Management of conjunctival perforation and late Seidel after XEN® surgery. / Manejo de la perforación conjuntival y Seidel tardío poscirugía XEN®.

CLINICAL CASE: The case concerns a 78 year-old woman with a history of XEN® surgery, in whom a conjunctival perforation was observed at the implant level at 18-months of follow-up, for which surgical intervention was decided. During surgery a short subconjunctival portion was found (0.5mm). An unsuccessful attempt was made to extract it by traction, but the XEN® broke easily. Finally, it was decided to cut it to scleral level, and suture the conjunctiva. During the first week there was a decrease in intraocular pressure (6mmHg), to subsequently increase to 25, and deciding to start medical treatment. DISCUSSION: Conjunctival exposure of the XEN® stent is a rare but potentially serious complication. To avoid it, a meticulous surgical technique is important when implanting it. If this occurs, it is important to identify the cause. If it is due to a short subconjunctival portion, a therapeutic alternative is to cut the implant at this level to avoid further complications.

Efficacy of the SENSIMED Triggerfish® in the postoperative follow-up of PHACO-ExPRESS combined surgery. / Eficacia del SENSIMED Triggerfish® para el seguimiento postoperatorio de la cirugía combinada FACO-ExPRESS.

OBJECTIVE: To determine the usefulness of the SENSIMED Triggerfish® system in the postoperative control of combined phacoemulsification and ExPRESS implant (PHACO-ExPRESS) surgery in patients with cataract and chronic open angle glaucoma (COAG) during a 2 months follow-up. METHODS: A prospective study conducted on 15 eyes that were subjected to PHACO-ExPRESS combined surgery. Using the SENSIMED Triggerfish® system, two records of the circadian patterns of intraocular pressure (IOP) were performed, one before and one after surgery. A record was made of the best corrected visual acuity (BCVA), comorbidities, previous IOP, and 7-30-60 days after surgery, as well as any hypotensive drugs and complications. RESULTS: The final sample was 12 eyes. The mean pre-operative BCVA (log MAR chart) before surgery was 0.5±0.2, and after surgery 0.14±0.1 (P=.02). The previous IOP was 18.7±3.8mmHg with 2.9±0.7 drugs. The mean IOP at 7, 30, and 60 days after surgery decreased to 13±4.1mmHg (P=.002), 13.5±2mmHg (P=.001), and 13.9±2.5mmHg (P=.001), respectively. The amplitudes of the circadian curves changed significantly after surgery (P=.007). The mean values between daytime and night-time periods decreased significantly from 146.8±80.9 mVeq and 61.2±92.mVeq before surgery to 36.4±36 mVeq (P=.000), and -23,2±47.6mVeq (P=.014) after surgery, respectively. There were complications in one patient. CONCLUSIONS: The SENSIMED Triggerfish® monitoring system showed changes in the curves of the circadian patterns, as well as decreased mean amplitudes after the combined PHACO-ExPRESS technique, suggesting that it may become a useful tool for postoperative follow-up of COAG.

Prospective study of filtering blebs after XEN45 surgery. / Estudio prospectivo de las ampollas de filtración poscirugía de implante XEN45.

OBJECTIVE: To qualitatively analyse the evolution of filtering blebs after XEN surgery, by using anterior segment optical coherence tomography (AS-OCT). METHODS: A prospective study was performed on filtering blebs of 30 eyes with cataracts and glaucoma, surgically operated on using phacoemulsification and XEN45 implantation (PHACO-XEN). AS-OCT was used to analyse bleb morphology and reflectivity at 3, 6, and 12 months after surgery. Functionality was studied considering an intraocular pressure (IOP)≤18mmHg without antihypertensive medication. RESULTS: The IOP enabled the blebs to be classified into non-functional: flat (6.67%) and encapsulated (3.33%); and functional (90%), which were then divide by their morphology into cystic (5/27), diffuse (2/27), and layered (20/27). Cystic types had a mean IOP of 12.8, 12.6, and 14.0mmHg at 3, 6 and 12 months, respectively. In the diffuse type, the mean IOP was 13.0, 11.5 and 13.0mmHg at 3, 6 and 12 months, respectively. In the layers pattern the mean IOP was 14.45, 14.55 and 14.8mmHg at 3, 6 and 12 months respectively. The percentage of blebs with high reflectivity was 48.15%, 62.96%, and 77.78%, at 3, 6 and 12 months, with a mean IOP of 14.23, 14.59, and 15.14mmHg in each time period, respectively. CONCLUSION: AS-OCT could be a good predictor of bleb functionality in PHACO-XEN surgery. Those with a cystic pattern or low reflectivity seem to have better post-operative success. Nevertheless, more long-term studies are required.

Qualitative analysis of repaired filtering blebs with anterior segment-optical coherence tomography. / Análisis cualitativo de ampollas de filtración reparadas mediante tomografía de coherencia óptica de segmento anterior.

