Abstract
Purpose
To report on the implantation of a XEN 45 gel implant in a patient with glaucoma associated with congenital aniridia.
Observations
A 60-year old man with familial congenital aniridia and glaucoma presented with intraocular pressure of 30 mmHg in his right eye despite maximal topical treatment with four medications. Implantation of a XEN gel stent was performed without complications after subconjunctival injection of mitomycin-C (0.1 mL of 0.02%). At the two-year follow-up, the patient’s intraocular pressure was 12 mmHg with one topical medication. No needling of the filtering bleb was required. No excessive fibrosis of the conjunctiva or worsening of the existing keratopathy was noted.
Conclusions
The XEN 45 implant could be an option in the treatment of aniridia-associated glaucoma.
1
Introduction
Congenital aniridia is a panocular malformation that involves the cornea, iris, anterior chamber angle, lens, retina, and the optic nerve. Secondary ocular complications such as keratopathy, cataract, and glaucoma are common. Approximately 50% of patients with aniridia have glaucoma, and it often requires surgical intervention.
In recent years, minimally invasive glaucoma surgery has become an alternative to traditional glaucoma surgery. The XEN 45 (Allergan, Dublin, Ireland) was recently approved by the US Food and Drug Administration for the treatment of glaucoma. This gelatin stent is placed ab interno, creating a drainage pathway from the anterior chamber through the sclera to the subconjunctival space. Implantation with XEN 45 for indications such as open-angle glaucoma, uveitic glaucoma, neovascular glaucoma, ICE syndrome, and steroid-induced ocular hypertension have been reported.
In this report, we describe the implantation of a XEN gel stent in a patient with congenital aniridia and glaucoma.
2
Case report
A 60-year old man had familial congenital aniridia and related nystagmus, ptosis, keratopathy, cataract, and a 23-year history of bilateral glaucoma. Cataract surgery was performed in his right eye in 2015. In 2018, the intraocular pressure (IOP) in his right eye increased to 30 mmHg despite maximal topical medications with a fixed combination of brinzolamide and brimonidine tartrate (Simbrinza, Alcon, Fort Worth, TX, USA) and timolol and bimatoprost (Ganfort UD, Allergan, Dublin, Ireland). Oral acetazolamide (Diamox, Mercury Pharmaceuticals Ltd, London, UK) and topical preservative-free dexamethasone 1 mg/ml (Monopex, Laboratoires Théa, Clermont-Ferrand, France) 4 times daily was prescribed. Four weeks later, a XEN 45 gel stent was implanted. Subconjunctival injection of mitomycin-C (MMC) (0.1 mL of 0.02%) was performed. Then, the anterior chamber was filled with an ophthalmic viscosurgical device (OVD) (Healon GV; Abbott Medical Optics, Abbott Park, IL, USA). The injector needle entered the anterior chamber via a clear corneal incision and advanced through the sclera slightly anterior to the trabecular meshwork. The implant was placed in the subconjunctival space in the superonasal quadrant. The OVD was evacuated, corneal incisions were hydrated, and bleb formation was confirmed. Finally, intracameral cefuroxime (Aprokam, Laboratoires Théa, Clermont-Ferrand, France) was injected. Topical dexamethasone 6 times daily was continued for the first month then gradually tapered off over a period of 6 months. The IOP was 4 mmHg on the first post-operative day, 4 mmHg at 1 week, 5 mmHg at 1 month, 10 mmHg at 3 months, and 11 mmHg at the 6-month follow-up. A small cystic appearance was noted in the filtering bleb at this time ( Fig. 1 ). At the one-year follow-up, the IOP was 16 mmHg with preservative-free tafluprost (Taflotan, Santen, Osaka, Japan). 17 months after the surgery, tafluprost was discontinued and substituted with preservative-free timolol (Timosan, Santen, Osaka, Japan). At the two-year follow-up, the IOP was 12 mmHg with preservative-free timolol as monotherapy. Needling was not performed during the postoperative period. No excessive fibrosis of the conjunctiva or worsening of the keratopathy was noted ( Fig. 2 ).
