XEN-Augmented Deep Sclerectomy: Step-by-step Description of a Novel Surgical Technique for the Management of Open-angle Glaucoma.

AIM AND BACKGROUND: The present case report describes a novel surgical technique combining XEN gel stent implantation and deep sclerectomy: XEN-augmented deep sclerectomy (XEN-DS). CASE DESCRIPTION: An active 96-year-old Caucasian woman suffering from pseudoexfoliative glaucoma (PEXG) presented with intraocular pressure (IOP) of 24 mm Hg and a double arcuate visual field defect [mean deviation (MD) -9.6 dB] in her only functional eye despite maximal medical therapy. Considering (1) the magnitude of IOP reduction sought, (2) the risk of complications associated with trabeculectomies and glaucoma drainage devices, and (3) the risk of missed appointments due to the patient's personal and social circumstances, it was decided to tailor the surgical treatment to this patient's specific characteristics combining two existing surgical techniques. Following conjunctival dissection, a superficial scleral flap was lifted 2 mm more posteriorly than in conventional DS, and a XEN gel stent was implanted ab externo through the anterior wall of the deep sclerectomy, into the anterior chamber. A mitomycin C-soaked autologous space maintainer was used. No peri- or postoperative complications were observed. Following XEN-DS, her IOP stabilized between 5 mm Hg and 8 mm Hg through 6 months, and her visual field MD improved to -1.5 dB. DISCUSSION: The present case report is a proof of concept for this novel surgical technique, confirming that XEN-DS has the potential to achieve substantial and persistent IOP reductions in PEXG with a satisfactory safety profile. Clinical studies are warranted to confirm these results. HOW TO CITE THIS ARTICLE: Niegowski LJ, Gillmann K, Baumgartner JM. XEN-Augmented Deep Sclerectomy: Step-by-step Description of a Novel Surgical Technique for the Management of Open-angle Glaucoma. J Curr Glaucoma Pract 2021;15(3):144-148.

[Filtering surgery in glaucoma: comparative study of three surgical approaches]. / Chirurgie filtrante dans le glaucome: étude comparative de trois approches chirurgicales.

INTRODUCTION: The multiple complications observed with trabeculectomy encouraged the re-emergence of non penetrating glaucoma surgery (NPGS) in the 1980's. Since then, several modifications have been developed in order to improve success rates and safety. We describe a new variation of deep sclerectomy (DS) in which we include an autologous corneal stromal implant soaked in mitomycin C and sutured to the scleral bed. Next, we compare intraocular pressure (IOP) at 2 years in three groups: I: DS; II: DS with autologous implant soaked in mitomycin C; III: conventional trabeculectomy. PATIENTS AND METHODS: All surgeries were performed by the same surgeon. There were 40, 22 and 15 eyes with medically uncontrolled primary open angle glaucoma (POAG) in groups I, II and III, respectively. All patients underwent the usual pre- and postoperative exams over 24 months. Selected patients underwent Visante OCT (Optical Coherence Tomography) (Carl Zeiss, Meditec, Inc. Germany) examination of their anterior segments. RESULT: Age and sex distribution in all three groups showed no statistical difference. Mean preoperative IOP was 24 ± 11 mmHg, 26 ± 14 mmHg and 25 ± 9 mmHg in group I, II and III, respectively (P>0.8). Mean postoperative IOP was 14 ± 3 mmHg, 10 ± 3 mmHg and 13 ± 4 mmHg (P=0.05) at six months; 16 ± 4 mmHg, 13 ± 3 mmHg and 11 ± 4 mmHg (P=0.02) at 12 months; and 15 ± 4 mmHg, 12 ± 3 mmHg and 14 ± 4 mmHg (P=0.2) at 24 months. Mean number of eye medications dropped from 1.85, 2.18 to 1.92 (P>0.05) preoperatively in group I, II, and III, respectively, to and 0.25, 0.05 to 0.18 (P=0.02) at 24 months. Patients with a visible implant under the bleb at 24 months had a better outcome. DISCUSSION: DS with autologous implant significantly reduced IOP at 12 and 24 months. The results seem better than those obtained with collagen implants, most likely due to the persistence of the corneal implant under the bleb at 2 years. Its non-resorption and the minimal fibrosis at the level of the scleral bed may be related to the fact that it is an autologous material which has been soaked with mitomycin C. CONCLUSION: DS with autologous implant soaked in mitomycin C, an inexpensive technique, demonstrates medium-term efficacy in the surgical management of POAG. Our results suggest that our technique may enhance both success rate and efficacy in lowering IOP. Further long-term studies are needed.

