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      Migration of XEN45 Implant: Findings, Mechanism, and Management

      case-report

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          ABSTRACT

          Aim

          The aim of this study is to report the mechanism of XEN migration and its management.

          Background

          Over the past decade, new less invasive surgical approaches for glaucoma have been devised and carried out successfully. One such technique is the use of the XEN gel stent. We present a rare and relatively unknown complication of XEN migration and present in detail the likely mechanism by which this occurs, and its subsequent management.

          Case description

          A 73-year-old male with primary angle closure on maximal medical treatment presented with an intraocular pressure of 30 mm Hg in the left eye. The visual acuity was 6/5, iridocorneal angles were open in all four quadrants, and the cup disc ratio was 0.4. As phacoemulsification alone was unlikely to adequately lower intraocular pressures, the patient underwent combined phacoemulsification and XEN implantation. Although the patient had a good postoperative result with pressures lowered to 11 mm Hg, 4 months after the operation, the XEN was found to have migrated 4 mm into the anterior chamber, associated with a low-grade uveitis. The patient subsequently had the XEN explanted a new XEN inserted. Pressures lowered 1 month postoperatively to 14 mm Hg.

          Conclusion

          XEN migration is likely due to a combination of mechanical and frictional forces. If the XEN is positioned such that more than 2 mm is in the subconjunctival space, the XEN is likely to be angled upward and, therefore, be more susceptible to these forces and undergo migration.

          Clinical significance

          It is essential that XEN implants are correctly sited and that this is confirmed intraoperatively to prevent the need for further procedures.

          How to cite this article

          Ali ZC, Khoo DI, et al. Migration of XEN45 Implant: Findings, Mechanism, and Management. J Curr Glaucoma Pract 2019;13(2):79–81.

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          Most cited references10

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          Prevalence of ocular surface disease in glaucoma patients.

          Eamon Leung, Felipe Medeiros, Robert N. Weinreb (2008)
          To examine the prevalence of ocular surface disease (OSD) in glaucoma patients. This was a cross-sectional study. One hundred and one patients, 18 years of age or older, with open-angle glaucoma or ocular hypertension were consecutively recruited for the study. Patients with a history of use of cyclosporine, steroids, topical ocular nonsteroidal anti-inflammatory drugs, or punctal plugs within the last 3 months were excluded. Each patient completed an Ocular Surface Disease Index questionnaire and underwent evaluation by Schirmer test, corneal and conjunctival lissamine green staining, and tear break-up time. Using Ocular Surface Disease Index for measuring symptoms of dry eye, 60 (59%) patients reported symptoms in at least 1 eye. Severe symptoms were reported by 27 (27%) patients. Schirmer testing showed 62 (61%) patients with decrease in tear production in at least 1 eye. Severe tear deficiency was presented in 35 (35%) patients. Corneal and conjunctival lissamine green staining showed positive results in 22 (22%) patients. None had severe staining. Tear break-up time showed abnormal tear quality in 79 (78%) patients and severe decrease in tear quality was found in at least 1 eye in 66 (65%) patients. Multivariate logistic regression models were used to investigate the association between the number of benzalkonium chloride (BAK)-containing eyedrops and results on the clinical tests of OSD. After adjustment for age and sex, each additional BAK-containing eyedrop was associated with an approximately 2 times higher odds of showing abnormal results on the lissamine green staining test (odds ratio=2.03; 95% confidence interval: 1.06 to 3.89; P=0.034). A large proportion of patients with open-angle glaucoma or ocular hypertension had signs and/or symptoms of OSD in at least 1 eye. The coexistence of OSD and the use of BAK-containing medications may impact vision-related quality of life in this patient population.
          Article 0 comments Cited 184 times – based on 0 reviews     Review now
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            Performance and Safety of a New Ab Interno Gelatin Stent in Refractory Glaucoma at 12 Months.

            Barbara Niksch, Davinder S Grover, William Flynn … (2017)
            To evaluate the intraocular pressure (IOP)-lowering performance and safety of an ab interno gelatin stent (XEN 45 Gel Stent, Allergan plc, Irvine, California, USA), a minimally invasive glaucoma surgery device, in refractory glaucoma.
            Article 0 comments Cited 95 times – based on 0 reviews     Review now
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              Ab interno approach to the subconjunctival space using a collagen glaucoma stent.

              Richard Lewis (2014)
              This review considers a minimally invasive ab interno approach to glaucoma filtration surgery. Glaucoma filtration surgery can be defined as an attempt to lower intraocular pressure (IOP) by the surgical formation of an artificial drainage pathway from the anterior chamber to the subconjunctival space. Subconjunctival drainage of aqueous fluid has been a cornerstone of glaucoma surgery for more than a century. Varying techniques have been deployed to provide access to this space. Yet, despite numerous innovations in filtering surgery to achieve safe IOP reduction, too many short-term and long-term complications are associated with this surgery. This article describes the development of a new, soft, and permanent ab interno collagen implant (XEN gel stent) to optimize aqueous drainage to the subconjunctival space. Specific characteristics are critical in designing such an implant. Determining the optimum size of the device lumen to avoid hypotony while maximizing long-term outflow is crucial. Other topics discussed include material, length, diameter, flexibility, stability, and biocompatibility of the implant. Preclinical and human eye testing shows that the implant does not seem to occlude inside the lumen and the implant material does not appear to cause tissue reaction in the eye. The ab interno placement of the stent offers an alternative for lowering IOP with a minimally invasive procedure, minimum conjunctival tissue disruption, restricted flow to avoid hypotony, and long-term safety.
              Article 0 comments Cited 74 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Curr Glaucoma Pract
                Journal ID (iso-abbrev): J Curr Glaucoma Pract
                Journal ID (publisher-id): JOCGP
                Title: Journal of Current Glaucoma Practice
                Publisher: Jaypee Brothers Medical Publishers
                ISSN (Print): 0974-0333
                ISSN (Electronic): 0975-1947
                Publication date (Print): May-Aug 2019
                Volume: 13
                Issue: 2
                Pages: 79-81
                Affiliations
                [1 ]Department of Medical Retina, Manchester Royal Eye Hospital, Manchester, UK
                [2–4 ]Department of Ophthalmology, East Lancashire Teaching Hospitals, Blackburn, UK
                Author notes
                Zaria C Ali, Department of Medical Retina, Manchester Royal Eye Hospital, Manchester, UK, Phone: +44 7715233383, e-mail: zariaali@ 123456gmail.com
                Article
                DOI: 10.5005/jp-journals-10078-1253
                PMC ID: 6743307
                PubMed ID: 31564799
                SO-VID: e916feb8-00e5-4e35-a6eb-acaae055a665
                Copyright © Copyright © 2019; Jaypee Brothers Medical Publishers (P) Ltd.
                License:

                © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                Categories
                Subject: Case Report

                Keywords: complications,minimally invasive procedure,surgical treatment,xen
                Data availability:
                Keywords: complications, minimally invasive procedure, surgical treatment, xen

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