XEN-45 in the management of early glaucoma surgery: A national Delphi consensus study.

BACKGROUND AND OBJECTIVE: Recommendations on general glaucoma management and the use of early minimally invasive and microincisional surgeries are limited. This study aimed to establish consensus regarding glaucoma management, focusing on the XEN-45 gel stent implant. METHODS: A Delphi consensus-driven process was used. The scientific committee led the study, identified the expert panel, and participated in elaborating the questionnaire. Fifty-one panelists were invited to complete, on a nine-point Likert scale, an 89-item questionnaire covering three topic blocks. Two Delphi rounds were performed. Consensus was achieved if ≥66.6% of panelists reached agreement or disagreement. RESULTS: Panelists agreed on 84 items related to the patients' quality of life, the therapeutic algorithm and patient profile, and surgical and pre- and post-operative management. Panelists agreed on the suitability of XEN stent implants to treat glaucoma at different stages and for different patient profiles: young patients, elderly or with significant comorbidities, and with myopic glaucoma, patients who failed previous surgeries, and with previous poor post-operative experience. XEN surgery was considered a therapeutic step prior to classic filtering surgery and a possible first surgical option in elderly patients with comorbidities and uncontrolled intraocular pressure. XEN surgery allows the patient to return to routine daily activities faster than conventional filtering surgeries and to reduce and/or eliminate topical treatments. CONCLUSIONS: This Delphi-driven consensus resulted in a series of general recommendations for glaucoma management, including those related to patient quality of life, therapeutic algorithm, and patient profile, and specific ones regarding the use of XEN stent gel surgery.

Budget impact analysis of the XEN®63 for the treatment of primary openangle glaucoma in Spain.

BACKGROUND AND OBJECTIVE: To evaluate the economic impact in Spain derived from the introduction of the XEN®63 implant as a surgical alternative in the management of primary open angle glaucoma (POAG) with or without cataract in refractory patients. MATERIALS AND METHODS: A budget impact analysis was designed to estimate the costs of surgical treatment of POAG from the perspective of the Spanish National Health System (NHS), over a time horizon of 1 year. The comparators considered (trabeculectomy, deep non-penetrating sclerectomy, Ahmed valve, iStent inject, Preserflo® microshunt and XEN®45) correspond to those used in Spanish public clinical practice. For the calculation of the target population, market shares and resource use in terms of follow-up visits, additional procedures and post-surgery complications, data from the literature were used and validated with a panel of 4 experts. Unit costs (€ 2021) were obtained from the ESALUD database. RESULTS: The inclusion of XEN®63 could generate savings of €2,569,737 after one year since its introduction, derived from savings in the cost of the implant and procedure (-€423,120; -0.7%), follow-up visits (-€777,407; -4.5%), additional procedures (-€1,048,145; -20.6%) and post-surgery complications (-€321,065; -14.2%). CONCLUSIONS: The incorporation of XEN63®in the surgical arsenal for the treatment of refractory POAG with and without cataracts could generate savings for the NHS.

Posterior chamber implantation of a Preserflo Microshunt in a patient with a compromised endothelium.

The objective of the present case is to describe a variation in the Preserflo Microshunt surgical technique, placing it in the posterior chamber to minimise the risk of endothelial cell loss in cases with a compromised endothelium. The patient was a 72-year-old pseudophakic woman, with granular dystrophy and a primary diagnosis of open-angle glaucoma presenting with a progressive visual field defect and an IOP of 26 mmHg with maximal medical therapy. The cornea had incipient stromal folds with an endothelial count of 700 cells/mm2. A Preserflo Microshunt was implanted in the posterior chamber to minimise the possibility of further damage to the corneal endothelium. Six months after surgery, the implant remains functional. The IOP is 9 mmHg without medications. As far as we know, this is the first Preserflo implanted in the posterior chamber described in the literature.

Update on the usefulness of optical coherence tomography in assessing the iridocorneal angle. / Actualización de la utilidad de la tomografía de coherencia óptica para el estudio del ángulo iridocorneal.