OBJECTIVE: To provide a qualitative analysis of filtering blebs after being surgically repaired due to late blebs leaks. METHODS: Blebs were studied 6 months after surgical reparation using AS-OCT Triton (Topcon®). An analysis was made of the morphological pattern and internal structures of blebs, including the covering, in 10 patients. The images were obtained using OCTs at a wavelength of 1050nm. RESULTS: According to the Hirooka classification, three different patterns were found in the structure of blebs, which made it possible to correlate them with their functionality. A full covering was observed in 70% of the cases, and they showed sub-epithelial cysts (cystoid pattern). Two cases showed a full conjunctival retraction without Tenon's covering. The walls were thin, with a de-structured bleb (diffuse pattern) being visualised. In the third group, the image showed a partial conjunctival retraction with Tenon's covering. There were some sub-epithelial diffuse cysts with walls following a laminar pattern. CONCLUSION: Using AS-OCT, it is possible to study the bleb's characteristics in detail, as well as the cover, in the case of blebs requiring repair due to late leaks, using conjunctival advancement. It allows for the early visualisation of conjunctival retractions that were not visible in a slit lamp, and to predict the functionality of the blebs by their morphology.

Combined phacoemulsification and XEN45 surgery from a temporal approach and 2 incisions. / Cirugía combinada mediante facoemulsificación e implante XEN45 con acceso temporal y 2 únicas incisiones.

OBJECTIVE: To assess the safety and effectiveness of phacoemulsification combined with XEN45 implant surgery in patients with cataract and open-angle glaucoma, with 12-month follow-up. METHODS: A prospective study conducted on 30 eyes requiring phacoemulsification with, at least, 2 medications to control intraocular pressure (IOP). Phacoemulsification combined with XEN45 implant surgery was performed within 15minutes of administering subconjunctival mitomycin C. Surgery was performed through 2 temporal incisions, separated by 90°, using the inferior to enter the XEN45 and to implant it in the superior nasal region. A record was made of the best corrected visual acuity, IOP before and 1 day, 1 month, 3 months, 6 months, 9 months, and 12 months after surgery, the number of antiglaucomatous medications, and complications. RESULTS: The best corrected visual acuity was 0.37±0.2 and 0.72±0.15 before and 12 months after surgery, respectively. The pre-operative IOP was 21.2±3.4mmHg, with 3.07 drugs, decreasing by 61.65% on the first day, 37.26% at 1 month, 35.05% at 3 months, 31% at 6 months, 30.6% at 9 months, and 29.34% at 12 months. The number of medications decreased by 94.57%. Complications occurred in 3 eyes, 2 of them were excluded because we could not complete the implantation (280° subconjunctival haemorrhage and XEN extrusion when trying to reposition). In a third case, the bleb was encapsulated at 5 months after surgery. CONCLUSIONS: The phacoemulsification combined with XEN45 implant surgery can effectively reduce IOP and the number of drugs in mild-moderate open-angle glaucoma, as they rehabilitate the VA. The use of only 2 micro-invasive incisions makes it simple, quick and safe, with few complications at 12 months follow-up from surgery.

[Brimonidine absorption and release from 1. Day acuvue disposable contact lenses]. / Absorción y liberación de brimonidina por lentes de contacto desechables 1.Day acuvue.

PURPOSE: We studied absorption and release of brimonidine tartrate while wearing 1 Day Acuvue contact lenses. MATERIAL AND METHOD: A regression chart was obtained from 320 nm ultraviolet absorption (UV) for different dilutions of brimonidine tartrate in ophthalmic solutions (Alphagan(R)). 40 microliter of opthalmic solution was placed in the concavity of the contact lens; after a series of time intervals, lens was drained and introduced in a test-tube containing 2 ml of saline and underwent a quick cleansing. Next, lens was withdrawn from this tube and introduced into another test tube containing 2 ml of saline. Test tube was changed at intervals of 5 minutes. UV absorption is measured on each resulting tube until reading is 0. Contents of tubes in microgram of product were calculated according to regression chart. Total absorption will show substance penetration in lens. Release of substance is appreciated when lens is loaded during 1 minute and then placed in a tube containing 2 ml of saline introduced in the spectrophotometer which measures UV absorption minute by minute. RESULTS: Within the first minute, 51.54 microgram of product are absorbed (64.42% of a total of 80 microgram contained in a drop of ophthalmic solution), 20% found in lens surface and 44% penetrated the lens. If soaked during 3 minutes, lens takes 71% of fluid, 20% on surface and 50% into the lens itself. Release in 2 ml of saline is 19.33 microgram (37.5% of 51.54 microgram) in 1 hour, 25.57 microgram (49.6%) in 2 hours and 29.7 microgram (57.6%) after 3 hours. If saline is changed every 5 minutes, 100% of product is released in 35 minutes. CONCLUSION: Disposable contact lenses 1. DAY ACUVUE(R) are able to take and release brimonidine tartrate in vitro.