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PURPOSE: The XEN45 gel stent implant (Allergen, CA, USA) is one of many micro-invasive surgical options available to glaucomatologists. Our case series describes the presentation, treatment, and possible risk factors of XEN45 gel stent related endophthalmitis. OBSERVATIONS: A 71 year old Chinese man and a 88 year old Caucasian woman underwent XEN45 gel stent implantation for primary open angle glaucoma. They presented with endophthalmitis at 7 and 4 months post-surgery respectively. The first patient had stent exposure with blebitis while the second patient did not show any signs of conjunctival defect, stent exposure, bleb leak nor blebitis. Both patients were treated immediately with intravitreal, topical and systemic antibiotics, followed by early vitrectomy. The implant was removed in the first, but not in the second patient. Vitreous cultures grew Streptococcus Viridans in the first patient and Haemophilus influenzae in the other. Unfortunately, the first patient eventually sustained a total retinal detachment requiring surgery and did not recover his vision. The second patient however, recovered with a good Snellen's visual acuity of 6/9 and maintenance of good intraocular pressure and bleb formation. CONCLUSIONS: Exogenous endophthalmitis related to XEN45 gel stent implantation is a rare but devastating complication. The risks factors identified were multiple post-operative procedures, bleb exposure, conjunctival defect, use of antifibrotics, blepharitis and prolonged post-operative antibiotics. XEN45 gel stent implant provides a different challenge to ophthalmologists compared to trabeculectomy as more post-operative procedures are required to prevent subconjunctival scarring. Great care should be taken to individualize the use of antifibrotics in each patient to balance the risk of subconjunctival fibrosis with the risk of infection. In patients with stent exposure we propose early closure of the conjunctiva to close off the portal of entry for pathogens and reduce the need for prophylactic topical antibiotics.
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AIM: To study the microvascular density of the macular and optic nerve head in healthy and glaucoma subjects using optical coherence tomography angiography. METHODOLOGY: We performed a cross-sectional cohort study on healthy subjects and patients with glaucoma. The AngioVue Enhanced Microvascular Imaging System was used to capture the optic nerve head and macula images during one visit. En face segment images of the macular and optic disc were studied in layers. Microvascular density of the optic nerve head and macula were quantified by the number of pixels measured by a novel in-house developed software. Areas under the receiver operating characteristic curves (AUROC) were used to determine the accuracy of differentiating between glaucoma and healthy subjects. RESULTS: A total of 24 (32 eyes) glaucoma subjects (57.5±9.5-y old) and 29 (58 eyes) age-matched controls (51.17±13.5-y old) were recruited. Optic disc and macula scans were performed showing a greater mean vessel density (VD) in healthy compared with glaucoma subjects. The control group had higher VD than the glaucoma group at the en face segmented layers of the optic disc (optic nerve head: 0.209±0.05 vs. 0.110±0.048, P<0.001; vitreoretinal interface: 0.086±0.045 vs. 0.052±0.034, P=0.001; radial peripapillary capillary: 0.146±0.040 vs. 0.053±0.036, P<0.001; and choroid: 0.228±0.074 vs. 0.165±0.062, P<0.001). Similarly, the VD at the macula was also greater in controls than glaucoma patients (superficial retina capillary plexus: 0.115±0.016 vs. 0.088±0.027, P<0.001; deep retina capillary plexus: 0.233±0.027 vs. 0.136±0.073, P<0.001; outer retinal capillary plexus: 0.190±0.057 vs. 0.136±0.105, P=0.036; and choriocapillaris: 0.225±0.053 vs. 0.153±0.068, P<0.001. The AUROC was highest for optic disc radial peripapillary capillary (0.96), followed by nerve head (0.92) and optic disc choroid (0.76). At the macula, the AUROC was highest for deep retina (0.86), followed by choroid (0.84), superficial retina (0.81), and outer retina (0.72). CONCLUSIONS: Microvascular density of the optic disc and macula in glaucoma patients was reduced compared with healthy controls. VD of both optic disc and macula had a high diagnostic ability in differentiating healthy and glaucoma eyes.