydrodynamic energy in the form of a shockwave that ravels down the lumen, dispersing and clearing invisible intraluminal cellular debris. [12] After the Nd: YAG shock wave treatment, we reestablished the flow of the cortical material-occluded XEN implant, which was similar to their study. After this approach, the patency of the XEN implant was improved dramatically.…”

Section: Discussionsupporting

confidence: 81%

“…Consequently, the authors anticipated a disruption effect of Nd: YAG laser treatment for cortical materials occluding the internal ostium of the XEN gel stent. Fellman et al suggested hydrodynamic energy in the form of a shockwave that ravels down the lumen, dispersing and clearing invisible intraluminal cellular debris [12] . After the Nd: YAG shock wave treatment, we re-established the flow of the cortical material-occluded XEN implant, which was similar to their study.…”

Section: Discussionsupporting

confidence: 78%

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Recanalization of XEN-45 gel stent occlusion with cortical material after phaco-XEN surgery using Nd: YAG laser treatment

Seo

Lim

2021

Medicine

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Introduction: The XEN Gel Stent (Allergan Inc., CA, USA) has been widely used in minimally invasive glaucoma surgery to lower intraocular pressure considering reasonable efficacy and safety profiles. However, the XEN gel stent could be occluded by fibrin, blood clots, or the iris due to its small lumen design for preventing postoperative hypotony. To date, only a few studies have assessed XEN occlusion after combined phacoemulsification with XEN gel implantation and how to manage this condition. We describe the first case report of XEN gel stent obstruction by cortical material, demonstrated by anterior segment optical coherence tomography (AS-OCT), which resolved effectively after low-energy neodymium-doped yttrium aluminum garnet (Nd: YAG) laser shock wave treatment. Patient Information: A 76-year-old Korean male patient underwent uncomplicated phaco-XEN-gel stent implantation and presented with low intraocular pressure (IOP) with a well-functioning filtering bleb during the first postoperative 4 days. On postoperative day 5, the XEN lumen was occluded by the cortical material, with an intraocular pressure elevation of 28 mm Hg. Slit-lamp examination revealed that cortical material was causing a block into the internal ostium of the XEN gel implant. AS-OCT examination also demonstrated the presence of hyper-reflective materials at the intraluminal portion and peritubular portion around the internal ostium of the XEN gel implant. Diagnosis: XEN gel stent occlusion with cortical material after Phaco-XEN surgery. Interventions: Low-energy Nd: YAG laser shock wave treatment. Outcomes: The IOP dropped from 28 mm Hg to 8 mm Hg immediately after treatment. Transient hypotony and a slightly shallow anterior chamber were noted over the 3 days after YAG laser treatment. The IOP continued to be well-controlled until 3 months later (range; 6 - 12 mm Hg). Conclusions: To the best of our knowledge, this is the first case report on the efficacy of Nd: YAG laser treatment for recanalization of XEN implant occluded by the cortex. Moreover, AS-OCT could provide additional clinical information for recanalization of the XEN gel stent.

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Section: Discussionsupporting

confidence: 81%

Section: Discussionsupporting

confidence: 78%

Recanalization of XEN-45 gel stent occlusion with cortical material after phaco-XEN surgery using Nd: YAG laser treatment

Seo

Lim

2021

Medicine

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“…In this regard, Fellman et al outlined a technique of Nd:Yag laser treatment in the proximity of the intracameral tip portion of the stent to disperse only supposed intraluminal debris. 34 Although the greater lumen diameter of the XEN63 with respect to XEN45 prevented the complete obstruction in this case series, it was not possible to achieve an adequate reduction in IOP with the restoration of the XEN patency. Indeed, a further needling procedure was required to restore the space between the conjunctiva/tenon's capsule and the sclera and overcome the conjunctival fibrosis resistance.…”

Section: Discussionmentioning

confidence: 67%

Anterior Segment Optical Coherence Tomography for Cases of High Intraocular Pressure Following XEN Implant for Glaucoma