The iridocorneal angle, due to its implications in the physiopathology of aqueous humour drainage, is a fundamental structure of the anterior chamber. Anterior segment optical coherence tomography is a rapid and non-invasive technique that obtains images in vivo. The high resolution allows it to analyse the normal anatomy of the angle, any alterations, and the changes that occur after different therapeutic interventions. Anterior segment optical coherence tomography technology has evolved to provide images that allow the identification and quantification of the angular structures in healthy subjects and in glaucoma patients, and especially the trabecular meshwork and the Schlemm's canal. It also enables the angle width to be quantified, with some objective parameters that have been standardised in recent years, such as the trabecular-iris angle, the angle opening distance, and the trabecular-iris area. This technique has multiple uses in the study of the different mechanisms of angle closure, the evaluation of changes after a laser peripheral iridotomy or iridoplasty after cataract surgery, as well as after the implantation of phakic lenses.

Agreement and clinical comparison between a new swept-source optical coherence tomography-based optical biometer and an optical low-coherence reflectometry biometer.

PurposeTo compare measurements taken using a swept-source optical coherence tomography-based optical biometer (IOLmaster 700) and an optical low-coherence reflectometry biometer (Lenstar 900), and to determine the clinical impacts of differences in their measurements on intraocular lens (IOL) power predictions.MethodsEighty eyes of 80 patients scheduled to undergo cataract surgery were examined with both biometers. The measurements made using each device were axial length (AL), central corneal thickness (CCT), aqueous depth (AQD), lens thickness (LT), mean keratometry (MK), white-to-white distance (WTW), and pupil diameter (PD). Holladay 2 and SRK/T formulas were used to calculate IOL power. Differences in measurement between the two biometers were determined using the paired t-test. Agreement was assessed through intraclass correlation coefficients (ICC) and Bland-Altman plots.ResultsMean patient age was 76.3±6.8 years (range 59-89). Using the Lenstar, AL and PD could not be measured in 12.5 and 5.25% of eyes, respectively, while IOLMaster 700 took all measurements in all eyes. The variables CCT, AQD, LT, and MK varied significantly between the two biometers. According to ICCs, correlation between measurements made with both devices was excellent except for WTW and PD. Using the SRK/T formula, IOL power prediction based on the data from the two devices were statistically different, but differences were not clinically significant.ConclusionsNo clinically relevant differences were detected between the biometers in terms of their measurements and IOL power predictions. Using the IOLMaster 700, it was easier to obtain biometric measurements in eyes with less transparent ocular media or longer AL.

Effect of pharmacological pupil dilation on measurements and iol power calculation made using the new swept-source optical coherence tomography-based optical biometer.

PURPOSE: To determine whether pupil dilation affects biometric measurements and intraocular lens (IOL) power calculation made using the new swept-source optical coherence tomography-based optical biometer (IOLMaster 700©; Carl Zeiss Meditec, Jena, Germany). PROCEDURES: Eighty-one eyes of 81 patients evaluated for cataract surgery were prospectively examined using the IOLMaster 700© before and after pupil dilation with tropicamide 1%. The measurements made were: axial length (AL), central corneal thickness (CCT), aqueous chamber depth (ACD), lens thickness (LT), mean keratometry (MK), white-to-white distance (WTW) and pupil diameter (PD). Holladay II and SRK/T formulas were used to calculate IOL power. Agreement between measurement modes (with and without dilation) was assessed through intraclass correlation coefficients (ICC) and Bland-Altman plots. RESULTS: Mean patient age was 75.17±7.54 years (range: 57-92). Of the variables determined, CCT, ACD, LT and WTW varied significantly according to pupil dilation. Excellent intraobserver correlation was observed between measurements made before and after pupil dilation. Mean IOL power calculation using the Holladay 2 and SRK/T formulas were unmodified by pupil dilation. CONCLUSIONS: The use of pupil dilation produces statistical yet not clinically significant differences in some IOLMaster 700© measurements. However, it does not affect mean IOL power calculation.

Perioperative pharmacological management in patients with glaucoma.