[Retinopathy of prematurity and the "immaturity index"]. / La rétinopathie du prématuré et "l'index d'immaturité".

GOAL: To find an index which enables one to differentiate any high risk premature newborn of developing a retinopathy of prematurity. METHOD: Two groups of newborn are studied: 1) all the children under 2550 g at birth time and born between january 1979 and september 1987 and having had a diagnosis of retinopathy of prematurity, 2) all the children who were examined by the author from october 1987 to july 1990. RESULTS: 33 of the 118 children studied suffered from a retinopathy of prematurity. Small gestational age and weight is considered to be high risk as well as the association with necrotizing colitis, intracranial hemorrhage, hyaline membrane disease and/or bronchopulmonary dysplasia, oxygen therapy and sepsis. For all these factors studied p is less than 0.0001. We utilized the multiple regression coefficients to define the "Immaturity Index". CONCLUSION: The index is very specific in defining any child with no risk of developing the disease. It has a sensitivity of 0.9 in detecting any newborn suffering from a retinopathy over grade 2. It is much more powerful than any biological variable (gestational age or weight, oxygen therapy time) in predicting retinopathies (60%).

[Comparison of astigmatism due to ambulatory cataract surgery with 3 different techniques]. / Comparaison de l'astigmatisme induit dans la chirurgie ambulatoire de la cataracte selon 3 techniques différentes.

We show that there was little difference in the average astigmatism induced in three surgical groups (Extracapsular (EC), Phacoemulsification with and without scleral tunnelization) at the last control. An examination of a second group of patients shows a significant reduction in the time necessary for recovering at least 80% of the final visual function and a significant shortening of the time elapsed before the prescription of the glasses in the group of patients operated on using phaco with tunnellization. Just as there is a significant relationship between the post-operative cyclinder and postoperative phase 1, there is also a reduction in, and early and lasting stabilisation of, the cyclinder induced by surgery using small incisions. We show that the technique of vectorial calculation brings into play discontinuous trigonometric functions that require great prudence when interpreting statistics of cylinders induced by surgery.

[Benefits of ambulatory surgery in cataract surgery]. / Qu'apporte la chirurgie ambulatoire à l'opération de la cataracte.

We monitored 300 patients who had undergone ambulatory cataract operations. Patients are more and more preferring this type of surgery, which allows them to go home immediately after the operation. We compare ambulatory ECCE and phacoemulsification operations and their complications, advantages and disadvantages. We shall not go into the real cost-saving benefits of this type of surgery compared with conventional surgery, as these have already been demonstrated in other countries. Ambulatory surgery requires that the patient is to be monitored after the operation, which is difficult to do in large centers. We explain the reasons for this. We discuss the indications and contra-indications of this type of cataract procedure.

Stroke secondary to multiple spontaneous cholesterol emboli.

We describe one male, 49-year-old diabetic patient in whom regressive stroke with aphasia and right-sided hemiparesia was related to multiple small emboli in the left paraventricular cortex. Simultaneous presence of several cholesterol emboli in the left eye ground and detection of an atheromatous plaque at the homolateral carotid bifurcation let assume that the cerebral emboli originated from that plaque and also consisted of cholesterol crystals. The patient was discharged on low-dose aspirin (100 mg/day) after neurologic improvement. Follow-up at one year revealed clinical stability, recurrence of the cholesterol emboli at the eye ground examination and no change of the carotid plaque. Cholesterol embolization with renal failure, hypertension and peripheral arterial occlusions causing skin ulcerations is classical in case of atheromatous aortic disease but stroke has rarely been reported in this syndrome. However, more frequent use of invasive procedures (arteriography, transluminal angioplasty, vascular surgery) or thrombolytic treatment might increase its incidence in the near future.

Expectancy and heart rate as predictors of the speech performance of stutterers.

Three adult stutterers who displayed a preexperimental pattern of consistent expectation and occurrence of stuttering were studied in a single-subject design. Multiple linear regression analyses led to the conclusion that cognitive (signalled) expectancy was predictive of stuttering for two of the subjects. The third subject evidenced essentially no relationship between signalled expectancy and disfluent performance. For two subjects, neither mean heart rate nor heart rate variability was predictive of speech performance. For the third subject, mean heart rate was predictive but heart rate variability was not. For two subjects, there was essentially no relationship between the measured physiologic variables and cognitive expectancy. However, for the third subject both mean heart rate and heart rate variability were significantly predictive of cognitive expectancy. These results suggest that adult stutterers should not be viewed as a homogeneous group with respect to preutterance activity that is either cognitive or physiologic. The relationship between preutterance heart rate, heart rate variability, and expectancy responses and between these preutterance variables and subsequent stuttering appears to be individualistic.