Tatti,

Lixi,

Demarinis

et al. 2023

Journal of Glaucoma

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Precis: This study showed that the XEN patency should be verified by OCT imaging in cases of encapsulated blebs. Although fibrosis plays the principal role, humour aqueous flow reduction could affect the “spacer” effect that inhibits the fibroblast attachments. Purpose: To evaluate the application of the AS-OCT imaging in studying the relationship between a low flow rate through the XEN63 and the development of a cystic bleb. Methods: Retrospective case series of three eyes presenting a cystic bleb after a XEN63 implantation for uncontrolled IOP. Demographic and clinical data were obtained from medical records. The imaging findings, complications and managements following the surgery were evaluated. Results: Three patients, with an average age of 67.3 years, initially showed a patent stent lumen and a functional bleb after surgery. The IOP of all eyes increased on average at 28.3 days from the surgery, with a mean value of 39.66 mmHg. The slit lamp examination showed a cystic bleb. The AS-OCT imaging confirmed the previous finding and revealed either a partial or total occlusion of the stent internal ostium. A Nd:YAG laser, in proximity of the ostium, was performed in order to resolve the obstruction. Although the AS-OCT imaging showed the device patency and the IOP immediately decreased, the latter became elevated again. Consequently, in all the cases a further needling procedure was needed to achieve an adequate IOP reduction. Six months after the two-step procedure, the IOP averaged 13.33 mmHg, the XEN63 lumens appeared cleared and the blebs showed a functional morphology. No adverse events were observed. Conclusion: The development of a cystic bleb may result from an altered balance between the flow-rate through the XEN63 and the fibrosis development in the postoperative healing process. A proper follow up based on slit lamp biomicroscopy, IOP measurement and AS-OCT imaging is advisable to estimate and manage a cystic bleb following XEN63 implantation.

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“…In the meta-analysis by Xz et al 11 , the common postoperative complications after Xen implantation were transient hypotony(9.59%), hyphema (5.53), transient IOP spikes ≥ 30 mmHg (2.11% on average), while implant occlusion (0.93%), implant malposition (0.88%), and implant exposure(0.57%) were relatively uncommon. Fellman et al 17 reported six patients with intraluminal cellular debris after Xen45 surgery were successfully treated with low energy Nd:YAG laser shockwave therapy aimed just the intracameral tip of the gel stent through a gonioscopy lens. Seo et al 18 used the Nd: YAG laser (0.8mJ, 2 shots) to successfully recanalize an Xen45 Gel Stent occlusion with cortical material.…”

Section: Discussionmentioning

confidence: 99%

Rescue of Xen45 Gel Stent Implant Occlusion In Refractory Glaucoma: A Case Report

Zhang

Xiang

Zhang

et al. 2023

Preprint

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Background Xen Gel Stent implant is a new minimally invasive surgical treatment for glaucoma that has been proven effectiveness and safety profile. However, it may also lead to some complications. Xen Gel Stent occlusion is a relatively rare complication reported less frequently and has limited treatment experience. In our case report, we proposed a novel surgical treatment using a 10 − 0 nylon suture to recanalize the occluded Xen45 Gel Stent successfully. Case presentation: A 16-year-old female patient had bilateral juvenile glaucoma for the past 5 years. Her right eye had undergone three glaucoma surgeries but failed. At a presentation to our hospital, the intraocular pressure (IOP) in the right eye was 30 mmHg despite the application of four topical eye drops. Xen45 Gel Stent implant was chosen for treatment, but six days after implantation, the IOP rose to 40 mmHg due to an occlusion of the tip of Xen45 Gel Stent in the anterior chamber. Nd: YAG laser shockwave therapy was attempted but failed. The patient eventually had to return to the operating room for a revision procedure. A 10 − 0 nylon suture was threaded through the Xen45 Gel Stent to recanalize it. The IOP was successfully controlled in the 11-month follow-up. Conclusion If postoperative occlusion arises after Xen45 Gel Stent implantation, surgery using 10 − 0 nylon suture to recanalize Xen45 Gel Stent should be considered as a relatively safe, effective, and minimally invasive alternative that does not require removal or trimming of Xen45 Gel Stent.

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Rescue of Failed XEN-45 Gel Implant by Nd:YAG Shock Wave to Anterior Chamber Tip to Dislodge Hidden Intraluminal Occlusion

Cited by 9 publications

References 13 publications

Recanalization of XEN-45 gel stent occlusion with cortical material after phaco-XEN surgery using Nd: YAG laser treatment

Recanalization of XEN-45 gel stent occlusion with cortical material after phaco-XEN surgery using Nd: YAG laser treatment

Anterior Segment Optical Coherence Tomography for Cases of High Intraocular Pressure Following XEN Implant for Glaucoma

Rescue of Xen45 Gel Stent Implant Occlusion In Refractory Glaucoma: A Case Report

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