REVIEWS AIM: When a phacoemulsification, a filtration surgery or a combined surgery are necessary, questions about the convenience of continuing certain antiglaucomatous drugs could appear. The aim of this review article is to unify criteria that will guide daily clinical practice and including the developing algorithms of action in the preoperative and postoperative periods of filtration surgery and/or cataract surgery. PROPOSED PROTOCOLS: In the preoperative period of cataract surgery, the use of non-steroidal anti-inflammatory drugs is at the discretion of the surgeon, with the monodose presentation being recommended. The suspension of prostaglandines a fewdays before the surgery should be considered. Preservative-free drugs ensure a better recovery of the ocular surface (OS) after cataract surgery. Once all modifying factors of the intraocular pressure (IOP) have been removed, baseline IOP should be evaluated again, choosing preservative-free antiglaucomatous drugs when needed. The use of preservative-free ocular antihypertensive drugs and steroids in the preoperative period of glaucoma surgery reduces the risk of surgical failure. The interruption of prostaglandines is recommended. In the postoperative period of glaucoma surgery, steroids are the anti-inflammatory treatment of choice, the preservative-free ones being preferred. When reintroducing antiglaucomatous treatment, preservatives should be avoided to prevent scarring. The appropriate perioperative management of patients with glaucoma is essential to obtain a correct control of IOP, improve the situation of the OS, prevent complications and improve the result of the filtration surgery and cataract surgery. CONCLUSIONS: this protocol aims to unify the different lines of action in order to decrease the incidence of adverse events and maximize the surgical outcome.

[Optic neuropathy in a case of recurrent idiopathic hypertrophic pachymeningitis unresponsive to steroids and immunosuppressants]. / Neuropatía óptica en un caso de paquimeningitis hipertrófica idiopática recurrente sin respuesta a esteroides e inmunosupresores.

CASE REPORT: A 38-year-old female patient with bilateral papilledema who presented with loss of vision in her left eye. The Magnetic Resonance Imagining (MRI) showed thickening of the dura mater, and the intracranial pressure was elevated. A cancer, infectious, and autoimmune origin was ruled out. DISCUSSION: The initial response to high doses of corticoids was satisfactory, with disappearance of the optic disc enema, with visual acuity and an improvement in the MRI. However, after one year without treatment she had a new outbreak of the disease. Despite renewed treatment with corticoids and azathioprine, the patient developed a left optic neuropathy and irreversible visual loss.

[Papillitis due to Epstein-Barr virus infection in an adult patient]. / Papilitis por infección del virus de Epstein-Barr en paciente adulto.

CASE REPORT: A 70-year- old woman who consulted due to poor vision in her right eye for 2 weeks. The examination showed a visual acuity (VA) of 0.6 and 1.0, with normal anterior pole and intraocular pressure and a relative afferent pupillary defect. Some papillitis was observed in the fundus of her right eye. The high levels of acute phase reactants led to an initial diagnosis of arteritic anterior ischemic optic neuropathy (AAION) and treatment with corticosteroids was started. DISCUSSION: According to the age of the patient, the fundus and the high levels of acute phase reactants, the initial diagnosis was AAION. However, the atypical papillitis features, with good AV and non-specific perimetry, together with a suitable medical history, and a profile of viral characteristics, with laboratory confirmation, led to the diagnosis of a primary papillitis infection due to Epstein-Barr virus, a very rare case due to the advanced age of the patient.

[Post-laser in situ keratomileusis refractive changes induced by glaucoma in the absence of keratectasia]. / Cambios refractivos post-keratomileusis láser in situ inducidos por hipertensión ocular aguda sin signos de ectasia corneal.

CASE REPORT: We report the case of a 34 year-old man with progressive loss of visual acuity in his left eye, who was diagnosed with pigmentary glaucoma with an intraocular pressure of 32mmHg. Eight years previously, the patient had undergone refractive surgery (LASIK). Hypotensive treatment led to a significant refractive change accompanied by flattening of the corneal curvature. DISCUSSION: We propose that a high intraocular pressure acting on a cornea weakened by refractive surgery can provoke corneal steepening, inducing refractive changes even in the absence of keratectasia.

Effects of corneal thickness on the intraocular penetration of travoprost 0.004%.

PURPOSE: To determine whether the intraocular penetration of travoprost 0.004% is affected by central corneal thickness. METHODS: Sixty-four patients who were scheduled for cataract surgery without any other ophthalmologic pathology of significance were enrolled in this study. At 120 min before surgery, one drop of travoprost 0.004% was instilled in the eye to be operated on. At the start of surgery, a sample of aqueous humour was extracted to subsequently determine its AL-5848 concentration. These concentrations were compared among three groups of patients established according to central corneal thickness measurements obtained by ultrasound pachymetry. RESULTS: Mean AL-5848 concentrations were 3.27±2.03 ng/ml in Group I (CCT<511 microns), 3.27±2.44 ng/ml in Group II (CCT≥511 and ≤574 microns), and 2.73±2.15 ng/ml in Group III (CCT>574 microns), indicating no significant differences among the groups. CONCLUSIONS: We were unable to demonstrate the greater or lesser penetration of travoprost depending on corneal thickness, which could explain differences in patient responses to this drug.

[0.1% dexamathasone and 1% rimexolone. A comparative study in the postoperative treatment after cataract extraction]. / Dexametasona al 0,1% versus rimexolona al 1%. Estudio comparativo en el postoperatorio de la cirugía de cataratas.

PURPOSE: To compare the efficiency and secondary effects of using 1% rimexolone or 0.1% dexamethasone as postoperative treatment for cataract surgery. MATERIALS AND METHODS: A prospective study performed on a cohort of 37 patients undergoing cataract surgery by phacoemulsification with no intraoperative complications at the Hospital Clínico San Carlos, Madrid. After surgery, 19 of the patients were randomly assigned to receive topical 0.1% dexamethasone (DEX group) as inflammatory treatment and the remaining 18 subjects were treated with 1% rimexolone ( RIMEX group) following the same regime. Twenty four hours and one month after surgery, visual acuity, conjunctival hyperaemia, anterior chamber cells, anterior chamber flare, intraocular pressure, corneal thickness and macular edema were determined in each patient. RESULTS: The repeated measures test performed on 24 hours and 1 month data revealed a significant difference between the two treatments in terms of Tyndall (p = 0.001) and flare (p= 0.034) values; these variables being lower in the dexamethasone group. No differences were observed in the remaining variables examined. CONCLUSIONS: Rimexolone is as efficient and safe as dexamethasone for the treatment of patients undergoing cataract extraction.

Angle-closure glaucoma after piggyback intraocular lens implantation.

PURPOSE: To report a case of angle closure glaucoma after piggyback intraocular lens implantation and its treatment. METHODS: The authors present the case of a 75-year-old woman who was seen in the emergency department with angle closure glaucoma. Two years before she had undergone piggyback intraocular lens (IOL) implantation in order to correct a refractive error after cataract surgery. Ultrasound biomicroscopy revealed a closed angle with synechiae in 360 degrees as well as the presence of two IOLs: one in the capsular bag and the other in the ciliary sulcus. Extraction of the anterior IOL was precluded due to the poor endothelial count. Peripheral iridotomy and trabeculectomy were ineffective to lower the intraocular pressure (IOP); the authors decided to implant with an Ahmed valve and to place the valve's tube between the two IOLs to protect the endothelium. RESULTS: After Ahmed valve implantation, IOP maintains stable around 10-12 mmHg without medical treatment. CONCLUSIONS: Ahmed valve implantation is a good option in angle closure glaucoma due to piggyback. The placement of the valve's tube between the two IOLs is a good option to protect corneal endothelium.

Ocular inflammatory signs observed in a cohort of Spanish patients with Behçet disease and ocular inflammation.

PURPOSE: To study the clinical characteristics of a cohort of Spanish patients diagnosed with Behcet disease and who also presented ocular inflammation. METHODS: Thirty cases of Behçet disease were studied retrospectively. The authors studied age distribution, distribution by sex, clinical course, laterality, type of uveitis, secondary glaucoma, corneal involvement, hypopyon, iris-lens synechiae, secondary cataract, cystoid macular edema (CME), and papillitis (optic neuritis). RESULTS: Fourteen of the patients were men and 16 were women (ratio 0.875:1). The mean age of the patients was 35.24 years (+/-10.917; 21-61 years). In 23 patients, the disease course was recurrent. In 9 patients, the disease manifested unilaterally. In 5 patients showing unilateral onset, the contralateral eye became affected. In 2 of the 30 patients, uveitis exclusively affected the anterior segment. In 8 patients, uveitis was solely posterior. There was one case of intermediate uveitis. The remaining 19 patients showed panuveitis. Three had focal chorioretinitis. One had diffuse chorioretinitis. Fifteen showed signs of diffuse vasculitis. Eight patients showed focal vasculitis. CONCLUSIONS: Women were slightly more affected than men, although the authors found no significant correlation between sex and the clinical variables examined. Apart from one unexpected case of intermediate uveitis, the observations are similar to those reported for other patient series.

[Sectorial conjunctival epitheliectomy and amniotic membrane transplantation for partial limbal stem cells deficiency]. / Epiteliectomía conjuntival sectorial y trasplante de membrana amniótica en insuficiencia limbar parcial.

CASE REPORT: A 74-year-old man developed a partial limbal stem cell deficiency secondary to a chemical injury in the left eye. He was treated with a sectorial conjunctival epitheliectomy and amniotic membrane transplantation. After 3 weeks there was an intact, smooth and stable corneal epithelium. DISCUSSION: This case report emphasizes that conjunctival epitheliectomy and amniotic membrane transplantation appears to be a safe and effective method of restoring a stable corneal epithelium for cases of partial limbal stem cell deficiency.

Endogenous Pseudomonas endophthalmitis in an immunocompetent patient.

PURPOSE: To report an unusual case of community-acquired Pseudomonas aeruginosa pneumonia in an immunocompetent host complicated by orbital cellulitis, panophthalmitis, and subcutaneous nodules. METHODS: An otherwise healthy 47-year-old woman presented with a 24-hour history of fever, cutaneous nodules, right sided pleuritic chest pain, and eyelid edema with severe vision loss in her right eye. A chest X-ray demonstrated a homogeneous infiltrate in the right upper lobe. Ophthalmic examination revealed signs of metastatic orbital cellulitis and panophthalmitis. Culture specimens from blood, sputum, skin, and vitreous showed a significant growth of P. aeruginosa species. RESULTS: Intravenous antibiotic therapy led to resolution of the pneumonia, cutaneous nodules, and orbital cellulitis. Despite intravitreal and topical antibiotics, the patient finally required enucleation. CONCLUSION: This case represents a rare combination of manifestations in an immunocompetent patient with P. aeruginosa infection. It highlights the accelerated course that may result from P. aeruginosa infection, the difficulties of treatment, and the poor prognosis in the case of eye involvement.

[Late endophthalmitis following Ahmed valve]. / Endoftalmitis tardía tras implantación de válvula de Ahmed.

CASE REPORT: A 71-year-old woman with a history of aphakic glaucoma underwent implantation of an Ahmed valve and scleral grafting in her right eye. Postoperative visual acuity was 0.5 and intraocular pressure was 12 mmHg during treatment with brimonidine tartrate (0.2%). Nine months after implantation she suffered a conjunctival infection which was treated with hygienic measures and topical antibiotic therapy. Four days later, she developed an endophthalmitis which was treated with topical, intravitreous and intravenous vancomycin and ceftazidime. The Ahmed drainage implant was replaced at 72 hours. Laboratory culture yielded Haemophilus influenzae. Four days later, the eye was enucleated. DISCUSSION: Endophthalmitis is an uncommon complication of glaucoma drainage implant surgery. Exposure of the drainage tube represents the greatest risk factor for this condition. Removal of the implant in the first 24 hours is recommended if a good visual prognosis is to be achieved.